Every finding on record at Cedar Haven Healthcare Center

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.

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 the facility policy titled, Administering Medications, last reviewed October 1, 2025, revealed that nursing staff were to check the label of all medications three times to verify that the right medication, at the right dose, was being administered at the right time with the right method to the right resident. The expiration date on the medication label was to be checked prior to administration. Opened multi-dose containers were to have the date opened recorded on the container.Review of the facility policy titled, Specific Medication Administration Procedures, last reviewed October 1, 2025, revealed that prior to removing a medication from a container, the nurse administering the medication must check the label against the appropriate order, note applicable supplemental labeling, and follow any relevant directions. The container of any multi-use medications was to be checked for an expiration date before administration.Review of the facility policy titled, Medication Not Available Procedure, last reviewed October 1, 2025, revealed that the Registered Nurse (RN) supervisor was to be contacted if an ordered over-the-counter (OTC) medication was not available in a medication cart at the time of administration to obtain the medication from central supply. Nurse management was to be notified if a system-wide issue was identified. In an interview on February 2, 2026, at 9:57 a.m., the Central Supply Manager stated that OTC medications were stored in central supply and medication carts were stocked as needed by staff. She stated that if no one was working in the supply room to provide access, facility staff had access to the room with a code to the door lock. The Central Supply Manager was not aware of all staff who had access to that code. She reported that in addition to nursing staff, therapists, and nurse aides had collected materials from the central supply after hours. OTC medications in closed, factory-labeled bottles were observed on open shelves in the supply room on February 2, 2026, at 10:05 a.m. The room was accessed via keypad lock.In an interview on February 2, 2026, at 11:53 a.m., Licensed Practical Nurse (LPN) 1, reported that OTC medications had been stored in both medication carts on the 4F nursing unit in open plastic cups with incomplete, handwritten labels. She stated that OTC medications were to be properly stored in their factory-labeled bottles with the lids closed and the date written on the top when the bottles were opened. Observations on units 1C, 1D, 3C, 3D, 3F, and 4F on February 2, 2026, from 12:47 p.m. through 3:40 p.m., revealed that OTC medications were stored in open plastic cups with handwritten labels inside the medication carts. Observation of the medication carts on unit 1C revealed that medication cart 1 contained seven cups containing pills with handwritten labels that read: Amea Red (LPN 4 identified this as an eye supplement), Guaifenesin ER 600 mg, Melatonin 5 mg, Cetirizine 10 mg, Iron, B12 100, and Fiber Con. LPN 4 was unable to determine the doses, manufacture dates, expiration dates, or when the original containers of the medications had been opened. Observation of medication cart 2 revealed three cups containing pills with handwritten labels that read: ASA EC, Mucinex, and Ibuprofen 200 mg. There was also a cup labeled: Senna 8.6, which contained a mixture of red, pink, and brown pills. LPN 5 was unable to determine the doses, manufacture dates, expiration dates, or when the original containers of the medications had been opened. She was unable to identify all pills in the cup labeled Senna 8.6. Residents 11, 16, 17, 18, 19, 20, 22, 23, and 24 had medications stored in the medication carts and physician's orders that would correlate with the medications found in clear cups. Observation of the medication carts on unit 1D revealed that medication cart 3 contained seven cups with pills that had handwritten labels that read: Oyster Shell D3, Cranberry 450, Vit D 2000 iu, omep 2D, MVI, cetirizine, and vit D3 2000 iu. LPN 3 was unable to determine the doses, manufacture dates, expiration dates, or when the original containers of the medications had been opened. Residents 10, 25, 26, and 27 had medications stored in medication cart 3 and physician's orders that would correlate with the medications found in the cups. Observation of the medication carts on unit 3C revealed three cups containing pills with handwritten labels that read: Vitamin D3 50,000 iu, Docusate, and Vit C 500 mg, in medication cart 4. LPN 8 was unable to determine the doses, manufacture dates, expiration dates, or when the original containers of the medications had been opened. Residents 9, 28, 29, 30, 31 had medications stored in the medication cart and physician's orders that would correlate with the medications found in the cups. Observation of the medication carts on unit 3D revealed four cups containing pills with handwritten labels that read: Senna 8.6 mg, Vitamin D3 50,000, Multivitamin, and Fiber-lax, in medication cart 5. LPN 9 was unable to determine the manufacture dates, expiration dates, or when the original containers of the medications had been opened. Residents 12, 13, 14,and 15 had medications stored in the medication cart and physician's orders that would correlate with the medications found in the cups. Observation of the medication carts on unit 3F revealed two cups containing pills with handwritten labels that read: Vit D 2,000 iu, and Tylenol 500, in medication cart 6. The cart also contained a cup labeled: Iron 325, which contained white and black pills. LPN 6 was unable to determine the manufacture dates, expiration dates, or when the original containers of the medications had been opened. LPN 6 was unable to identify all pills in the cup labeled Iron 325. Observation of medication cart 7 revealed two cups containing pills with handwritten labels that read: Calcium 600+D 10 mcg, and Iron 325. LPN 7 was unable to determine the manufacture dates, expiration dates, or when the original containers of the medications had been opened. Residents 32 and 33 had medications stored in the medication carts and physician's orders that would correlate with the medications found in the cups. Observation of the medication carts on unit 4F revealed 14 cups containing pills with handwritten labels that read: Docusate Sodium, Ibuprofen, Oyster Calcium, Iron, Multi vitamins, Cranberry, Mag Ox, Aspirin, ASA 81, Docusate, Multivit, Therems, Fe sulp, and Oyster Cple, in medication cart 8. Observation of medication cart 9 revealed two cups containing pills with no labels along with ten cups containing pills with handwritten