Cedar Haven Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cedar Haven Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF761Feb 2, 2026

  Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store and label medications on six of 10 nursing units (1C, 1D, 3C, 3D, 3F, 4F) and in the central supply room, to ensure the correct and safe administration of medications for 34 of 43 sampled residents (Residents 9-42). This failure put residents at risk for medication administration errors and resulted in an Immediate Jeopardy situation.Findings include:Review of the facility policy titled, Specific Medication Administration Procedures, last reviewed October 1, 2025, revealed that all medications stored in carts, in medications rooms, or in central supply were to be locked at all times unless in use or under the direct observation of the medication nurse.Review of… […]

• Actual harm, isolatedF600Nov 21, 2024

  Based on facility policy review, clinical record review, review of documentation submitted by the facility, and staff interview, it was determined that the facility failed to ensure that residents were free from mental abuse, which resulted in psychosocial harm for two of 36 residents reviewed. (Residents 65, 227) Findings include: Review of the facility policy entitled, Abuse definitions, prevention and reporting, last reviewed October 2024, revealed that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. […]

• Actual harm, isolatedF689Jan 27, 2022

  Based on facility policy review, clinical record review, review of incident reports and staff interview, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls resulting in injury and failed to ensure that staff implemented assessed safety interventions in order to prevent falls resulting in injury and actual harm for two of three sampled residents who were at risk for falls. (Residents 17, 142) In addition, the facility failed to ensure that staff provided assessed supervision to prevent accidents for one of one sampled residents who required aspiration precautions. […]

• No harm, potential for more than minimal, widespreadF801Mar 31, 2026

  Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time registered dietitian. Findings include: In an interview conducted on March 31, 2026, at 2:45 p.m., the Administrator confirmed that there was not a full-time dietitian onsite at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

• No harm, potential for more than minimal, widespreadF812Dec 9, 2022

  Based on policy review, observation, and staff interview, it was determined that the facility failed to store food under sanitary conditions in the dietary department. Findings include: Review of the facility policy entitled, Dietary Services, last reviewed September 30, 2022, revealed that sanitary conditions were to be maintained in the storage and preparation of food. Observations during the initial tour of the kitchen on December 6, 2022, at 10:33 a.m., revealed various particles of food and liquid on the shelves in coolers one and four. In coolers three and four, there was various particles of debris on the floor. In cooler three there were four beef patties in a plain bag that was not labeled or dated. […]