Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Haven Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified that the facility did not employ a full-time registered dietitian and also lacked a qualified dietary services manager to oversee food and nutrition services in the dietitian’s absence. During an interview, the Administrator confirmed that no full-time dietitian was onsite and no qualified dietary manager had been designated, resulting in noncompliance with management requirements for staffing the dietary department.
Surveyors found that OTC medications were not stored and labeled according to facility policy and professional standards. In central supply, OTC medications in factory-labeled bottles were kept on open shelves in a keypad-accessed room used by multiple types of staff, and the central supply manager did not know exactly who had the access code. On six nursing units, multiple med carts contained OTC medications poured into open plastic cups with handwritten labels, including vitamins, supplements, analgesics, laxatives, and other OTC drugs. LPNs on these units could not determine doses, manufacture dates, expiration dates, or when original containers were opened, and in some cases could not identify all pills in mixed or unlabeled cups, even though residents had physician orders corresponding to these medications. The DON acknowledged that OTC medications were being stored in this improper manner, and surveyors determined that this failure to properly store and label medications created an Immediate Jeopardy situation under F761-K.
A resident with congestive heart failure and end stage renal disease received new physician orders for Bumex, a chest x-ray, and double-portion protein at meals, but there was no documented evidence that the resident or their responsible party was notified of these changes. The DON confirmed the lack of documentation.
A resident was transferred to the hospital following a change in condition, but neither the resident nor their representative received the required written notification about bed-hold policies, reasons for transfer, or Ombudsman information at the time of transfer.
A resident with Parkinson's disease and dementia experienced a significant change in condition, including unresponsiveness and difficulty swallowing, which was not promptly communicated to the physician or responsible party. The issue was only addressed after the family intervened, leading to the resident's transfer to the hospital.
A nurse aide filmed a video exposing her breasts in a resident room with two residents present, violating the facility's abuse prevention and social media policies. The incident resulted in psychosocial harm to the residents, one of whom was cognitively impaired. Despite prior training, the aide admitted to the misconduct, leading to her termination.
The facility failed to ensure accurate MDS assessments for two residents. One resident with end-stage renal disease requiring hemodialysis did not have this reflected in their MDS. Another resident with a urinary tract infection and bladder cancer requiring nephrostomy care also had an inaccurate MDS. These inaccuracies were confirmed by the RN Assessment Coordinator.
The facility failed to develop comprehensive care plans for four residents, neglecting to address identified needs such as psychotropic drug use, urinary incontinence, and pain management. Despite these issues being noted in the MDS CAA summaries, the care plans lacked necessary interventions, as confirmed by the DON.
A facility failed to follow physician's orders for a resident with hypertension by administering lisinopril without documenting blood pressure assessments. The resident's medication was given 49 times without checking if the systolic blood pressure was below 110 mm Hg, as required. This deficiency was confirmed by the DON.
A resident with hypertension and anxiety was identified as a candidate for a scheduled toileting program, but the facility failed to implement it. Despite being always incontinent of urine and needing staff assistance, the resident's care plan did not specify the type of incontinence or include a toileting program. The Nursing Home Administrator confirmed the absence of documentation for such a program.
The facility was found to have improperly disposed of trash and refuse, with items such as used briefs, gloves, and an opened plastic bag observed on the ground next to the dumpster. This indicates a failure in maintaining proper waste management practices.
Lack of Qualified Dietary Leadership in Absence of Full-Time Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager when there was no full-time registered dietitian onsite. During an interview on March 31, 2026, at 2:45 p.m., the Administrator confirmed that the facility did not have a full-time dietitian present and also did not employ a qualified dietary manager in the dietitian’s absence. This deficiency was cited under 28 Pa. Code 201.18(b)(3) related to management requirements for employing sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietitian.
