Cycle 1
Health 2024-11-21 · Fire 2024-11-21
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lebanon, PA
Cedar Haven Healthcare Center
2-star overall rating with 2-star inspections with abuse icon flag with $78,888 in total fines with 8 recent health deficiencies
590 South Fifth Avenue, Lebanon, PA
(717) 274-0421
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
324
Certified beds
Average residents
263
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.27
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,385
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9977
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.84
Baseline 22.41% · Performance 19.00% · Measure score 5.84 · Achievement 5.25 · Improvement 5.84
Healthcare-associated infections
4.61
Baseline 9.00% · Performance 6.96% · Measure score 4.61 · Achievement 2.94 · Improvement 4.61
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.93
Baseline 3.56 hours · Performance 3.91 hours · Measure score 2.93 · Achievement 2.93 · Improvement 1.10
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.89% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 11.88% · Lower 95% interval 8.56% |
| Discharge to community | 47.01% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 39.51% · Lower 95% interval 35.19% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 80% |
95.27%
15.3 pts worse
|
Numerator 56 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 50.98% |
53.69%
2.7 pts worse
|
Numerator 26 · Denominator 51 |
| Discharge mobility score | 47.06% |
50.94%
3.9 pts worse
|
Numerator 24 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 70 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 7.25% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 0.87% |
8.2%
7.3 pts worse
|
Numerator 3 · Denominator 346 |
| Staff flu vaccination coverage | 25.91% |
42%
16.1 pts worse
|
Numerator 114 · Denominator 440 |
| Discharge function score | 43.14% |
56.45%
13.3 pts worse
|
Numerator 22 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 6 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.2% |
86.9%
0.7 pts worse
|
93.4%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 90.9% · Q3 81.1% · Q4 79.0% · 4Q avg 86.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
93.5%
3.8 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
3.2%
3.5 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.1% · Q3 7.6% · Q4 4.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
6.5%
4.2 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.2% · Q3 0.9% · Q4 2.2% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 11.1% · Q3 7.5% · Q4 6.8% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.9% |
19.9%
1 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 21.9% · Q3 20.7% · Q4 20.7% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.8% |
18.7%
7.1 pts worse
|
16.7%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 25.9% · Q3 24.6% · Q4 23.4% · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.1% |
0.2%
0.1 pts better
|
0.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.5% |
19.6%
6.9 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 28.7% · Q3 26.0% · Q4 19.5% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
18.3%
4.3 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 26.1% · Q3 22.7% · Q4 20.8% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.8% · Q3 1.9% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.8% · Q3 3.0% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
26.4%
3.3 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 33.0% · Q3 27.7% · Q4 30.5% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.3%
2.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.5% · Q3 2.4% · Q4 1.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.0% |
68.9%
13.9 pts worse
|
81.7%
26.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.0% · Q2 60.2% · Q3 51.4% · Q4 46.7% · 4Q avg 55.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
9.8%
0.5 pts worse
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 10.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.5%
2.8 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.6% · Q3 4.2% · Q4 1.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.4% |
68.7%
27.3 pts worse
|
79.7%
38.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
23.1%
2.7 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 26.1% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-02-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-28
G · Actual harm
2024-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-20
C · Minimal harm
2024-11-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-12-20
D · Potential for more than minimal harm
2023-12-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-09
F · Potential for more than minimal harm
2022-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-10
C · Minimal harm
2022-12-09
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-01-10
Penalties and ownership
What sits behind the stars
$78,888
2024-11-21
Fine
Fine · fine $78,888
Fine
Ownership
Blalack, Charles
5% Or Greater Direct Ownership Interest · Individual
Lehman, Gary
Operational/Managerial Control · Individual
Pearlstein, Robert
Operational/Managerial Control · Individual
Stauffer, George
Corporate Director · Individual
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#3
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