LEBANON, PA — Pennsylvania Department of Health surveyors identified an immediate jeopardy situation at Cedar Haven Healthcare Center on February 2, 2026, following a complaint investigation that uncovered widespread medication storage and administration failures, according to a state inspection report published March 14.
The survey documented that the 430-bed facility failed to properly store and label medications on six of ten nursing units and in the central supply room, as reported by state health officials. Inspectors found the facility also failed to ensure correct and safe medication administration for 34 of 43 sampled residents, according to the Department of Health report.
"This failure put residents at risk for medication administration errors and resulted in an Immediate Jeopardy situation," state surveyors wrote in the inspection report. Under Pennsylvania regulations, immediate jeopardy designation indicates a resident faces imminent risk of serious injury, harm, impairment, or death due to regulatory noncompliance.
The facility's administrator received notification of the immediate jeopardy determination at 5:15 p.m. on February 2, according to the state report. Cedar Haven implemented corrective measures the same day, and surveyors validated removal of the immediate jeopardy status at 8:55 p.m. following observation of training completion and policy reviews, as reported in the inspection documentation.
State inspectors also documented staffing violations during their review. The survey found Cedar Haven failed to meet Pennsylvania's mandated nurse aide-to-resident ratios on six of 21 days examined, according to the Department of Health. State regulations require minimum ratios of one nurse aide per ten residents during day shifts, one per eleven residents during evening shifts, and one per fifteen residents overnight. The facility fell below these minimums on four day shifts, one evening shift, and three night shifts during the review period, according to inspection findings.
The inspection further revealed that Cedar Haven failed to provide the minimum 3.2 hours of direct nursing care per resident in each 24-hour period on four of ten days reviewed, as documented by state surveyors.
Pennsylvania Department of Health spokesperson Eli Steiker-Ginzberg explained that survey results become publicly available at least 41 days after inspections occur. "This timeframe allows the report to include not only the inspection findings, but also a Corrective Action Plan," Steiker-Ginzberg stated in response to media inquiries. "Skilled nursing facilities in Pennsylvania work collaboratively with the Pennsylvania Department of Health throughout this process and are often already implementing corrective measures by the time the survey is officially published."
CMS Inspection History
Cedar Haven Healthcare Center maintains a 2-star overall rating from the Centers for Medicare & Medicaid Services, placing it below average among U.S. nursing homes. The 324-licensed-bed facility operates as a for-profit partnership in South Lebanon Township at 590 South 5th Avenue.
Federal inspection records show Cedar Haven has accumulated 43 total deficiencies across 19 inspections documented in the CMS database. The facility's most recent federal inspection on December 22, 2025, cited deficiencies related to notification requirements, according to CMS records.
The facility holds a 2-star rating for health inspections and quality measures, with a 3-star staffing rating from CMS. Recent federal inspection findings include two citations in 2025 for failure to immediately notify residents, doctors, and family members of situations affecting residents, both assessed at severity level D. A December 2023 inspection documented deficiencies in providing activities of daily living assistance, treatment according to care plans, and accident hazard prevention, according to CMS records.
Ownership & Operations
Cedar Haven Acquisition LLC, the facility's operator, filed for Chapter 11 bankruptcy protection in January 2026, as reported by local media. Court filings indicate the company seeks approval for a $27 million sale that values the real estate at $27 million and allocates $100,000 toward business operations and other assets, according to bankruptcy documents.
The Pennsylvania Attorney General's office, representing the Department of Human Services, has filed objections to the proposed sale transaction, as reported in court proceedings.
Resources for Families
Families concerned about care quality at Pennsylvania nursing homes can contact the Pennsylvania Long-Term Care Ombudsman at 1-800-254-5164. The ombudsman program provides free advocacy services for nursing home residents and investigates complaints confidentially.
Residents and families can also report concerns directly to the Pennsylvania Department of Health's complaint hotline or contact the National Long-Term Care Ombudsman Resource Center at 1-800-677-1116. Additional information about resident rights and reporting procedures is available at ltcombudsman.org.
Pennsylvania law protects residents and family members from retaliation when filing complaints about nursing home care with state or federal authorities.
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