Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Cedarbrook Senior Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment on four nursing units. A men’s bathroom had a stained privacy curtain, and multiple mechanical lifts, sit-to-stand lifts, mobile vital signs baskets, and a Broda chair had thick hair and debris wrapped around their wheels. A mobile bedside commode in a men’s bathroom contained a collection bucket with yellow liquid and brown spatter that remained unemptied and uncleaned over several days, with a urine odor present. Additional equipment on another unit also had hair, debris, and a dried white substance on its surfaces, demonstrating a pattern of unclean resident care equipment and bathroom fixtures.
A resident with vascular dementia, heart disease, and a history of stroke had physician orders for a wander alert bracelet and aspirin as an antiplatelet, but the MDS assessment inaccurately documented these treatments. The MDS indicated that no wander alarm was used during the look-back period and incorrectly coded the resident as receiving an anticoagulant rather than an antiplatelet. The RN Assessment Coordinator later confirmed that the MDS should have reflected daily use of a wander alert bracelet and antiplatelet therapy.
Surveyors found that staff failed to provide necessary fingernail and grooming care to two residents who were care planned as needing assistance with ADLs. One resident with a history of stroke and hemiparesis was repeatedly observed in bed with long, chipped, and dirty fingernails, and reported that she preferred short nails, needed them cut, had not been offered nail care, and had not refused it. Another resident with primary HTN and chronic CHF was observed on multiple occasions in a wheelchair with similarly long, chipped, and dirty fingernails. For both residents, there was no documentation that nail care was offered or that care was refused, and the DON confirmed they should have received fingernail care.
Surveyors found that staff failed to follow physician orders for medications and diagnostic testing for three residents. One resident with recurrent UTIs continued to receive methenamine even while receiving ordered antibiotics, despite instructions to hold the methenamine when antibiotics were prescribed. Another resident with diabetes, CKD, and Alzheimer’s received fast-acting insulin with meals on multiple occasions when blood glucose levels were documented as below 100 mg/dL, contrary to ordered hold parameters. A third resident with a vesicointestinal fistula had an ordered cystogram that was not scheduled within the physician-specified two-week timeframe because the appointment request was not sent to the scheduler promptly.
A resident with vascular dementia, muscle weakness, and tremors, who was care planned and had MD orders for foam-handled utensils, a suction lip plate, and a two-handled cup with lid at all meals, was repeatedly observed in the dining room without this adaptive equipment on lunch trays. On multiple occasions, the suction lip plate and foam utensil handles were missing, and at another meal the foam handles, suction lip plate, and two-handled cup with lid were all absent. The DON acknowledged that the resident should have received all ordered adaptive eating equipment at every meal.
Staff failed to follow the facility’s Enhanced Barrier Precautions policy for a resident with diabetes, chronic kidney disease, obstructive uropathy, and an indwelling urinary catheter. The resident’s care plan required staff to use gowns and gloves during close contact care, including brief changes. During observation, a NA changed the resident’s brief wearing gloves but no gown, while an RN present acknowledged that a gown should have been used. The DON later confirmed that staff were required to wear a gown during this type of care, demonstrating noncompliance with the facility’s infection control policies.
A resident with dementia and severe cognitive impairment was found by family to have a patch of hair missing or extremely short on the front of the scalp, and the resident’s daughter reported concern that the hair had been shaved and that there was a bruise along the scalp line. Facility policy required immediate reporting of all alleged abuse and injuries of unknown source to nursing leadership, the Abuse Coordinator, and state and local officials, but the facility did not report this allegation or the associated injury to the State Survey Agency or local agencies. The ADON acknowledged that the alleged violation was not reported as required, resulting in a failure to follow mandated abuse reporting regulations.
A resident with dementia, Alzheimer's disease, and severe cognitive impairment, who required staff supervision for personal hygiene and had known wandering and exit-seeking behaviors, was not adequately protected from accident hazards. Despite a care plan calling for setup assistance and safety cues for grooming, the resident obtained and used a disposable razor, later found in a purse in her closet, and was noted to have a patch of hair missing or extremely short on the front of her scalp, which she reported she had cut herself. The ADON acknowledged the resident should not have had a razor in her possession.
