Health inspection·December 9, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to report an allegation of abuse to the local Area Agency of Aging and the State Survey Agency for of one of 36 sampled residents. (Resident 50) Findings include: Review of the facility policy entitled, Abuse Definitions, Prevention, and Reporting, last reviewed September 30, 2022, revealed that the Administrator or their designee would report all allegations of abuse immediately to the Department of Health Field Office and to the Area Agency on Aging. Clinical record review revealed that on August 26, 2022, Resident 50 stated that Resident 99 hit her and was found covering her left eye. The area above her left eye was noted to be reddened and Resident 50 stated that it hurt. On August 31, 2022, staff heard Resident 50 screaming and found Resident 99 in her bathroom. Resident 50 stated that Resident 99 hit her four times in the head. According to the nurse's note Resident 50's pain level seemed to be 10 out of 10 based on a 1-10 scale. In an interview on December 9, 2022, at 1:15 p.m., RN 1 said there was no documentation to support that the State Department of Aging and the State Survey Agency were notified of the allegation of abuse. 28 Pa. Code 201.18(e)(1) Management. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 395770 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 395770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Haven Healthcare Center 590 South Fifth Avenue Lebanon, PA 17042 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)