Pennsylvania Department of Health
CEDAR HAVEN HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CEDAR HAVEN HEALTHCARE CENTER
Inspection Results For:

There are 160 surveys for this facility. Please select a date to view the survey results.

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CEDAR HAVEN HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey in response to three complaints completed on March 31, 2026, it was determined that Cedar Haven Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.\~

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:
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.

Plan of Correction - To be completed: 04/21/2026

Qualified Dietary Staff
1. Facility is unable to retroactively correct past deficiency.

2. A Full Time on-site Dietitian has been hired.

3. Administrator will be educated on Qualified Dietary Staff Requirement by 4/20/2026.

4. Administrator/Designee will audit Full-Time Dietitian hours weekly x4 weeks, then monthly x2 months to ensure full time hours are worked. Results will be forwarded to QA committee.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for three of 12 days reviewed.

Findings include:

Review of nursing schedules for 12 days from March 19 through 30, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 10 residents on day shift (7:00 a.m. to 3:00 p.m.) on March 22 and 29, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on March 20, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on March 29, 2026.

In an interview on March 31, 2026, at 2:45p.m., the Administrator confirmed that the facility did not meet the minimum nurse aide to resident ratios for the above-mentioned dates.

Plan of Correction - To be completed: 04/21/2026

1. Facility is unable to correct past deficiency.
2. The facility has an active recruitment/retention plan to fill open positions which includes contracts with Staffing Agencies. The facility is also currently hosting a Nurse Aide training course, with job offers being extended at the completion of the training.
3. Staff Scheduler and DON will be educated on what the ratio for NA to resident is, the importance of meeting C.N.A ratios, and that the facility is actively recruiting C.N.As and/or per diem staff.
Agency will be utilized for open shifts as needed and available.
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON, Admin. All efforts will be made to meet the staffing ratio. 
If call offs occur, C.N.A's that are working in ancillary departments will be moved to an assignment.
4.The DON or designee will conduct an audit of the C.N.A ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for one of 12 days reviewed.

Findings include:

Review of nursing schedules for 12 days from March 19 through 30, 2026, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on March 22, 2026.

In an interview on March 31, 2026, at 2:45 p.m., the Administrator confirmed that the facility did not meet the minimum Licensed Practical Nurse to resident ratios for the above-mentioned date.

Plan of Correction - To be completed: 04/21/2026

1. Facility is unable to correct past deficiency.
2. The facility has an active recruitment/retention plan to fill open positions which includes contracts with Staffing Agencies.
3. Staff Scheduler and DON will be educated on what the ratio for LPN to resident is, the importance of meeting LPN ratios, and that the facility is actively recruiting LPN and/or per diem staff.
Agency will be utilized for open shifts as needed and available.
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON, Admin. All efforts will be made to meet the staffing ratio. 
If call offs occur, LPN's that are working in ancillary departments will be moved to an assignment.
4.The DON or designee will conduct an audit of the C.N.A ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 04/21/2026

1. The facility is unable to retroactively provide a minimum PPD hours for cited dates.
2.A facility wide audit was completed to ensure PPD was met. A review of projected ppd for the week was completed and implement staffing plans accordingly.
The facility has actively been hiring licensed staff, with an increased focus on CNA new hires in the last month.
3.The DON and Scheduler will be re-educated on what the PPD is, and ensuring the PPD is met. A daily staffing meeting with scheduler, DON and NHA has been on-going to review census and staffing to ensure we are meeting required PPD for nursing.
4.The DON or designee will conduct an audit of the nursing PPD to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

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