The facility failed to serve meals promptly, resulting in two residents being left without meals while others at their table were eating. One resident waited 10 minutes, and another waited 30 minutes before being served.
The facility failed to ensure that the MDS assessments were completed to accurately reflect the status of two residents. Clinical record reviews revealed that Sections C and D of their MDS assessments were incomplete. The MDS Coordinator confirmed that these sections were not completed during the assessment period.
The facility failed to implement physicians' orders for three residents. One resident was not weighed daily as ordered, another was not provided with compression stockings, and a third was given blood pressure medication despite elevated readings without notifying the physician.
Failure to Maintain Clean and Safe Resident Care Equipment and Bathrooms
Penalty
Summary
Surveyors determined that the facility failed to provide a safe, clean, and comfortable environment on four of 13 nursing units (C3, D2, D3, and D4). On Unit C3, the men’s bathroom contained a blue privacy curtain that was dirty with stains on both sides. On Unit D2, two mechanical lifts were observed with thick hair and debris wrapped around their wheels. On Unit D3, one mechanical lift and a sit-to-stand lift had thick hair and debris wrapped around the wheels, a mobile vital signs basket had thick hair and debris on its wheels, and a Broda chair between resident rooms had thick hair and debris wrapped around its wheels. In the men’s bathroom on Unit D3, a mobile bedside commode had a collection bucket containing yellow liquid and a brown substance spattered inside, and this bucket remained unemptied and uncleaned over multiple observations on three separate days, with an odor of urine coming from the commode. On Unit D4, two mechanical lifts and a mobile vital signs basket were also observed with thick hair and debris wrapped around the wheels, and there was a dried white substance on the legs of the vital signs basket. These conditions were cited under 42 CFR 483.10(i) Safe Environment and related Pennsylvania Code provisions, and the deficiency had been previously cited on 5/9/2025.
Inaccurate MDS Coding for Wander Alarm and Antiplatelet Therapy
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one sampled resident when clinical record review, observation, and staff interview showed discrepancies between physician orders and the MDS coding. The resident had vascular dementia, heart disease, and a history of stroke, with a physician’s order dated July 25, 2019 directing staff to apply a wander alert bracelet. However, the MDS assessment dated January 23, 2026 indicated in Section P (restraints and alarms) that the resident was not wearing a wander alarm during the last seven days of the look-back period, despite the order for daily use of a wander alert bracelet. Additionally, a physician’s order dated July 15, 2024 directed staff to administer aspirin as an antiplatelet medication, but the same MDS assessment documented that the resident was receiving an anticoagulant medication during the last seven days of the review period. The MDS therefore inaccurately reflected the type of medication being administered, coding aspirin as an anticoagulant instead of an antiplatelet. In an interview, the RN Assessment Coordinator confirmed that the MDS completed on January 23, 2026 was inaccurate and should have captured both the use of an antiplatelet medication and the daily use of a wander alert bracelet.
Failure to Provide Assisted Nail and Grooming Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and nail care for two residents who required assistance with activities of daily living (ADLs). Clinical record review showed that one resident had a history of stroke with hemiparesis and was care planned as needing staff assistance with ADLs. On multiple observations over three consecutive days, this resident was seen in bed with long, chipped fingernails that were dirty with a substance underneath. The resident stated she preferred her nails short, that her nails needed to be cut, that staff had not offered to cut her nails, and that she had not refused such care. There was no documentation in the clinical record indicating that nail care had been offered or that the resident had refused. Another resident, with diagnoses including primary hypertension and chronic congestive heart failure and who was also care planned as requiring staff assistance with ADLs, was observed on three separate days out of bed in a wheelchair with similarly long, chipped, and dirty fingernails with a substance underneath. For this resident as well, there was no evidence in the record that staff had offered nail care or that the resident had refused it. During an interview, the Director of Nursing confirmed that both residents should have been provided with fingernail care, indicating that the expected nursing services for grooming were not carried out as required.