Improper Storage and Labeling of OTC Medications in Medication Carts and Central Supply
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were properly labeled and securely stored in accordance with facility policy and accepted professional standards. Facility policies required that all medications in carts, medication rooms, or central supply be locked at all times unless in use or under the direct observation of the medication nurse, and that nursing staff check medication labels and expiration dates prior to administration. Policies also required that opened multi-dose containers be dated when opened and that the label of all medications be checked against the physician’s order before removal from the container. Additionally, the facility’s procedure for unavailable medications required staff to obtain OTC medications from central supply when not available in the cart and to notify nurse management if a system-wide issue was identified. Surveyors found that OTC medications in central supply were stored in closed, factory-labeled bottles on open shelves in a room accessed by a keypad lock. The Central Supply Manager stated that staff had access to the room via a code, but she was not aware of all staff who had the code, and reported that therapists and nurse aides, in addition to nursing staff, had collected materials from central supply after hours. This meant that OTC medications were not stored in locked compartments accessible only to authorized personnel, contrary to the facility’s own policy and accepted standards for medication security. On six of ten nursing units (1C, 1D, 3C, 3D, 3F, and 4F), surveyors observed OTC medications stored in open plastic cups with handwritten labels inside medication carts, rather than in their original, labeled bottles. On unit 1C, one cart contained seven cups labeled with drug names such as an eye supplement, guaifenesin ER 600 mg, melatonin 5 mg, cetirizine 10 mg, iron, B12 100, and Fiber Con, but the LPN could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened. Another cart on the same unit contained cups labeled with ASA EC, Mucinex, Ibuprofen 200 mg, and a cup labeled Senna 8.6 that contained a mixture of red, pink, and brown pills, some of which the LPN could not identify. Residents on this unit had physician orders that correlated with the medications stored in these cups. On unit 1D, a medication cart contained seven cups labeled with various supplements and medications, including Oyster Shell D3, Cranberry 450, Vit D 2000 iu, omep 2D, MVI, cetirizine, and vit D3 2000 iu. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, even though residents on the unit had orders corresponding to these medications. On unit 3C, a cart contained cups labeled Vitamin D3 50,000 iu, Docusate, and Vit C 500 mg, and the LPN again could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened, despite residents having corresponding physician orders. On unit 3D, a medication cart contained cups labeled Senna 8.6 mg, Vitamin D3 50,000, Multivitamin, and Fiber-lax, and the LPN could not determine manufacture dates, expiration dates, or when the original containers had been opened, while residents on the unit had orders matching these medications. On unit 3F, one cart contained cups labeled Vit D 2,000 iu and Tylenol 500, and another cup labeled Iron 325 that contained white and black pills, some of which the LPN could not identify or trace back to an original container. A second cart on 3F contained cups labeled Calcium 600+D 10 mcg and Iron 325, with the LPN again unable to determine manufacture dates, expiration dates, or opening dates of the original containers, even though residents had corresponding orders. On unit 4F, one medication cart contained 14 cups labeled with various medications and supplements, including Docusate Sodium, Ibuprofen, Oyster Calcium, Iron, Multi vitamins, Cranberry, Mag Ox, Aspirin, ASA 81, Docusate, Multivit, Therems, Fe sulp, and Oyster Cple. Another cart on the same unit contained two unlabeled cups with pills and ten cups with handwritten labels such as Vit B12, Cranberry, Ibuprofen, Iron, Aspirin, Multivit, Oyster Cal, Thera-M, VitD, and Certizine. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, and could not identify the pills in the two unlabeled cups, even though residents on the unit had physician orders that correlated with the medications in these cups. The DON confirmed that OTC medications were improperly stored and labeled in open, hand-labeled cups in the medication carts. The surveyors determined that this failure to properly store and label medications put residents at risk for medication administration errors and resulted in an Immediate Jeopardy situation at F761-K.
Removal Plan
- Discard and destroy all medications observed in medication cups or unlabeled cups, or any medication that is unable to be identified.
- Replace any discarded medication with an unopened, labeled OTC medication bottle.
- Store OTC medications in the original, labeled bottle in the medication carts and administer to residents following medication administration policies.
- Submit OTC medication orders with the Clinical Supply order and purchase needed OTC medications from a local pharmacy if not sent, backordered, or out of stock.
- Change the Central Supply keylock code and provide it only to central supply staff and RN Supervisors.
- Train all licensed and central supply staff regarding storage of medications, proper distribution of OTC medications, and the medication not available procedure.
- Audit all medication carts to ensure no loose or unlabeled medications are stored in any cart.
Failure to Notify Resident or Responsible Party of Physician-Ordered Treatment Changes
Penalty
Summary
The facility failed to notify a resident or their responsible party of changes in physician-ordered treatments. Clinical record review showed that the resident, who had diagnoses including congestive heart failure and end stage renal disease, received new physician orders for Bumex (a diuretic) twice daily, a chest x-ray, and double-portion protein at meals over several days. There was no documented evidence that the resident or their responsible party was informed of these changes. The Director of Nursing confirmed during interview that there was no documentation of such notifications.
Failure to Provide Written Notification of Bed Hold and Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative regarding bed-hold policies and the reasons for a facility-initiated transfer to the hospital. Clinical record review showed that after a change in condition, the resident was transferred and admitted to the hospital. However, there was no documentation indicating that the resident's representative received written information about the bed hold or the transfer at the time it occurred. Additionally, required information about Ombudsman services was not provided in writing as mandated by regulations.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a significant change in the resident's condition. The resident, who had diagnoses including Parkinson's disease and dementia, exhibited signs of a change in condition on February 1, 2025. A nurse noted that the resident was not acting like herself, had difficulty grasping a cup, and was unresponsive to questions. Later, the resident was unable to eat supper, chew, or swallow without encouragement, prompting the nurse to order a speech therapy screen. Despite these observations, there was no evidence that the physician or responsible party were notified of the resident's condition change until the following day, February 2, 2025, when the resident's family alerted the nurse to the change in mental status. The nurse then documented that the resident was alert but unresponsive, unable to move her arms or legs, and nonverbal. The physician was finally notified and instructed the staff to send the resident to the hospital for evaluation. The Director of Nursing confirmed that the responsible party and physician should have been notified earlier.
