Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cranberry Place during CMS and state inspections, most recent first.
A resident with quadriplegia and intact cognition, care planned and documented as requiring a two-person assist for bed mobility, was being checked by a NA who knew another aide was supposed to assist. The NA rolled the resident toward herself, noted a bowel movement, and turned away to look for supplies while waiting for help, despite the two-person assist requirement. During this time, the resident slid off the bed to the floor. She was initially assessed with only redness to the upper back but complained of increased left leg pain, and was later transferred to the hospital, where she was found to have a left femoral neck fracture. Facility investigation determined the NA failed to follow the care plan and Kardex instructions for two-person bed mobility, and the NHA and DON substantiated neglect during care.
A resident with quadriplegia, intact cognition, and documented dependence for mobility was care planned and Kardexed for bed mobility with assist x2. Despite this, a NA began providing bed-level care alone, rolled the resident toward herself, and briefly turned away to locate supplies while waiting for additional help. During this interval, the resident slid from the bed to the floor. The resident was subsequently found on the floor, later complained of left leg pain, and was transferred to the hospital where a left femoral neck fracture was identified. Facility investigation determined that the NA failed to follow the care plan and Kardex requirement for two-person assistance with bed mobility, directly contributing to the accident and resulting harm.
A resident with diabetes, a prior femur fracture, and ESRD experienced a fall and right distal radius fracture when a NA used a one-person stand-and-pivot transfer while preparing the resident for dialysis, despite the most recent Kardex indicating a sit-to-stand transfer with assistance of two. Therapy had changed the resident’s transfer status, but this update was not incorporated into the Kardex or care plan. The ADON reported that therapy provides paper change-of-status notices to nursing, and the NHA confirmed the facility failed to address or implement the therapy instructions as required.
Surveyors found that the facility did not ensure required information was communicated to a receiving health care provider when a resident with HF, Parkinson's disease, and HTN was transferred to the hospital. Review of the clinical record showed no documentation that care plan goals, advance directives, specific instructions for ongoing care, resident representative information, or other necessary details to meet the resident’s needs were sent with the transfer, and the DON confirmed this failure during interview.
Food storage, sanitation, and temperature monitoring failures were observed in the kitchen and on nursing unit kitchenettes. Food items in the Main Kitchen and on a unit kitchenette were missing required labels or dates, the ice machine had a black substance on the lid, the 3-compartment sink log was left blank for all meals, two dining staff had hair not fully covered by hair nets, and refrigerator temp logs were missing on the North, East, and West unit kitchenettes.
Expired supplies were found on the West, North, and East Unit crash carts, and the facility’s crash cart logs did not show that the West Unit cart was checked on several listed dates. Observations identified expired IV tubing and short-term kits, blood collection needle and tubing sets, povidone-iodine swab sticks, a StayFIX device, suction tubing, and an adult nonrebreather mask and tubing kit. An LPN and an RN confirmed the findings, and the DON was informed that the crash carts were not in safe operating condition.
The facility failed to ensure call bells were consistently accessible to residents. During a Resident Council meeting, all residents present reported that staff did not leave call bells within reach, and in a separate group meeting, two residents stated that call bells were often placed where they could not reach them. One resident with HTN, GERD, and multiple sclerosis, care planned to have the call light within reach, was observed in bed with the call bell clipped to a pillow in a position that could not be activated using head movement, the only method available due to inability to move the arms. After a NA repositioned the pillow, the resident could activate the call light, and the NA confirmed it had been inaccessible in its prior position. The NHA confirmed the facility’s failure to accommodate these call bell needs.
The facility failed to maintain sufficient nursing staff, resulting in repeated missed showers, delayed call-light responses, and cold meals. Residents and their representatives reported long waits for assistance, including extended delays for toileting and help with meals, and noted that staffing levels varied by day and shift. Staff, including NAs, an RN, and an LPN, confirmed that when staffing was low, showers were not completed, trays were slow to be passed, and call lights had to wait. Several residents with conditions such as HTN, GERD, multiple sclerosis, atrial fibrillation, aphasia, depression, and renal failure missed scheduled showers or experienced prolonged call-light activation while needing pain medication or assistance with a Foley catheter. Facility staffing data also showed excessively low weekend staffing, and the DON acknowledged that the facility did not have enough nursing staff to meet residents’ needs during the identified periods.
The facility failed to develop comprehensive care plans for three residents with specific care needs. One resident had a trach and required frequent respiratory assessments, but no trach care plan was in place. Two other residents had COVID isolation/contact and droplet precaution orders, yet their care plans did not include management and monitoring of isolation precautions; the IP and DON confirmed the omissions.
Nursing Not Present at Care Conferences: The facility failed to include nursing in care conferences for multiple residents. Records showed residents with diagnoses including HF, CAD, AFib, HTN, COPD, anxiety, cellulitis, progressive MS, bacteremia, and UTI, while sign-in sheets and progress notes documented that nursing was unavailable or not in attendance during the meetings. The DON confirmed nursing was not present as required.