labels that read: Vit B12, Cranberry, Ibuprofen, Iron, Aspirin, Multivit, Oyster Cal, Thera-M, VitD, and Certizine. LPN 1 was unable to determine the doses, manufacture dates, expiration dates, or when the original containers of the medications had been opened. LPN 1 was unable to identify the pills contained in the two unlabeled cups. Residents 36, 37, 38, 39, 40, and 41 had medications stored in the medication carts and physician's orders that would correlate with the medications found in the cups. In an interview on February 2, 2026, at 3:43 p.m., the Director of Nursing (DON) confirmed that OTC medications were improperly stored and labeled in open, hand-labeled cups in medication carts. On February 2, 2026, at 5:15 p.m., the Administrator was informed that the failure to properly store and label medications constituted an Immediate Jeopardy situation at F761-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.The facility implemented the following corrective action plan: 1. All medications that were observed in medication cups/unlabeled cups or any medication that was unable to be identified was to be discarded and destroyed.2. Any medication that was discarded was to be immediately replaced with an unopened, labeled, OTC medication bottle.3. OTC medications would be stored in the original, labeled bottle in the medication carts and administered to residents following the policies relevant to medication administration.4. Procedures for ordering and stocking OTC medications would require that orders be submitted weekly with the Clinical Supply order. In the event that a medication was not sent, backordered, or runs out, needed OTC medications would be purchased from a local pharmacy.5. The Central Supply keylock code would be changed and given only to central supply staff and RN Supervisors.6. All licensed and central supply staff would be trained regarding storage of medications, proper distribution of OTC medications, and the medication not available procedure. Staff on shift at the time of the IJ were trained immediately. All others will be trained during their next shift.7. All medication carts would be audited on each shift for seven days, then once daily for seven days by the Administrator or a designee to ensure no loose or unlabeled medications are stored in any cart.The surveyor validated that the Immediate Jeopardy was removed on February 2, 2026, at 8:55 p.m., through observation, interviews, review of the facility training, and review of facility policies and procedures following the facility's implementation of the corrective action plan for the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.9(a)(1)(c) Pharmacy services.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident or responsible party of physician ordered changes for one of five sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure and end stage renal disease. Review of the clinical record revealed that on December 11, 2025, the physician ordered for staff to administer Bumex (a diuretic medication) two milligrams twice a day. On December 12, 2025, the physician ordered for staff to obtain a chest x-ray, and on December 15, 2025, the physician ordered for the resident to receive double-portion protein at meals. There was no documented evidence that Resident 1 or their responsible party was notified of the change in treatment related to physician orders for Bumex, a chest x-ray, and double-portion protein with meals.In an interview on December 22, 2025, at 2:42 p.m., the Director of Nursing confirmed there was no documented evidence that the resident or the resident's responsible party was notified of the changes.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to notify the resident and the resident's representative of the bed hold and transfer, including the reasons for the move, and Ombudsman information, in writing at the time of a facility-initiated transfer from the facility for one of three sampled residents who were transferred to the hospital. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documentation to support that the resident's representative was provided written information regarding a bed hold or the transfer to the hospital at the time of the facility-initiated transfer.28 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(2) Management

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to notify resident's physician and responsible party of change in condition for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included Parkinson's disease and dementia. On February 1, 2025, at 1:48 p.m., a nurse noted that Resident 1 was not acting herself, she had dropped a cup off her table in the morning, had trouble grasping the cup and did not respond to when asked how she was feeling. At 5:03 p.m., the nurse noted that Resident 1 continued to seem off for the shift. At 6:34 p.m., the nurse documented that Resident 1 was unable to eat supper, was unable to chew and needed encouragement to swallow. The nurse placed an order for a speech therapy screen. On February 2, 2025, at 6:17 a.m., the nurse documented that Resident 1 continued to have weakness and was still not talking. At 11:52 a.m., Resident 1's family alerted the nurse that the resident had a change in mental status and requested the resident be sent to the emergency room to be evaluated At 12:13 p.m., the nurse documented that Resident 1 was alert but unresponsive, unable to move her arms or legs, unable to perform hand grasps, and nonverbal. There was no evidence to support that the physician or responsible party were notified of the resident's change in condition until 12:13 p.m. on February 2, 2025. The physician instructed staff to send the resident to the hospital to be evaluated. The resident was transferred to the hospital at approximately 12:35 p.m. In an interview on February 11, 2025, at 2:25 p.m., the Director of Nursing confirmed that the resident's responsible party and physician should have been notified of the resident's change in condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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. This included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Review of documentation entitled, Use of Social Media, in the facility's, Employee Handbook, dated December 2023, revealed that use of personal cell phones and other personal devices for other than work-related purposed while on duty was expressly prohibited. Clinical record review revealed that Resident 65 was admitted to the facility on [DATE], and had diagnoses that included cognitive communication deficit and insomnia (difficulty sleeping). Review of the Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs) dated October 4, 2024, revealed that the resident had no cognitive impairment. Clinical record