Plan Of Correction
1. Resident 1's provider and family notified. Meeting with RP was held and status updates provided. 2. Reviewed all residents who were transferred to hospital in last 30 days for notification of RP and provider. 3. Re-educate licensed nurses on the importance of promptly notifying the physician and responsible party regarding any significant change in a resident's condition. 4. Perform weekly audits for the next four weeks of residents transferred out of facility with changes in condition to ensure compliance with notification procedures. 5. DON/designee will report audit findings at next 2 QAPIs for review and recommendations.
Mental Abuse Incident Involving Nurse Aide
Penalty
Summary
The facility failed to protect two residents from mental abuse, resulting in psychosocial harm. The incident involved a nurse aide, Employee 1, who filmed a video in a resident room where she exposed her breasts while two residents were present. This act was captured on video and shared via a text message, which was later reported. The facility's policy on abuse prevention and reporting, as well as the use of social media, explicitly prohibits such behavior, indicating a breach of protocol by Employee 1. Resident 65, who had no cognitive impairment, and Resident 227, who was cognitively impaired, were both present during the incident. The facility's documentation confirmed that Employee 1 had received prior training on abuse prevention and the prohibition of using personal devices for non-work-related purposes. Despite this, Employee 1 admitted to filming the video, acknowledging the wrongdoing. The facility substantiated the allegation of mental abuse against the residents, leading to Employee 1's termination.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the current status of two residents. Resident 57, who had end-stage renal disease and required hemodialysis, had a care plan indicating dialysis on specific days. However, the MDS assessment did not reflect that the resident received dialysis. Similarly, Resident 178, diagnosed with a urinary tract infection and bladder cancer, had a care plan that included nephrostomy care. The MDS assessment for this resident also failed to indicate the presence of a nephrostomy. These inaccuracies were confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS assessments for both residents were not accurate.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, as identified in their comprehensive assessments. Resident 49, who was admitted with diagnoses including diabetes, kidney disease, and heart failure, had a care plan that did not address psychotropic drug use and urinary incontinence, despite these issues being noted in the Minimum Data Set (MDS) Care Area Assessment (CAA) summary. Similarly, Resident 62, with dementia and hypertension, had no interventions for urinary incontinence included in their care plan, even though it was identified as a need in the MDS CAA summary. Resident 133, diagnosed with hypertension and anxiety, was receiving both an antipsychotic and antidepressant, yet their care plan lacked interventions for psychotropic drug use. Resident 242, with a fractured femur, pain, and dementia, was receiving pain medication, but their care plan did not address pain management. The Director of Nursing confirmed the absence of documented evidence that these care areas were addressed in the care plans, indicating a failure to meet the residents' identified needs.
Failure to Document Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for one of the 36 sampled residents, specifically Resident 224. The policy on Medication Administration, last reviewed in October 2024, required staff to administer medications according to the physician's written orders and to document vital signs in the Medication Administration Record as indicated. Resident 224, who had a diagnosis of hypertension, was prescribed lisinopril to be administered once daily, with the condition that it should not be given if the resident's systolic blood pressure was less than 110 mm Hg. However, a review of the Medication Administration Records for October and November 2024 showed that the medication was administered 49 times without any documentation of blood pressure assessment prior to administration, as required by the physician's order. This was confirmed by the Director of Nursing during an interview on November 21, 2024.
Failure to Implement Scheduled Toileting Program for Resident
Penalty
Summary
The facility failed to assess and provide appropriate services for bladder incontinence for one resident. According to the facility's Bowel and Bladder Management policy, staff were required to complete a urinary incontinence assessment upon admission and whenever there was a change in a resident's urinary tract function. This included reviewing the pre-admission history, assessing the current bladder elimination problem, and identifying causes of incontinence. If a change in incontinence was noted, staff were to implement a toileting diary to determine the resident's voiding pattern and develop a toileting program. The type of urinary incontinence was to be identified in the care plan with specific interventions. For Resident 133, who was admitted with diagnoses including hypertension and anxiety, a Bowel and Bladder Program Screener indicated the resident was a candidate for a scheduled toileting program. However, the Minimum Data Set assessment showed the resident was always incontinent of urine and required staff assistance for toileting, yet was not on a toileting program. The care plan did not identify the type of urinary incontinence, nor was there evidence of a scheduled toileting program being implemented. The Nursing Home Administrator confirmed the lack of documentation for a toileting program for this resident.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and refuse, as observed in the trash compactor area. During the inspection, various items were found on the ground next to the dumpster, including two used briefs, four used gloves, and a large opened plastic bag. This observation was made on November 19, 2024, at 10:30 a.m., indicating a lapse in proper waste management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lebanon Skilled Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 15 | 0 |
| Alpine Valley Post Acute And Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Cornwall Manor | 4.2 mi | ★★★★★ | 0 | 0 |
| Myerstown Nursing And Rehab Llc | 5.6 mi | ★★★★★ | 11 | 0 |
| Lebanon Valley Home The | 5.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.