Failure to Follow Physician Orders for Medications and Diagnostic Testing
Penalty
Summary
The deficiency involves failures to follow physician orders and ordered parameters for medications and diagnostic testing for three residents. For one resident with frequent urinary tract infections and cerebral infarction with hemiparesis, a physician ordered methenamine daily for UTI prevention with instructions not to administer it when an antibiotic was ordered. Later, the physician ordered cephalexin for seven days, followed by doxycycline for seven days. Review of the MAR showed that staff administered both antibiotics while continuing to give methenamine, contrary to the physician’s order. The DON confirmed that the physician’s orders were not followed and medications were administered outside the ordered parameters. Another resident with diabetes, chronic kidney disease, and Alzheimer’s disease had an order for insulin lispro with meals, which was later increased, with instructions to hold the insulin if the resident was not eating or if blood sugar was less than 100 mg/dL. The MAR showed that staff administered the insulin with breakfast on four occasions when the documented blood sugar was below 100 mg/dL, contrary to the order. A third resident with a vesicointestinal fistula was discharged from the hospital with an order for a cystogram to be completed in two weeks. The attending physician approved and ordered the test and directed staff to schedule the appointment, but there was no evidence that staff requested the appointment until several days later, and the cystogram was ultimately scheduled beyond the two-week timeframe. The DON confirmed that the request for the appointment was not sent to the scheduler in a timely manner.
Failure to Provide Ordered Adaptive Eating Equipment at Meals
Penalty
Summary
The facility failed to provide ordered adaptive eating equipment and utensils for a resident with vascular dementia, muscle weakness, and tremors. The resident’s care plan identified a risk for nutrition problems and specified the need for foam handles on utensils, a suction lip plate, and a two-handled cup with a lid for all meals. Physician orders directed staff to provide a two-handled cup with lid beginning in early September 2025 and to provide foam utensil handles and a suction lip plate beginning in early October 2025 with all meal trays. Despite these orders and care plan directives, multiple dining observations showed that the resident did not receive the required adaptive equipment. On two consecutive lunch observations, the resident’s tray did not include the suction lip plate or foam utensil handles, and on a subsequent lunch observation, the tray lacked the foam handles, suction lip plate, and the two-handled cup with lid. In an interview, the DON confirmed that the resident should have been provided with all of this adaptive equipment at every meal.
Failure to Follow Enhanced Barrier Precautions During Brief Change
Penalty
Summary
Facility staff failed to follow the facility’s Enhanced Barrier Precautions policy for a resident requiring infection prevention measures. The policy, last reviewed on February 7, 2026, required staff to wear a gown and gloves during high-contact resident care activities, such as changing briefs. Clinical record review showed that Resident 2 was admitted with diabetes, chronic kidney disease, and obstructive uropathy, and had an indwelling urinary catheter. The resident’s care plan specified that Enhanced Barrier Precautions were required and directed staff to wear gloves and gowns during close contact interactions. On April 16, 2026, at 10:29 a.m., a nurse aide was observed changing the resident’s brief while not wearing a gown, despite a registered nurse present at the time acknowledging that a gown should have been worn. In a subsequent interview, the Director of Nursing confirmed that staff should have worn a gown while changing this resident’s brief, indicating noncompliance with the facility’s infection prevention and control policies and Pennsylvania nursing services regulations.