review revealed that Resident 227 was admitted to the facility on [DATE], and had diagnoses that included dementia, anxiety and depression. Review of the MDS assessment dated [DATE], revealed that the resident was cognitively impaired. Review of information submitted by the facility dated October 31, 2024, revealed that Witness 1 received a video text message from Employee 1, a nurse aide, where Employee 1 was visible exposing her breasts in a resident room with Residents 65 and 227 present and observing the incident. In a written statement dated October 31, 2024, the Nursing Home Administrator noted that the video showed Employee 1 in scrubs in a resident room with music playing. Employee 1 held the video at chest level and above, revealing her face, one breast, sticking her tongue out, and spinning around the room for a full 360-degree view, with two residents visible in the room. These residents were identified as Residents 65 and 227. In a telephone statement dated November 1, 2024, Employee 1 admitted to filming the video and that she knew it was wrong. Review of facility documentation reflected that Employee 1 had initially received training on abuse prevention and reporting on November 19, 2018. Review of the facility documentation entitled Personal device usage/social media acknowledgment, dated March 22, 2019, revealed that Employee 1 had received training that under no circumstances would employees be allowed to photograph, or video/audio record any resident without prior permission of the Executive Director and express written permission from the resident or the responsible party for the resident. In a written statement dated October 31, 2024, the Nursing Home Administrator noted that Resident 65 refused to talk about the incident. Review of the clinical record, revealed that Resident 65 was examined by the Certified Physician's Assistant following the incident. Resident 227 was examined by the Certified Physican's Assistant and psychology following the incident. Review of the information dated November 7, 2024, submitted by the facility reflected that the facility had substantiated the allegation of mental abuse of Residents 65 and 227 by Employee 1. Employee 1 was terminated by the facility. Based on these findings, the facility failed to ensure that Residents 65 and 227 were free from mental abuse and psychosocial harm. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for four of 36 sampled residents. (Residents 49, 62, 133, 242) Findings include: Clinical record review revealed that Resident 49 was admitted to the facility on [DATE], and had diagnoses that included diabetes, kidney disease, and heart failure. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated August 29, 2024, noted that the resident's psychotropic drug use and urinary incontinence was to be addressed in the care plan. Review of the medication administration records revealed the resident was receiving an antidepressant at the time of the MDS CAA summary. There was no evidence that interventions to address Resident's 49's psychotropic drug use and urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 62 was admitted to the facility on [DATE], and had diagnoses that included dementia and hypertension (high blood pressure). The MDS CAA summary dated June 4, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 62's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 133 was admitted to the facility on [DATE], and had diagnoses that included hypertension and anxiety. The MDS CAA summary dated October 22, 2024, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration records revealed the resident was receiving both an antipsychotic and antidepressant at the time of the MDS CAA summary. There was no evidence that interventions to address Resident's 133's psychotropic drug use was included in the current care plan. Clinical record review revealed that Resident 242 was admitted to the facility on [DATE], and had a diagnoses that included fracture of lower end of right femur (broken leg), pain, and dementia. The MDS CAA summary dated September 30, 2024, noted that the resident's pain was to be addressed in the the care plan. Review of the medication administration records revealed the resident was receiving pain medications the time of the MDS CAA summary. There was no evidence that interventions to address Resident's 242's pain were included in the current care plan. In an interview on November 21, 2024, at 9:45 a.m., the Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 36 sampled residents. (Resident 224) Findings include: Review of the policy entitled, Medication Administration, last reviewed October 2024, revealed that staff were to administer medications in accordance with the written orders of the physician. Vital signs were to be entered into the Medication Administration Record as indicated. Clinical record review revealed that Resident 224 had diagnoses that included hypertension (high blood pressure). On June 27, 2024, the physician ordered staff to administer a blood pressure medicine (lisinopril) once a day. Staff were not to administer the medication if the resident's systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm Hg). Review of Resident 224's October and November 2024 Medication Administration Records revealed that staff administered the medication 49 times with no documentation that the blood pressure was assessed prior to medication administration per physician's order. In an interview on November 21, 2024, at 9:30 a.m., the Director of Nursing confirmed there was no documented evidence that the blood pressure was taken prior to medication administration per physician's order for Resident 224. CFR 483.25 Quality of Care Previously cited 12/1/23 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of two of 36 sampled residents. (Residents 57 and 178) Findings include: Clinical record review revealed that Resident 57 had diagnoses that included end stage renal disease. Review of Resident 57's care plan revealed she required hemodialysis. On July 3, 2024, the physician ordered for the resident to receive dialysis on Mondays, Wednesdays, and Fridays. The MDS assessment, dated October 17, 2024, did not indicate that Resident 57 received dialysis. Clinical record review revealed that Resident 178 had diagnoses that included a urinary tract infection and bladder cancer. Review of Resident 178's care plan revealed he had a nephrostomy. On November 1, 2024, the physician ordered staff to provide nephrostomy care. The MDS assessment, dated November 6, 2024, did not indicate that Resident 178 had a nephrostomy. In an interview on November 20, 2024, at 9:40 a.m., the Registered Nurse Assessment Coordinator (RNAC1) confirmed that Residents 57's and 178's MDS assessments were inaccurate.