Foley catheter care and dignity measures were not provided for multiple residents with indwelling catheters. One resident’s catheter bag was observed hanging without a dignity cover and had no current MD orders or care plan for catheter care, while another resident with neurogenic bladder had a leaking Foley with a wet brief and empty drainage bag that required manipulation and flushing. A third resident with urinary retention reported the catheter needed adjustment and also lacked a dignity bag; the DON confirmed the facility failed to ensure appropriate catheter treatments and services were provided.
Failure to Document Trauma Triggers in Care Plans: The facility failed to provide trauma-informed care for three residents with a trauma history by not documenting specific triggers or how to avoid them in their care plans. Two residents were gunshot victims with do not knock signs posted outside their doors, and staff confirmed loud noises were triggers, but this was not reflected in the care plans. A third resident’s care plan also omitted a known restriction that she was not to have male caregivers, despite staff awareness of that need.
Improper Storage of Open and Undated Medications: The facility failed to store medications and biologicals in a safe, secure, and orderly manner on three medication carts. An LPN and RN confirmed that multiple items, including lantus pens, insulin lispro, cyclosporine eye drops, albuterol sulfate nebulizer solution, budesonide solution, and ipratropium bromide, were open and missing required open or expiration dates.
Surveyors found that the facility did not ensure necessary pressure ulcer prevention and treatment services for two residents. One resident with quadriplegia was observed using Prafo and bunny boots on a routine schedule described by the resident, but there were no corresponding physician orders or documented schedule for these devices. Another resident with multiple comorbidities had a physician’s order for twice-daily cleansing of the coccyx and peri/groin area with soap and water and application of zinc-based barrier cream, but the Treatment Administration Record showed the treatment was missed on an evening shift. The DON confirmed that ordered pressure ulcer prevention measures were not consistently provided or monitored for these residents.
Failure to ensure a resident was free from misappropriation of property occurred when a wallet and passport could not be located. The resident was cognitively intact and had diagnoses including PVD, HTN, and a seizure disorder. Two nurses recalled the grey bag being kept in the narcotic drawer for safe keeping, but searches of the med cart, nurses' station, med room, and resident room did not find it. The resident's son reported the wallet contained a bank card, SS card, and military ID, and the DON confirmed the facility could not locate the property.
Missing Physician Orders for Wander Guard and Colostomy: The facility failed to obtain physician orders for a wander guard for one resident and for colostomy management for another resident. One resident had COPD, A-fib, and anxiety, and a nurse note documented a wander guard placed on the right ankle without a corresponding order. The other resident had PVD, sepsis, and anemia, and the care plan included colostomy management, but the physician orders contained no colostomy order. The DON confirmed the missing orders.
Failure to properly manage respiratory equipment and CPAP care for two residents. One resident with respiratory failure, Parkinson's disease, and aphasia had an AVAPS mask left hanging on an IV pole instead of stored in a bag, and another resident with heart failure and OSA had a nebulizer left on the bedside table, a CPAP order missing device settings, and a care plan without CPAP interventions. Staff confirmed the equipment was not stored as required and the CPAP documentation was incomplete.
Delayed Social Services and Placement Referrals: A resident with HF and CAD remained frustrated about being unable to find a facility closer to home or transfer to a setting with more liberty, with psych notes documenting unchanged mood and feelings of being stuck. Facility records showed the last housing and placement referrals were months earlier, and the Social Service Director confirmed no further referrals to other nursing facilities had been sent out, despite policy requiring social services to coordinate and document outside referrals.
A facility failed to include carvedilol parameters on a resident’s MAR for a heart medication. The resident had HF and CAD, and the MAR showed carvedilol 6.25 mg BID for HTN, but the required BP/HR parameters were absent for an extended period before appearing later on the MAR. The DON confirmed the facility did not follow manufacturer guidelines in identifying the medication parameters.
Failure to schedule needed dental care for a resident with PVD, sepsis, and anemia. The contracted dental provider noted the resident may need surgical extractions and an OMFS consult, and staff documented calls to multiple oral surgeons to arrange teeth removal. However, no appt had been set up, and the UM stated it could take up to two years because the resident required stretcher transport; the NHA confirmed the dental services were not obtained.
The facility failed to notify the State agency when its Medical Director changed. Facility records showed one physician served as Medical Director, and the NHA later confirmed that a different physician had taken over as Medical Director months earlier without the required notification to the State agency.
The facility failed to conduct a QAA meeting with all required committee members for one of four quarters. Review of QAPI policy and attendance records showed the NHA was not present at the QAA meeting, and the NHA later confirmed the omission during interview.
Failure to Offer Flu and Pneumonia Vaccinations: The facility failed to ensure that influenza and pneumococcal vaccines were offered to two residents. One resident had HTN, renal insufficiency, and DM, and another had anemia, paraplegia, and anxiety. Review of the clinical records found no documented evidence that either vaccine was offered or administered, and the IP confirmed the omission.
A NA did not have annual in-service training on Effective Communication in the personnel file, despite facility policy requiring all staff to complete initial orientation and annual in-service topics including effective communication with residents and family. The DON confirmed the training was not provided.
