Health inspection·May 9, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, employee file review, and staff interview, it was determined that the facility failed to ensure employees completed required abuse training in a timely manner for two of eleven sampled newly hired employees. (Employees 11 and 26) Residents Affected - Few Findings include: Review of the facility policy entitled, Resident Abuse, Neglect, Misappropriation of Property, and other related offenses, last reviewed October 8, 2024, revealed that the facility was to educate staff upon hire and ongoing thereafter regarding the facility's policy to prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. Review of employee files revealed the following: Employee 11 (E11) had been working at the facility as an executive chef since November 14, 2024. There was no documented evidence that E11 had been educated per the facility policy on abuse prevention upon hire. In an interview on May 9, 2025, at 10:36 a.m., the Assistant Administrator confirmed that E11 had not been educated on abuse prevention per the facility policy. Employee 26 (E26) had been working at the facility as a contracted agency nurse aide. There was no documented evidence that E26 had been educated per the facility policy on abuse prevention upon hire. In an interview on May 9, 2025, at 10:38 a.m., the Director of Nursing confirmed that E26 had not been educated on abuse prevention per the facility policy. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.19(3)(7)(8) Personnel policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395465 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Senior Care and Rehabilitation 350 S. Cedarbrook Road Allentown, PA 18104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for three of 41 sampled residents. (Residents 228, 372, 481) Findings include: Clinical record review revealed that Resident 228 had diagnoses that included epilepsy, type 2 diabetes, muscle weakness, dementia, osteoporosis, Alzheimer's disease, and a history of falls prior to admission. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated January 9, 2025, indicated that the resident had a history of falls, was severely cognitively impaired, required assistance to transfer and ambulate, and had a bed alarm. Review of the care plan dated February 10, 2025, indicated that Resident 228 was at risk for falls, wandered, required a bed and a chair alarm, needed fall mats (cushions place on the floor to minimize injury), and needed periodic checks of the the bedding to avoid entanglement. On March 29, 2025, a nurse noted that Resident 228 was found on the floor with sheets tangled around her legs after a loud noise was heard from her room. According to the facility investigation into the fall, the bed alarm and fall mats were not in place at the time. In an interview on May 8, 2025, at 11:33 a.m., the Director of Nursing and Assistant Administrator confirmed the bed alarm and fall mats were not in place at the time of the incident. Clinical record review revealed that Resident 372 had diagnoses that included a history of a traumatic brain injury and a loss of motor function to the right side of the body. Review of the MDS assessment dated [DATE], revealed that the resident had impaired function to one side of her body. Review of the current care plan revealed that Resident 372 was to have a foam roll placed in her right palm and a bracelet on her right arm to indicate to staff that the right limb was not to be used to take blood pressures or draw blood from that side. On May 6, 2025, at 10:30 a.m. and 12:05 p.m., and on May 7, 2025, at 9:30 a.m., 12:44 p.m., and 1:42 p.m., the resident was observed without the foam roll or the bracelet. In an interview on May 8, 2025, at 9:32 a.m., the Director of Nursing stated that the foam roll should have been in Resident 372's hand and the limb alert bracelet should have been on her arm. Clinical record review revealed that Resident 481 had diagnoses that included difficulty walking and muscle weakness. Review of a facility incident report, dated March 7, 2025, revealed Resident 481 had a fall while refusing to use her walker. There was no evidence that interventions to address Resident 481's refusal to use her walker were included in the current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395465 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Senior Care and Rehabilitation 350 S. Cedarbrook Road Allentown, PA 18104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, facility policy review, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent falls for one resident (Resident 228), and failed to thoroughly investigate a fall to prevent reoccurrence for one resident (Resident 481) of nine sampled residents who had falls. Findings include. Clinical record review revealed that Resident 228 was admitted to the facility on [DATE], and had diagnoses that included muscle weakness, osteoporosis, Alzheimer's disease, and a history of falls prior to admission. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated January 9, 2025, indicated that the resident had a history of falls, was cognitively impaired, requiring assistance from staff for mobility, and used an alarm while in bed. Since July 10, 2024, the care plan indicated that the resident was at high risk for falls and that staff was to place an alarm on the resident's bed or chair to alert staff of unsafe movement, and that staff was to place mats on the floor beside the bed. According to nurses' notes, the resident had multiple falls, including falls on August 19, 2024, September 26, 2024, October 8, 2024, November 24, 2024, December 12, 2024, and February 21, 2025. After the fall on December 12, 2024, the care plan also indicated that the resident was at risk for tripping on her bedsheet, and that staff was to ensure she did not get tangled in her bedding. On March 29, 2025, a nurse noted that Resident 228 fell while in her room, and was found on the floor with her legs wrapped in her blankets. The facility investigation into the fall revealed that her bed alarm was not in place, and that there were no mats beside her bed in accordance with her care plan. In an interview on May 8, 2025, at 11:33 a.m., the Director of Nursing and Assistant Administrator confirmed the bed alarm and fall mats were not in place at the time of the incident. Clinical record review revealed that Resident 481 had diagnoses that included difficulty walking and muscle weakness. Review of Resident 481's care plan revealed she was at risk for falls and that staff was to assist with transfers and walk with using a rolling walker. Review of a facility incident report, dated March 7, 2025, revealed Resident 481 had a fall in the shower room. According to the witness statement, dated March 7, 2025, Employee 26 indicated that Resident 481's walker was not in use during the incident. There was no documented evidence that the facility further investigated the fall to identify why the walker was not in place, and to prevent future falls in a similar situation. In an interview on May 8, 2025, at 11:32 a.m., the Abuse Coordinator confirmed that the fall should have been further investigated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395465 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarbrook Senior Care and Rehabilitation 350 S. Cedarbrook Road Allentown, PA 18104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of 13 nursing units. (C-3) Residents Affected - Few Findings include: Review of Food Committee Minutes from February through April 2025, revealed that residents had stated that their food was served cold and was not palatable. In a group interview on May 7, 2025, at 10:30 a.m., Residents 51, 444, and 494 reported that it was an ongoing problem that hot food was frequently served cold and food was not palatable. Review of facility documentation entitled, Test Tray Meal Evaluation, revealed that the hot entree, vegetable, and starch should be greater than 135 degrees Fahrenheit (F) at point of service to the residents. Results of a test tray audit conducted on May 7, 2025, at 1:19 p.m., after the last resident meal tray was served from the dining cart, revealed the grilled chicken was served at a temperature of 121.1 degrees F, the mashed potatoes were served at a temperature of 117.5 degrees F, the zucchini was served at a temperature of 110.8 degrees F, and the gravy at a temperature of 121.1 degrees F. The foods were noted to be below 135 degrees F and were not palatable to taste. On May 7, 2025, from 12:15 p.m. through 12:35 p.m., Residents 35 and 46 were observed eating lunch in their rooms and they stated that the hot foods were served cold and that they were not palatable. In an interview on May 7, 2025, at 1:30 p.m, the Food Service Director confirmed the food did not meet the policy guidelines for hot foods to be served at 135 degrees F and should have been hotter. 28 Pa. Code 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395465 If continuation sheet Page 5 of 5