Failure to Report Alleged Abuse and Injury of Unknown Origin to Required Authorities
Penalty
Summary
The facility failed to report an alleged violation involving suspected abuse and an injury of unknown origin to the State Survey Agency and local agencies as required by its own policy and state regulations. Facility policy on Resident Abuse, Neglect, Misappropriation of Property and Other Related Offenses, last reviewed February 7, 2026, required that all incidents and allegations of abuse, including injuries of unknown source, be reported immediately to the Nursing Supervisor, Nursing Administration, Abuse Coordinator, and to local and other officials as mandated by state law. Clinical record review showed that Resident 83 had dementia, cognitive communication deficiency, and Alzheimer's disease, with a Minimum Data Set indicating severe cognitive impairment. On April 6, 2026, nursing documentation reflected that the resident’s family alerted staff that a patch of hair was missing or extremely short on the front of the resident’s scalp, and a staff statement recorded that the resident’s daughter was concerned the resident’s hair had been shaved and that there was a bruise along the scalp line. Despite these allegations and the injury of unknown origin, there was no evidence that the facility reported the incident to the State Survey Agency or local agencies, and the Assistant Director of Nursing acknowledged that the facility failed to report the alleged violation to the appropriate authorities. This deficiency was cited under 28 Pa. Code 201.14(c) Responsibility of licensee, 28 Pa. Code 201.18(b)(1)(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Prevent Cognitively Impaired Resident’s Access to Razor
Penalty
Summary
The facility failed to implement adequate safety interventions to prevent accidents for one resident with severe cognitive impairment. The resident had diagnoses including dementia, cognitive communication deficiency, and Alzheimer's disease, and the MDS indicated she required staff supervision for bathing and personal hygiene tasks such as shaving, combing hair, and washing hands and face. Her care plan identified that she was at risk for severely impaired decision-making capacity related to these diagnoses and directed staff to provide setup assistance for hygiene and grooming and to provide cues for safety depending on her fluctuating cognitive status. The care plan also documented a behavior of wrapping jewelry and other personal belongings in tissues and placing items in various locations in her room, such as drawers, purses, and pillowcases. Facility documentation showed that the resident had been moved to a secure unit after multiple observations of wandering and exit-seeking behaviors. On a later date, a nurse's note documented that a patch of hair was missing or extremely short on the front of the resident's scalp, and the resident stated she had cut it herself with a razor. A search of her room revealed a disposable razor with a few small hair follicles inside a purse in her closet. In an interview, the Assistant DON stated that the resident should not have had a razor in her possession, indicating that staff had not prevented the resident from accessing the razor despite her cognitive impairment and need for supervision with personal hygiene.
Failure to Serve Meals Promptly
Penalty
Summary
The facility failed to ensure that meals were served in a manner that promoted and maintained each resident's dignity for two of 36 sampled residents. During the lunch meal on the Station 5 unit, Resident 82 was observed without a meal while other residents at the same table were eating. Resident 82 was looking around the room and reaching for other residents' trays and was not served her lunch tray until 10 minutes later. Similarly, on another day, Resident 175 was observed without a meal while other residents at the same table were eating. Resident 175 was seen throwing her hands in the air, making the sign of praying hands, and reaching towards other residents' trays. She was not served her lunch tray until 30 minutes later when staff members escorted her to her room. The Assistant Director of Nursing confirmed that meals in the dining room should be served one table at a time.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the residents' status for two of 36 sampled residents. Clinical record reviews revealed that Sections C (Brief Interview for Mental Status) and D (Mood Interview) of Resident 310's MDS assessment were incomplete. Similarly, Sections C and D of Resident 437's MDS assessment were also incomplete. In an interview, the MDS Coordinator confirmed that these sections were not completed during the assessment period to reflect the residents' current status.
Failure to Implement Physicians' Orders
Penalty
Summary
The facility failed to ensure that physicians' orders were implemented for three residents. Resident 402, diagnosed with congestive heart failure, diabetes mellitus, and dementia, had a physician's order to be weighed daily and notify the physician if the weight was outside the range of 150-160 lbs. The resident's weight exceeded this range on two occasions, but there was no documented evidence that the physician was notified. The Assistant Director of Nursing (ADON) confirmed this oversight during an interview. Resident 437, with chronic kidney disease and edema, had a physician's order to wear compression stockings while out of bed to prevent edema. The resident was observed multiple times without the compression stockings while out of bed. The Director of Nursing confirmed that the physician's order was not followed. Resident 450, with a history of stroke, high blood pressure, and dementia, had a physician's order to administer a blood pressure medication and notify the physician if the systolic blood pressure (SBP) was greater than 150 mm Hg. The medication was administered despite elevated SBP readings on several occasions, and there was no evidence that the physician was notified. The ADON confirmed this failure during an interview.
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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 Allentown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lehigh Valley Hospital Tsu | 0.6 mi | ★★★★★ | 1 | 0 |
| Luther Crest Nursing Facility | 1.4 mi | ★★★★★ | 5 | 0 |
| Cedar Crest Post Acute | 1.6 mi | ★★★★★ | 14 | 0 |
| Complete Care At Lehigh Llc | 2.5 mi | ★★★★★ | 6 | 0 |
| Phoebe Allentown Health Care Center | 2.7 mi | ★★★★★ | 1 | 1 |
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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.