The facility failed to provide annual Resident Rights training for one NA. The facility policy required all staff to complete initial orientation and annual in-service training on topics including resident rights, and the NA’s personnel file did not show Resident Rights training for the annual period reviewed. The DON confirmed the missing training during interview.
Failure to Provide Required QAPI Training: Facility records showed that one NA did not receive the required annual in-service training on the QAPI program. The facility’s policy required all staff to complete orientation and annual in-service topics, including QAPI, but the employee file lacked documentation of this training. The DON confirmed the missing QAPI training during interview.
A facility failed to provide annual Infection Control training for one of five staff members, a NA. Facility policy required all staff to complete annual in-service training, including the infection prevention and control program, but the NA’s personnel file did not show the required training for the year reviewed. The DON confirmed the training was not provided.
Failure to provide required Compliance and Ethics training for one NA. Facility policy required all staff to complete annual in-service training, including the compliance and ethics program, but one NA’s personnel file did not show this training for the annual period reviewed. The DON confirmed the missing training during interview.
Failure to Provide Required Annual Nurse Aide In-Service Training: The facility did not ensure that one of four sampled NAs received the required 12 hours of annual in-service education. Training records did not show that the NA completed the yearly requirement, and the DON confirmed the missing in-service hours during interview.
Incomplete contact information for the State Long-Term Care Ombudsman program, SSA, and APS was posted in the front hallway. The Ombudsman posting lacked a mailing address, and the SSA and APS postings lacked mailing addresses and email addresses. An RDCS confirmed the missing information.
For three consecutive months, residents unanimously reported during council meetings that staff failed to leave call bells within reach on all units and shifts. A resident also reported being left unattended in a wheelchair without access to a call bell, and the DON confirmed the facility did not effectively address these concerns.
A resident with multiple medical conditions reported being fondled by his roommate and expressed fear, stating that previous concerns had not been addressed. The facility's investigation was incomplete, lacking a written statement from the first responding nurse aide and documentation of the LPN's prior knowledge, despite policy requiring thorough investigation and documentation. The DON confirmed the investigation was not thorough.
A significant medication error occurred when a nurse administered insulin intended for one resident to another, after the recipient answered to the wrong name and the nurse failed to properly verify identity according to policy. The error was discovered after administration, and the affected resident required blood sugar monitoring and IV dextrose.
Surveyors found that several residents did not have proper physician orders, individualized care plans, or complete assessments for the use of wander guards, including missing interventions to check device batteries. Additionally, a resident with multiple chronic conditions received only half the prescribed dose of a medication due to a transcription error during admission. These deficiencies were confirmed by the DON and administrator through record review and interviews.
A resident with moderate cognitive impairment and multiple medical conditions was able to leave the facility unsupervised and was found outside with her belongings packed. The care plan did not include specific interventions or required checks for a wander guard, and the resident was not adequately supervised to prevent elopement, as confirmed by facility leadership.
A resident with significant communication and mobility impairments was physically abused by a nurse aide, who hit the resident multiple times during care. The incident was witnessed by a nurse, who intervened and reported the event. Facility leadership confirmed the abuse was substantiated, indicating a failure to ensure residents are free from abuse as required by policy and regulation.
A nurse aide was hired without prior verification of their professional license, as the required license check was completed after the employment start date. This lapse was confirmed by the HR director during a review of new hire files.
Surveyors observed that open lunch meats, cheeses, pasta, and graham cracker crumbs in the main kitchen were not labeled with open dates, contrary to facility policy requiring all food to be properly wrapped, labeled, and dated. This failure to follow food storage procedures was communicated to the NHA during the exit interview.
A resident with multiple chronic conditions and a cancerous lesion did not receive required weekly comprehensive wound assessments over several weeks, as mandated by facility policy. Staff confirmed the assessments were not completed or documented, despite ongoing physician orders for wound monitoring and care.
Facility staff did not consistently provide medications and wound care treatments as ordered by physicians for two residents, including missed doses of an antidepressant and multiple missed wound care treatments, despite facility policies requiring timely and accurate administration and documentation. These deficiencies were confirmed by the Wound Care Nurse and DON.
A resident with multiple diagnoses, including hypertension and cancer, did not receive two scheduled doses of a prescribed blood thinner because the medication was pending delivery. Facility policy required timely reordering to prevent such lapses, but this was not followed, resulting in a significant medication error as confirmed by the DON.
Two residents experienced actual harm due to failures in staff conduct and adherence to care plans. One resident was left alone in a van by a facility driver in an unfamiliar neighborhood, causing significant fear and mental anguish. Another resident, who required two-person mechanical lift transfers, was moved by a single aide without checking the care plan, resulting in a tibial plateau fracture. Staff interviews and documentation confirmed that established protocols and resident care policies were not followed.
Two residents suffered significant injuries due to inadequate supervision and improper assistance during bed mobility and transfers. One resident with cognitive and physical impairments fell from bed and sustained a head laceration requiring staples when rolled away from the caregiver during care. Another resident, who required two-person assist with a mechanical lift, was transferred by a single aide without the lift, resulting in a tibial plateau fracture. Documentation inconsistencies and failure to follow established procedures contributed to these incidents.