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of 36 sampled residents. (Resident 133) Findings include: Review of the facility policy entitled, Bowel and Bladder Management, last reviewed October 20, 2024, revealed that facility staff was to complete a urinary incontinence assessment upon admission and whenever there was a change in a resident's urinary tract function. Staff would review the pre-admission history, assess the resident's current bladder elimination problem, and identify causes of incontinence. If there was a change in incontinence staff would implement a toileting diary to determine a resident's voiding pattern for assistance in decision making and development of a toileting program. The type of urinary incontinence was to be identified in the care plan with specific interventions. Clinical record review revealed that Resident 133 was admitted to the facility with diagnoses that included hypertension (high blood pressure) and anxiety. A Bowel and Bladder Program Screener was completed on October 19, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set assessment, dated October 22, 2024, the resident needed assistance from staff for toileting, was always incontinent of urine, and was not on a toileting program. Review of the current care plan revealed that Resident 133's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented. In an interview on November 21, 2024, at 11:20 a.m., the Nursing Home Administrator confirmed that there was no documented evidence that a toileting program was implemented for Resident 133. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the trash compactor area on November 19, 2024, at 10:30 a.m., revealed various items on the ground next to the dumpster, including two used briefs, four used gloves, and a large opened plastic bag. 28 Pa Code 201.18(b)(3) Management.

Based on facility policy review, clinical record review, observation, and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for two of four sampled residents who required assistance with activities of daily living. (Residents 61, 78) Findings include: Review of the facility policy entitled, Nail Care, last reviewed August 14, 2023, revealed that nail care was to be provided so that residents could maintain a neat, clean appearance. Staff were to provide nail care during bathing and as needed. Clinical record review revealed that Resident 61 had diagnoses that included muscle weakness and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required extensive assistance from staff for personal hygiene. On November 28, 2023, at 12:44 p.m., Resident 61 was observed in bed and his fingernails were long and discolored. The resident stated that he preferred his nails to be short and had requested nail care within the past week, but it had not been provided. On November 29, 2023, at 11:50 a.m., the resident was again observed in bed and his nails remained long and discolored. Clinical record review revealed that Resident 78 had diagnoses that included motor and sensory neuropathy, muscle weakness, and cataract. Review of the MDS assessment dated [DATE], revealed that the resident required assistance from staff for activities of daily living. Review of the care plan revealed the potential for skin breakdown and interventions included that staff were to always keep the resident's fingernails short. On November 28, 2023, at 12:49 p.m., the resident was observed with elongated, discolored fingernails with sharp edges. There was debris under the right thumb nail. The resident stated that he preferred his nails to be short and that staff had not offered to provide nail care. On November 30, 2023, at 11:45 a.m., the resident's nails remained in the same condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that physicians' orders or care plan interventions were implemented for four of 39 sampled residents. (Residents 1, 61, 117, 188) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included anoxic brain damage, aphasia, and lack of coordination. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 1 was cognitively impaired and required total assistance from staff for dressing. Review of the current care plan revealed Resident 1 was at risk for skin breakdown with an intervention for staff to apply derma savers (padded arm sleeves) to arms. On November 28, 2023, from 11:19 a.m. through 12:30 p.m., and November 29, 2023, at 10:22 a.m., Resident 1 was observed without derma savers on her arms. Clinical record review revealed that Resident 61 had diagnoses that included dysphagia and dementia. Review of the MDS assessment dated [DATE], revealed that the resident required supervision from staff for eating. On August 23, 2023, the physician ordered staff to provide the resident with a puree diet with nectar thick liquids and the resident was to be under constant supervision and out of bed for all meals. On November 29, 2023, at 11:50 a.m., the resident was observed in bed. A cup of milk remained on the bedside table. The resident proceeded to drink the milk. There was no staff present providing supervision at this time. The resident stated that he was in bed for the entire meal. On November 30, 2023, the resident was again observed in bed eating his lunch from the tray on the overbed table. Clinical record review revealed