Health inspection·December 1, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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) Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395770 If continuation sheet Page 2 of 8 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 12/01/2023 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)

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 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395770 If continuation sheet Page 3 of 8 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 12/01/2023 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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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) Residents Affected - Few 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. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395770 If continuation sheet Page 4 of 8 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 12/01/2023 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)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm 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) Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395770 If continuation sheet Page 5 of 8 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 12/01/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395770 If continuation sheet Page 6 of 8 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 12/01/2023 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395770 If continuation sheet Page 7 of 8 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 12/01/2023 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395770 If continuation sheet Page 8 of 8