Care plans were not updated for three residents after significant events, including a traumatic transport experience, a head injury, and a fracture with new pain and mobility needs. The care plans did not reflect changes in psychosocial well-being, pain management, or monitoring needs following these incidents.
A resident with Parkinson's disease was prescribed Carbidopa-Levodopa to be taken as two tablets three times a day, but the facility administered only one tablet three times a day for 17 days. Staff interviews confirmed the error, which was not corrected upon admission despite discharge orders indicating the correct dosage.
The facility failed to submit plans and obtain occupancy approval from the Life Safety Division for the replacement of the fire alarm system, including all devices and the remote annunciator panel. This deficiency was confirmed by the maintenance supervisor during an observation and interview.
The facility failed to maintain its kitchen hood suppression system, lacking documentation of monthly visual inspections. Kitchen staff were uncertain about the location and operation of the manual activation for the hood fire suppression system. These issues were confirmed by the maintenance supervisor.
The facility failed to maintain its fire alarm system components, affecting the entire facility. Documentation for essential inspections and tests, such as annual and semi-annual inspections, smoke detector sensitivity, and battery checks, was missing. The maintenance manager confirmed the lack of documentation and noted the recent replacement of the fire alarm system.
The facility failed to maintain its sprinkler system as required, with missing documentation for a three-year full flow trip test and six sprinkler heads in the laundry room covered in dust and corrosion. These issues were confirmed by the maintenance supervisor.
The facility failed to provide necessary documentation for its generator, including the monthly battery-specific gravity or conductance test and the three-year, four-hour load test. An interview with the maintenance supervisor confirmed the absence of these records, indicating a lapse in maintenance and testing protocols.
Neglect During Bed Mobility Leading to Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during bed mobility care, resulting in a left femoral neck fracture. The resident had diagnoses including quadriplegia, gastroesophageal reflux disease, and hyperlipidemia, and was assessed as cognitively intact with a BIMS score of 15. The resident’s MDS and care plan documented that she was dependent for mobility and required assistance of two staff for bed mobility. The Kardex and care plan both specified a two-person assist for bed mobility due to her functional limitations. On the day of the incident, a nurse aide entered the resident’s room to check on her and was aware that another aide would be coming shortly to assist. Despite the documented requirement for two-person assistance, the aide rolled the resident toward herself and noted a bowel movement, then turned away to look for a towel or other item to begin care while waiting for help. During this time, the resident slid off the side of the bed and onto the floor. The aide reported that the resident slid off in such a way that there was no way to catch her, and immediately scanned the resident for obvious wounds or bleeding before finding a nurse to perform an assessment. Nursing documentation indicated that the resident was found sitting on the floor, leaning against the nightstand with her legs straight out and her head supported on a pillow against the mattress. Initial assessment noted no visible injuries other than redness to the left upper back, and the resident was assisted back to bed with a Hoyer lift and three staff. The resident complained of increased pain to the left leg, and the physician was notified with orders for x‑rays. Later, the resident was transferred to the hospital for altered mental status, decreasing blood pressure, and increased heart rate, and the hospital reported that she had sustained a left femoral neck fracture. The facility’s investigation concluded that the assigned nurse aide did not follow the Kardex and care plan instructions for required two-person bed mobility assistance, and the allegation of neglect was substantiated by the NHA and DON.
Failure to Follow Two-Person Assist Requirements During Bed Mobility Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement effective bed mobility interventions for a resident, resulting in a preventable accident and actual harm. Facility policy on resident mobility required that residents with limited mobility receive appropriate care, services, equipment, and assistance, and that staff identify and follow the resident’s current mobility status, including bed mobility and transfer needs. The resident’s MDS assessment documented quadriplegia, GERD, and hyperlipidemia, with a BIMS score of 15 indicating intact cognition. The MDS Section GG and the Kardex both identified the resident as dependent for mobility and requiring assistance of two staff for bed mobility. The resident’s care plan, initiated and updated prior to the incident, included a focus on ADL self-care performance deficit and specified that bed mobility required assist x2. Despite these documented requirements, on the day of the incident a nurse aide entered the resident’s room alone and began providing care. The aide rolled the resident toward herself, noted a bowel movement, and then turned away briefly to look for a towel or other item to perform care while waiting for another aide who had not yet arrived. During this time, the resident slid off the side of the bed and onto the floor. Nursing documentation indicated that the resident was found sitting on the floor, leaning against the nightstand with legs extended and her head supported on a pillow against the mattress. Initial assessment noted no obvious injuries other than redness to the left upper back, and the resident was returned to bed with a Hoyer lift and three staff, after which she complained of increased left leg pain. The resident was later transferred to the hospital for altered mental status, decreasing blood pressure, and increased heart rate, and was reported to have sustained a left femoral neck fracture. The facility’s investigation concluded that the assigned nurse aide did not follow the Kardex instructions and care plan requirement for two-person assistance with bed mobility, and that this failure directly contributed to the incident.