that Resident 117 had diagnoses that included dementia and heart failure. Review of the MDS assessment dated [DATE], revealed that Resident 117 was cognitively impaired. On November 1, 2023, the physician ordered staff to apply geri sleeves (arm protectors) to bilateral (both) arms at all times except for bathing. On November 28, 2023, from 11:20 a.m. through 1:40 p.m., and November 29, 2023, from 11:14 a.m. through 12:19 p.m., Resident 117 was observed without geri sleeves on her arms. Clinical record review revealed that Resident 188 had diagnoses that included localized edema, Parkinson's disease, and hypertension (high blood pressure). Review of the MDS assessment dated [DATE], revealed the resident had no cognitive impairment and required extensive assistance from staff for dressing. On April 7, 2023, the physician ordered for staff to apply TED (anti-embolism compression) stockings in the morning and remove at bedtime. On November 28, 2023, from 11:40 a.m. through 1:30 p.m., and November 29, 2023, from 11:17 a.m. through 1:25 p.m., Resident 188 was observed without TED stockings. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide adequate supervision and interventions in a timely manner in order to address behaviors for one of seven sampled residents with a potential for behaviors. (Resident 188) Findings include: Clinical record review revealed that Resident 188 was admitted to the facility on [DATE], and had diagnoses that included Parkinson's disease, dementia, psychosis, and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment and required supervision for locomotion on the unit. Review of the nurses' notes revealed that on November 25, 2023, Resident 188 was observed making threatening statements to her roommate. On November 26, 2023, the resident was pinching staff and grabbing staff at various times. On November 27, 2023, Resident 188 was attempting to kick, punch, and push staff. On November 30, 2023, at 9:51 a.m., the resident was pinching, hitting, and kicking staff, and pulling down wall decorations and throwing them. On November 30, 2023, at 2:12 p.m., Resident 188 pushed her roommate's side table causing her items to fall, was attempting to pull down the curtain, and attempted to spray soda on the staff. At 2:19 p.m., Resident 188 threw a soda bottle at her roommate. At this time, the social worker documented that the resident would be on one to one observation. The facility failed to evaluate the need for increased supervision until after the multipe behavioral episodes documented above. In an interview on December 1, 2023, at 12:23 p.m., the Administrator confirmed that the new intervention to place the resident on one to one observation was not implemented in a timely manner. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of as needed pain medication for two of six sampled residents on pain management. (Residents 162, 198) Findings include: Review of the facility policy entitled, Pain Management, last reviewed August 14, 2023, revealed that the facility was to provide adequate pain control for the residents. Pain was to be managed through non-pharmacological and pharmacological interventions. Clinical record review revealed that Resident 168 had diagnoses that included dorsalgia (back pain) and osteoporosis. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented, had frequent pain on a pain scale of seven out of ten, and had been administered pain medication in the last seven days. A review of the care plan revealed that the resident had chronic pain related to dorsalgia. There was an intervention for staff to utilize non-invasive pain relieving methods as an alternate to pain medication. There was a current physician's order for staff to administer pain medication (tramadol) every six hours as needed for moderate and severe pain. Review of the Medication Administration Records (MAR)'s revealed that staff had administered the tramadol 83 times in September 2023, and 66 times in both October and November 2023. There was no documented evidence that staff had offered non-pharmacological interventions prior to the administration of the as needed pain medication. Clinical record review revealed that Resident 198 had diagnoses of spinal stenosis and dementia. The MDS assessment dated [DATE], indicated that the resident had some memory impairment, had severe, frequent pain, and had been administered pain medication in the last seven days. A review of the care plan revealed that the resident had an alteration in musculoskeletal status related to cervical stenosis (narrowing at the spinal canal of the neck). There was a current physician's order for staff to administer pain medication (tramadol) every two hours as needed for pain. Review of the October 2023, MAR revealed that staff had administered the tramadol 15 times. Review of the November 2023, MAR revealed that staff had administered the tramadol 28 times. There was no documented evidence that staff had offered non-pharmacological interventions prior to the administration of the as needed pain medication. In an interview on December 1, 2023, at 11:05 a.m., the Administrator stated that there was no documented evidence that non-pharmacological interventions were offered prior to the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services. .