Failure to Implement Updated Therapy Transfer Recommendations
Penalty
Summary
Facility staff failed to identify and implement a change in therapy transfer recommendations for one of three reviewed residents, resulting in a fall and injury. The resident, who had diagnoses including diabetes mellitus, a left femur fracture, and end stage renal disease, had an MDS dated 2/8/26 reflecting these conditions. On 3/5/26, while a nursing assistant was getting the resident up for dialysis using a one-person stand-and-pivot transfer, the resident lost balance and fell. The most recent Kardex still indicated the resident required a sit-to-stand transfer with assistance of two staff, but this updated transfer status from therapy had not been incorporated into the Kardex or the care plan. During interviews, the ADON stated that the resident had been working with therapy and that the transfer status had been changed, but this change did not make it to the Kardex or care plan, explaining that therapy provides a paper change-of-status to nursing. An X-ray after the fall showed a right distal radius fracture, and the resident was sent to the hospital. The Nursing Home Administrator confirmed that the facility failed to address or implement therapy instructions for this resident as required, in violation of 28 Pa. Code 201.18(e) and 211.10(c)(d).
Failure to Communicate Essential Information During Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for a resident who experienced a facility-initiated transfer. Facility policy titled "Transfer and Discharge Notice" dated 2/2026 stated that the resident or representative would be notified prior to transfer or discharge and that documentation would be completed in the medical record. Resident R1 was admitted on an unspecified date and had an MDS dated 1/5/26 reflecting diagnoses of heart failure, Parkinson's disease, and hypertension. The resident was transferred to the hospital on 1/15/26 and did not return to the facility. Review of the resident’s clinical record showed no documented evidence that the facility communicated specific required information to the receiving provider for this transfer. Missing documentation included the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs at the receiving facility. In an interview on 3/4/26 at 2:45 p.m., the DON confirmed that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for this resident with a facility-initiated transfer, in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
Food Storage, Sanitation, and Temperature Monitoring Failures
Penalty
Summary
The facility failed to properly label and date food products in the Main Kitchen and on a nursing unit kitchenette. During observation in the Main Kitchen walk-in freezer, a bag of Asian blend vegetables, a bag of squash, and a bag of ravioli had no received date on the packages, and an opened bag of squash was not dated with the date it was opened. In the Main Kitchen dry storage area, an opened bag of egg noodles was also not dated with the date it was opened. On the North Hall Kitchenette, two yogurts were observed without a resident name or date. The facility also failed to maintain sanitary conditions and required monitoring in food service areas. The ice machine in the Main Kitchen had a black substance on the inside of the lid. The 3-compartment sink Temperature and Sanitizer Report log for January 2026 was left blank and did not record any wash temperatures or sanitizer solution concentrations for any breakfast, lunch, or supper meals, totaling 82 missed opportunities. During tray line, the Dining Services Director and Dining Services Supervisor were observed with the front portion of their hair uncovered by a hair net. Refrigerator Inspection Logs for January 2026 showed missing temperature documentation on the North, East, and West units, and the Nursing Home Administrator confirmed the facility failed to properly monitor refrigerator temperatures on all three nursing units.
Expired supplies found on three crash carts
Penalty
Summary
The facility failed to make certain that equipment was in safe operating condition for three of three crash carts: the West Unit, North Unit, and East Unit. Facility policies stated that the emergency crash cart must always be ready for emergencies and that the checklist should be completed at least weekly and after each use, while the daily signature log was to be completed daily to ensure the cart was in order and ready for use in case of emergency. During an observation of the West Unit crash cart, expired supplies were found, including intravenous secondary tubing sets, intravenous short-term kits, blood collection needle and tubing sets, and povidone-iodine swab sticks. The crash cart had a daily signature log on top of it, but the checklist documentation did not show that the cart was checked on several listed dates. An LPN confirmed these observations and that the facility failed to make certain the cart was in safe operating condition. Additional observations found expired supplies on the North Unit crash cart, including a blood collection needle and tubing set, a StayFIX fixation device, and nonconductive suction tubing, which an LPN confirmed. The East Unit crash cart also contained expired supplies, including intravenous short-term kits, povidone-iodine swab sticks, and an adult nonrebreather mask and tubing kit, which an RN confirmed. The DON was informed that the facility failed to make certain that equipment was in safe operating condition for all three crash carts.
Failure to Ensure Call Bells Were Accessible to Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ call bell needs, as required by its own policy on accommodation of needs. Resident Council meeting minutes documented that all 19 residents present unanimously reported that staff do not leave their call bells within reach. During a subsequent resident group meeting, two of seven residents stated that call bells are not always left where they can reach them and that staff put the call bells where residents cannot access them, noting that this happens frequently. These resident reports indicate a pattern of staff inaction in consistently positioning call bells so residents can independently summon assistance. In addition, surveyors reviewed the clinical record of one resident with diagnoses including hypertension, GERD, and multiple sclerosis, whose care plan directed staff to ensure the call light was within reach and to encourage its use for assistance. During observation, this resident was found lying in bed with the call bell clipped to the pillow beside the resident’s head. When asked how the call bell was activated, the resident explained an inability to move the arms and reliance on head movement to trigger the call bell. The resident attempted to move the head vigorously from side to side but could not reach the call bell and stated that even with such effort it could not be activated, and that the pillow needed to be moved to the left. When a nurse aide entered and repositioned the pillow, the resident was then able to activate the call light, and the aide confirmed the resident had been unable to activate it in the original position. The Nursing Home Administrator acknowledged that the facility failed to accommodate call bell needs for the residents identified in the council, group meeting, and observation.