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post Traumatic Stress Disorder for one of 39 sampled residents. (Resident 160) Findings include: Clinical record review revealed that Resident 160 had diagnoses that included Post Traumatic Stress Disorder (PTSD), multiple sclerosis, and major depressive disorder. There was a lack of documentation to support that the resident's PTSD diagnosis was assessed for symptoms and triggers or that interventions were developed and implemented to minimize re-traumatization. In an interview on December 1, 2023, at 9:20 a.m., the Administrator confirmed that there was no assessment completed or care plan developed to address Resident 160's PTSD diagnosis, symptoms, or triggers. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication storage room on one of nine nursing units. (Unit 4F) Findings include: Observation on December 1, 2023, at 11:10 a.m., revealed the medication room on the 4F nursing unit had controlled substances that were stored in an unlocked box inside an unlocked refrigerator and were not double locked. The unlocked medication box contained 40 vials of of Ativan, Benadryl, and Haldol (ABH) gel, which was composed of a controlled substance. In an interview on December 1, 2023 at 11:10 a.m., the Licensed Practical Nurse (LPN) 1 stated that the medication box should have been locked. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of resident council minutes, individual and group resident interviews, staff interviews, observations, and review of facility documentation, it was determined that the facility failed to ensure that residents were served preferred food items on their meal trays on three of nine nursing units, and included four of 39 sampled residents. (Nursing units 2C, 2D, and 3D, Residents 69, 90, 199 and 212) Findings include: Review of the resident council minutes dated September 11, 2023, revealed that the residents had expressed a concern that at meals there were often preferred food items missing from their trays. In a confidential group interview on November 28, 2023, at 10:30 a.m., the residents again stated that their meal trays did not include certain items such as, ketchup packets, sweeteners, creamers, cups, and butter. In addition, the residents also stated that often there was not enough coffee available at mealtimes. The residents stated that there were not enough coffee carafes provided when the carts were delivered to the units to fill or refill coffee mugs. On November 28, 2023, at 11:38 a.m., Resident 199 had received her lunch in her room. She was served a mug of hot water but had not been provided with a tea bag or sweetener packets on her tray. Review of her meal tray ticket revealed that she preferred to receive hot tea at lunch time. In an interview at this time, the resident stated that she preferred to have hot tea with sweetener at her meals. Clinical record review revealed that Resident 90 had diagnoses that included gout, major depressive disorder, and diabetes. Review of the Minimum Data Set assessment, dated October 4, 2023, revealed Resident 90 had no cognitive impairment. Observation of lunch on November 30, 2023, at 12:48 p.m., revealed that Resident 90 was served chicken, potato wedges, and peas. The meal ticket indicated that the resident was to be provided with chicken, potato wedges, and asparagus. At this time, the resident stated he did not want peas and would rather have had asparagus. In an interview on December 1, 2023, the Administrator stated that the dietary department ran out of asparagus during meal service and staff substituted the item with peas. There was no evidence that the staff or residents were notified of the substitution. Review of a list of coffee par levels for the breakfast and lunch meals dated November 2, 2023, and November 30, 2023, revealed that nursing unit 2C was to receive four carafes of coffee. Observation on the 2C nursing unit on November 29, 2023, at 1:08 p.m., Resident 212 had requested staff provide her with more coffee. Nurse Aide (NA) 1, stated that the carafes were empty, and there was no more coffee. Resident 212 stated that she desired more coffee and that the facility occasionally does not have enough coffee on the nursing units when additional is requested. During the same time, there was a total of three carafes of coffee observed on the meal trucks. In an interview at 1:10 p.m., NA 1 stated that the kitchen had been made aware that the unit required four carafes of coffee with lunch as residents requested additional cups of coffee. At this time, NA 2 stated that the kitchen did not routinely send at least four carafes of coffee with meals. Observation on the 2C nursing unit November 30, 2023, at 12:51 p.m., revealed that NA 1 called the main kitchen and requested additional coffee and a bowl of gravy for Resident 69. In an interview at 1:19 p.m., NA 1 stated that the additional coffee and side of gravy had not yet been delivered to the nursing unit. At 1:20 p.m. Resident 69 was observed in her room with her lunch tray that contained mashed potatoes. The resident stated that she had not yet received extra gravy, as requested, and was waiting for it to arrive to to eat the mashed potatoes. 28 Pa. Code 201.29(a) Resident rights.

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. There were multiple spots of dried food debris on the lids of the bulk flour and sugar containers. There was a container of white powder that was not labeled or dated, a scoop was stored inside of the container. In an interview at the time of the observation the Dietary Director stated the substance was thickener. In an interview conducted on December 6, 2022, at 11:15 a.m., the Dietary Director confirmed that the previously mentioned kitchen equipment items needed to be cleaned and the food items should have been labeled and dated. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.6(c) Dietary services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a licensed pharmacist conducted medication regimen reviews at least monthly for five of 36 sampled residents. (Residents 47, 76, 118, 145, 155) Findings include: Clinical record review revealed that between September and December 2022, the pharmacist reviewed Residents 47, 76, 118, 145, and 155's medication regimen only once. There was no documented evidence that Residents 47, 76, 118, 145, and 155's medication regimens were reviewed monthly. In an interview on December 9, 2022, at 1:20 p.m., RN1 confirmed that there was no documented evidence that a licensed pharmacist reviewed Residents 47, 76, 118, 145, and 155's monthly medication regimens in September and October 2022. 28 Pa. Code 201.18(e)(1)(3)(6) Management. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