Insufficient Nursing Staff Leading to Missed Showers and Delayed Call-Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and competent nursing staff to meet residents’ needs, resulting in missed care, delayed responses to call lights, and unmet basic care needs across multiple timeframes and care areas. Facility policy on sufficient and competent nursing staffing states that the facility will provide enough nursing staff with appropriate skills and competency to deliver care and services in accordance with resident care plans and the facility assessment. However, review of Payroll Based Journal data for one quarter showed excessively low weekend staffing, and resident council minutes from two meetings documented multiple residents’ concerns about long wait times for call lights to be answered. Grievance and concern forms also documented complaints that one staff member was covering half a floor, that it took two to two and a half hours to get a resident on a bedpan, and that this had happened repeatedly. Additional concerns from residents and resident representatives described cold meals and inadequate assistance with showers due to insufficient staffing. Resident council documentation and group resident interviews indicated that staffing adequacy varied by day and shift, and that residents who required a Hoyer lift often did not receive showers on days when staffing was low because two staff were needed to operate the lift. Several residents reported missing scheduled showers for this reason, and multiple residents reported waiting between 30 minutes and two hours for assistance on various shifts. Staff interviews with NAs, an RN, and an LPN corroborated these concerns, with staff stating that when staffing was low, showers were not completed, tray passing was delayed, residents could not always be gotten out of bed, and call lights had to wait. Specific resident records and observations further demonstrated the impact of insufficient staffing. One resident with diagnoses including hypertension, GERD, and multiple sclerosis was scheduled for showers twice weekly but reported frequently missing showers, and documentation showed missed showers on three specified dates, which the DON confirmed. Another resident with atrial fibrillation, hypertension, and pancreatic cancer had a care plan requiring prompt response to call lights; observation showed this resident’s call light active for 17 minutes for pain medication, with the final activation time reaching 22 minutes. A resident with hypertension, aphasia, and hypokalemia, scheduled for showers twice weekly at a set time, missed multiple scheduled showers, and reported that staff attributed missed showers to lack of staffing. Another resident with aphasia, depression, and lack of coordination, scheduled for showers twice weekly on day shift, also missed a scheduled shower and indicated they did not receive showers as scheduled. A further resident with atrial fibrillation, hypertension, and renal failure, care-planned for prompt call light response, had a call light active for 25 minutes for assistance with an indwelling Foley catheter, with the final activation time at 26 minutes, which was confirmed by an RN. The DON acknowledged that the facility failed to have sufficient nursing staff to provide necessary nursing and related services during the identified periods and for the identified residents.
Incomplete Care Plans for Tracheostomy and COVID Isolation Needs
Penalty
Summary
The facility failed to develop comprehensive care plans with specific, individualized interventions for three of six residents reviewed. Resident R2 had diagnoses including high blood pressure, diabetes, and respiratory failure, and the MDS indicated tracheostomy care was being performed. A physician order required respiratory tracheotomy assessment six times a day for a pre-existing 6 Shiley trach, and the resident was observed in bed with the tracheostomy present. However, the care plan failed to include a plan for the management and monitoring of the tracheostomy, and an RN confirmed the absence of a trach care plan. Resident R45 and Resident R116 both had physician orders for COVID isolation/contact and droplet precautions with care and services to be provided in the resident's room every shift for infection prevention. Resident R45's MDS listed high blood pressure, renal insufficiency, and diabetes, while Resident R116's MDS listed anemia, paraplegia, and anxiety. In both cases, the care plans failed to include a plan for the management and monitoring of COVID isolation, and the Infection Preventionist confirmed the missing care plans. The DON later confirmed that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of these residents.
Nursing Not Present at Care Conferences
Penalty
Summary
The facility failed to promote a multidisciplinary approach with care conferences for four of seven residents reviewed, as nursing was not present at the care conferences. For Resident R5, the clinical record showed admission with diagnoses of heart failure and CAD, and the interdisciplinary care plan conference sign-in sheet dated 10/22/25 included social service, dietary, therapy, the resident, and a family member, but did not include nursing. For Resident R40, the record showed diagnoses of COPD, anxiety, and cellulitis, and a progress note dated 12/17/25 indicated nursing was unavailable during the care conference meeting. For Resident R10, the record showed diagnoses of atrial fibrillation, heart failure, and hypertension, and progress notes dated 7/8/25 and 1/28/26 indicated nursing was unavailable during care conference meetings. For Resident R119, the record showed admission with diagnoses including progressive multiple sclerosis, bacteremia, and UTI, and a progress note dated 12/30/25 indicated nursing was unavailable during the care conference meeting. During an interview on 1/31/26 at 10:00 a.m., the DON confirmed there was no nursing in attendance at the care conferences as required.
Foley Catheter Care and Dignity Not Provided
Penalty
Summary
Appropriate catheter care and dignity measures were not provided for residents with indwelling Foley catheters. Facility policy required aseptic handling of the drainage system, review of the resident care plan for special needs, and use of dignity bags to cover urinary catheter bags. However, Resident R64’s urinary catheter bag was observed hanging on the bed without a dignity bag, and an RN confirmed the cover had been forgotten. R64’s current physician orders did not include orders for the type of urinary catheter or catheter care, and the current care plan did not include interventions for the catheter; the RN confirmed there were no current orders or care plan in place for the urinary catheter. Resident R83 had diagnoses including quadriplegia and neurogenic bladder and had an indwelling Foley catheter ordered for neurogenic bladder. A nursing note documented that the resident reported the catheter had been leaking, with a wet brief and an empty drainage bag; the nurse withdrew fluid from the balloon, advanced the catheter, and flushed it with sterile water, with return of drainage. Resident R151 had an indwelling Foley catheter related to urinary retention, and during observation and interview the resident stated the catheter needed adjustment because something was wrong with it; the Foley catheter also lacked a dignity bag. The DON stated that if a catheter was leaking it would be replaced with a new one and confirmed the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter for three residents.
Failure to Document Trauma Triggers in Care Plans
Penalty
Summary
The facility failed to provide trauma-informed care for three residents with a history of trauma by not identifying specific triggers or documenting how to avoid them in their care plans. Review of facility policies indicated that trauma-informed and culturally competent care should minimize triggers and re-traumatization and that care plans should address past trauma and identify ways to decrease exposure to triggers. However, the care plans for Resident R7, Resident R9, and Resident R56 each noted a history of trauma that affected the resident but did not identify the triggers or how to avoid them. Resident R7 and Resident R9 were both admitted with diagnoses including quadriplegia, and staff observations noted do not knock signs posted outside both residents’ doors. An RN confirmed that both residents were gunshot victims and that loud noises were triggers for them, but this information was not identified in the care plans. Resident R56 was admitted with hemiplegia, anxiety, and depression, and an RN confirmed that her care plan also failed to identify triggers or how to avoid them; the RN stated the resident was not to have male caregivers, but that was not included in the care plan. Social services stated that triggers were identified by asking residents if they had any, and if they reported them, the information would be placed on the care plan. The DON confirmed the facility failed to provide trauma-informed care for these three residents.
Improper Storage of Open and Undated Medications
Penalty
Summary
The facility failed to store medications and biologicals in a safe, secure, and orderly manner for three of four medication carts: the North Unit Back Hall, the [NAME] Unit Front Hall, and the East Unit Front Hall. The cited deficiency was based on observations of the carts and staff interviews, along with review of the facility policy titled Storage of Medications dated January 2026, which stated that medications and biologicals are to be stored safely, securely, and properly. On the North Unit Back Hall medication cart, R23's lantus pen, R80's lantus pen, and R146's insulin lispro vial were observed without an open date or expiration date. An LPN confirmed these observations and that the medications were not properly stored. On the [NAME] Unit Front Hall medication cart, cyclosporine eye drops, an eye itch relief bottle, and albuterol sulfate nebulizer solution were observed open and not dated, and an RN confirmed they were open without a date as required. On the East Unit Front Hall medication cart, budesonide solution and ipratropium bromide were observed open and not dated, and an LPN confirmed they were open without a date as required. The DON later confirmed the facility failed to store medications and biologicals in a safe, secure, and orderly manner for the three carts.
Failure to Follow Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received necessary services to prevent and treat pressure ulcers in accordance with physician orders and facility policy. For one resident with quadriplegia, high blood pressure, and a neurogenic bladder, surveyors observed the resident in bed on multiple occasions wearing Prafo boots and later reported use of bunny boots according to a schedule the resident described (Prafo boots in the morning while in bed and bunny boots starting at 5:00 p.m.). However, review of the clinical record and physician orders showed no documented orders or schedule for either the Prafo or bunny boots. A registered nurse confirmed that there were no current physician orders or schedules for these devices, despite their ongoing use. For another resident with high blood pressure, malnutrition, and heart failure, the clinical record contained a physician’s order to wash the coccyx and peri/groin area twice daily with soap and water and apply a zinc-based barrier cream, with instructions to report any decline in wound condition. Review of the Treatment Administration Record showed that this ordered treatment was not provided on one evening shift. The DON confirmed that the ordered pressure ulcer prevention treatment was not administered as prescribed and further acknowledged that the facility failed to ensure residents were monitored, assessed, and received necessary services to prevent pressure ulcers or wounds from developing for two of three residents reviewed.