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. (Resident 35) Findings include: Review of the facility policy entitled, Resident Falls Policy, last reviewed January 2021, revealed that the facility was to have a process of assessment, intervention and monitoring of falls in an effort to minimize fall risk. The team was to investigate and develop appropriate interventions for high-risk residents to prvevent falls. Clinical record review revealed that Resident 17 had diagnoses that included dementia with behavioral disturbance, anxiety, abnormal gait and mobility (difficulty walking), lack of coordination and a fractured right femur (the bone in the upper leg). Review of a fall risk evaluation, dated May 28, 2021, revealed that the resident had a history of falls, had memory impairment, and used short discontinuous steps and/or shuffling gait that put her at a high risk for falls. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment, required limited assistance for walking in her room, required supervision while walking in the corridor, and that her walking was not steady. Review of the care plan revealed the resident was at risk for falls due to poor safety awareness and a history of falls. The care plan included an intervention that staff provide one to one supervision as needed. Review of nurses' notes and incident reports revealed that Resident R17 experienced five falls between June 1, 2021, and August 18, 2021, all between the hours of 12:00 p.m., and 3:30 p.m. There was no documented evidence to support that the facility identified this pattern of falls and the facility failed to provide adequate supervision at these specific times in order to prevent further falls. On September 20, 2021, a nurse noted that at 3:15 p.m. the resident had an unwitnessed fall and was found in the hallway laying on her right side. A nurse noted that at this time, the staff heard a thud in the back hallway and found the resident on the floor beside a recliner chair laying on her right side. The resident was alert with confusion and had was complaining of discomfort to the right leg. According to the notes at that time, the resident stated she had pain when sitting up for dinner. A nurse noted on September 20, 2021 at 8:05 p.m., indicated that the resident continued to have pain throughout the evening. That evening at 8:33 p.m., an x-ray was done that showed a fractured hip. The resident was transferred to the hospital at 10:08 p.m. for further treatment of the serious injury (fractured hip) and was was admitted . Clinical record review revealed that Resident 142 had diagnoses that included Alzheimer's disease, dementia, the need for staff assistance with personal care, repeated falls, abnormal gait (walking), restlessness, and a left hip fracture. Review of a fall risk evaluation dated October 1, 2021, revealed that the resident had multiple falls in the last six months, had impaired memory, and was at a high risk for falls. The MDS assessment, dated October 11, 2021, indicated that the resident had memory impairment, exhibited physical and other types of behaviors, required extensive assistance from staff for bed mobility, transfers (moving from one surface to another) and dressing, and had a history of multiple falls. Review of the care plan identified the resident was at risk for falls because of her cognitive impairment and poor balance and included an intervention since May 23, 2019, for staff to apply gripper socks (socks with non-skid pads on the bottom to help prevent slipping) to help prevent falls. Review of a nursing note dated December 18, 2021, revealed that at 3:30 p.m., the resident was found lying on her left side in front of the sink in her room. The resident was rubbing her right hip and her left pelvis. When the staff attempted to move the resident onto her back she cried out ouch my hip. Staff notified the physician of the fall and the resident's complaints of hip and pelvic pain. The resident was sent to the hospital. On December 18, 2021, at 5:05 p.m., a nurse noted that the resident had been admitted to the hospital with a left hip fracture. Review of the incident report dated December 18, 2021, revealed that staff had found the resident lying on her left side in front of the sink in her room. At that time, the resident had on compression stockings (not gripper socks), and she had one shoe partly on one foot. The incident report indicated that the resident had on improper footwear (no gripper socks as care planned). The facility failed to ensure that the assessed safety intervention (gripper socks, proper foot wear), was in place as care planned in order to help prevent falls. This fall on December 18, 2021, resulted in a serious injury (fractured left hip), that required treatment at the hospital. In an interview on January 27, 2021, at 10:30 a.m., the Director of Nursing stated that the resident did not have the gripper socks on at the time of the fall and was to have on the assessed safety intervention (gripper socks) in order to prevent falls. Clinical record review revealed Resident 35 had diagnoses that included dysphagia (difficulty swallowing), gastroesophageal reflux disease, and [CONDITION(S)] disease. Review of the MDS assessment dated [DATE], revealed the resident required extensive assisstance with eating. On December 9, 2021, the physician ordered a dysphagia puree diet with honey thick liquids (mechanical altered to prevent choking) for the resident. Review of Resident 35's speech therapy discharge instructions, dated November 15, 2021, revealed that Resident 35 was to have constant assistance from staff during all meals. Review of the current care plan revealed Resident 35 had interventions for constant supervision or assistance with all meals. On January 25, 2022 between 12:08 p.m. and 12:37 p.m., Resident 35 was observed seated in her wheelchair in her room eating lunch with no staff present to provide supervision or assistance. On January 26, 2022 between 12:04 p.m. and 12:36 p.m., Resident 35 was again observed in her room in bed eating lunch meal with no staff present to provide supervision or assistance. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of select facility policy, review of documentation submitted by the facility and staff interview, it was determined that for one of four residents suspected of being abused, the facility failed to ensure that a resident was free from mental abuse (Resident 233). Findings include: Clinical record review revealed that Resident 233 had been admitted to the facility on (MONTH) 23, (YEAR), and had [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set assessment (MDS - a periodic review conducted to determine a resident's care needs) dated (MONTH) 21, (YEAR), indicated that the resident was severely cognitively impaired and was dependent on staff for activities of daily living (walking, bathing, toileting, eating, etc.) Review of documentation submitted by the facility on (MONTH) 28, (YEAR), indicated that on (MONTH) 27, (YEAR), at 6:00 PM Employee 1, Nurse Aide, had taunted Resident 233 until the resident was so agitated that the resident tried to hit Employee 1, and that Employee 1 then used her cell phone to make a video of the agitated resident. Review of facility investigation documentation of this incident revealed that two eyewitnesses (Employee 2 and Employee 3) reported that Employee 1 also told the resident that the resident's mother was dead. Employee 3 said Employee 1 commented how funny the resident's face was when she told the resident that her mother was dead. In an interview after the incident at 8:50 PM on (MONTH) 27, (YEAR), Employee 1 at first denied having made a video of the resident. However, when she was told about the two eyewitnesses, Employee 1 admitted that she had made a video of Resident 233. Two days later on (MONTH) 29, (YEAR), in a written statement, Employee 1 documented that she took a picture of the resident using her cell phone. Review of a facility policy entitled, Cell Phone Usage, dated (MONTH) (YEAR), revealed that staff were not permitted to use a cell phone while on duty. The policy indicated that taking resident photos or resident videos is a violation of a resident's privacy and is a HIPAA violation. In an interview on (MONTH) 18, (YEAR), at 10:30 AM the Director of Nursing reported that this policy had been in effect when Employee 1 had abused Resident 233 on (MONTH) 27, (YEAR). The facility documentation supported that Employee 1 had been trained on this policy on at least two occasions. For example, a document signed by Employee 1, dated (MONTH) 3, (YEAR), attested that Employee 1 was aware of and understood various facility policies, including that, .cell phone use is permitted on lunch and breaks only and that Employee 1, will comply with refraining from using while on duty. The facility inservice documentation (submitted by the Director of Nursing on (MONTH) 18, (YEAR), at 11:02 AM) dated (MONTH) 21, (YEAR), reflected that this inservice included that mental abuse included abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). Employee 1 signed that she attended this inservice on (MONTH) 21, (YEAR). Review of documentation submitted by the facility on (MONTH) 1, (YEAR), reflected that the facility had substantiated the allegation of mental abuse of Resident 233 by Employee 1. Based on these findings, the facility failed to ensure that Resident 233 was free from abuse. 28 Pa. Code 201.18(e)(1) Management Previously cited 5/22/17 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 5/22/17

Based on review of clinical records, select facility policy, facility documentation submitted to the state agency and staff interview, it was determined that the facility failed to prevent resident neglect that resulted in a fall and serious injury where the resident sustained [REDACTED]. Findings include: The clinical record review revealed that Resident 142 had been admitted to the facility on [DATE], after being hospitalized due to a fall and had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated March 6, 2017, reflected that the resident had a BIMS score (Brief Interview for Mental Status-screening tool for determination of an individual's cognitive status) of 9 (score of 8-12 indicates moderately impaired cognition) and needed staff assistance to walk, to transfer (getting out of bed, for example, or sitting down on a chair), and to toilet. The MDS assessment also indicated that the resident had fallen in the past three months. The care plan (a document that listed the resident's care needs and the measures that the staff were to implement to meet those needs) dated March 7, 2017, reflected that the resident had falls in the past and continued to be at risk for falls. The care plan reflected that the resident was on the facility's Fall Prevention Program. Review of facility policy dated April 2012, regarding this program revealed that one of the measures that the staff were to implement for every resident on the Fall Prevention Program was to provide, constant supervision during toileting. In an interview on May 11, 2017, Employee 5, the Assistant Director of Nursing, reported that a star was placed above the bed of each resident on the Fall Prevention Program so that the staff could easily identify which residents required this extra supervision. Review of documentation submitted by the facility on May 2, 2017, revealed that Employee 3, a Nurse Aide, had assisted Resident 142 to the bathroom and then left the resident unsupervised. While the resident was left alone in the bathroom, the resident fell and fractured the right humerus (the long bone in the upper arm). Documentation also reflected that the resident suffered a laceration of her left forehead, and that the laceration required sutures (stitches) to close the wound. In a written statement dated May 2, 2017, Employee 3 admitted that she left the resident alone in the bathroom while she went to get an incontinence brief for the resident. Documentation by Employee 5 dated May 11, 2017, reflected that in an interview on May 3, 2017, Employee 3 said that she had not looked above the resident's bed before assisting the resident to the bathroom, and so had not seen the star that indicated the resident was on the Fall Prevention Program. Review of the facility's investigation of this incident revealed a document entitled, Cedar Haven Healthcare Center Resident Care Acknowledgement. This one page document included the statement, I agree that I will not leave a Resident who is on the Fall prevention or Falling star program unsupervised during toileting. The document was dated April 21, 2017, and had been signed by Employee 3. Review of the facility investigation documentation revealed that as a result of the fracture, the resident required more assistance with bathing, eating, and with transfers. Documentation also reflected that the resident had pain related to the fracture and required narcotic medication ([MEDICATION NAME]) to manage her pain. Review of the May 2017 Medication Administration Record [REDACTED]. Documentation presented by the Director of Nursing dated May 4, 2017, reflected that the facility had determined during their investigation into the above incident that the allegation of neglect by Employee 3 had been substantiated. The facility failed to supervise a resident, who had been placed on the Fall Prevention Program, resulting in a fall which caused harm to the resident who sustained a fracture causing pain and decreasing the resident's functional abilities. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services