Resident personal property could not be located
Penalty
Summary
Failure to ensure that residents were free from misappropriation of property occurred for one resident, R155. The facility policy stated that abuse, neglect, exploitation, and misappropriation of resident property are strictly prohibited. R155 was admitted to the facility and had diagnoses of peripheral vascular disease, high blood pressure, and a seizure disorder. The MDS dated 12/9/25 indicated a BIMS score of 13, showing the resident was cognitively intact. Facility records showed that R155 was later admitted to the hospital, and on 1/14/26 the resident contacted the facility looking for a wallet and passport left there. The resident's son reported that the wallet contained a bank card, social security card, and military ID. During the investigation, two nurses recalled the wallet and passport and stated the grey bag had last been seen locked in the narcotic drawer on the west unit back hall narcotic box for safe keeping. The medication cart, surrounding area, nurses' station, medication room, and the resident's room were searched, but the grey bag was not found. The Social Services Director stated the facility investigated the missing items, and the DON confirmed the facility was unable to locate the resident's personal property.
Missing Physician Orders for Wander Guard and Colostomy
Penalty
Summary
The facility failed to obtain a physician order for a wander guard for Resident R40 and failed to obtain a physician order for a colostomy for Resident R59. Facility policy for physician orders stated the facility maintains a system for receiving, documenting, verifying, and carrying out physician orders. Resident R59 was admitted with diagnoses including peripheral vascular disease, sepsis, and anemia, and the most recent MDS dated 11/3/25 showed those diagnoses remained current. The most recent plan of care for Resident R59 identified the need for colostomy management, but the physician orders dated 1/12/26 contained no order for a colostomy. Resident R40 was admitted with diagnoses including COPD, atrial fibrillation, and anxiety, and the annual MDS dated 12/18/25 showed the diagnosis remained current. A nurse progress note dated 1/13/26 documented that a wander guard was placed on the resident's right ankle, but the resident's most recent physician orders contained no order for the wander guard. During interview on 1/30/26 at 1:12 p.m., the DON confirmed there was no physician order for either the wander guard or the colostomy.
Failure to Properly Store Respiratory Equipment and Complete CPAP Orders
Penalty
Summary
Appropriate respiratory care was not provided for two residents when respiratory equipment was found not stored according to facility policy. The facility policy for administering medications through a small volume handheld nebulizer stated that when treatment is complete, the nebulizer should be turned off, rinsed and disinfected according to protocol, and stored in a plastic bag with the resident's name and date when completely dry. Resident R8 had diagnoses including respiratory failure, Parkinson's disease, and aphasia, and had an order for AVAPS every night shift. During observation, R8's AVAPS mask was hanging on an IV pole next to the bed instead of being stored in a bag, and an RN confirmed it was not stored as required, stating that nurse aides sometimes remove it and do not put it in a bag. Resident R34 had diagnoses including heart failure, obstructive sleep apnea, and hyperlipidemia, and had an order for Ipratropium-Albuterol solution via nebulizer every four hours as needed, as well as CPAP at bedtime. During observation, R34's nebulizer was sitting on the bedside table and not stored in a bag, which an LPN confirmed. The CPAP order did not include the device settings, and the current care plan did not include interventions for the CPAP machine. An RN confirmed the CPAP order lacked settings and the care plan failed to include CPAP interventions, and the DON confirmed the facility failed to provide appropriate respiratory care for these two residents.
Delayed Social Services and Placement Referrals
Penalty
Summary
Medically-related social services were not provided in a sufficient and timely manner to meet the needs of one resident. The resident was admitted with diagnoses including heart failure and CAD. A psychiatric evaluation note dated 9/24/25 stated the resident’s mood was unchanged and that he remained frustrated that he was still unable to find a facility closer to home, saying he felt like a prisoner at Cranberry. A later psychiatric evaluation note dated 1/7/26 again documented that the resident’s mood was unchanged and that he remained frustrated that he was unable to go home or transfer to another facility with better liberty, stating that he felt stuck in a prison. Facility records showed that the last referrals related to housing and placement outside of the nursing care facility were dated July 2025. Review of the facility policy stated that social services personnel shall coordinate most resident referrals with outside agencies and document the referral in the medical record, and the social worker job description included documenting assessments, clinical team meeting minutes, and community resource referrals. During interview on 1/31/26, the Social Service Director confirmed that the facility had not sent out any referrals for other nursing care facilities and that the facility failed to provide sufficient and timely social services to meet the resident’s needs.
Missing Carvedilol Parameters on MAR
Penalty
Summary
The facility failed to identify parameters for carvedilol, a heart medication, on the medication administration record for one resident. Facility policy stated that pharmacy services include screening new medications for key parameters and that carvedilol requires monitoring of BP and HR, with instructions to take HR before administration and hold therapy if HR is below 50 bpm or if arrhythmia occurs. Review of the resident’s clinical record showed diagnoses of heart failure and CAD, and the MAR listed carvedilol 6.25 mg twice daily for HTN beginning 11/21/25. Review of the MAR for November 2025, December 2025, and January 2026 showed that carvedilol parameters were not included from 11/21/25 through 1/23/26, and the January 2026 MAR did not identify parameters until 1/23/26. During interview, the DON confirmed that the facility failed to follow manufacturer guidelines and identify parameters for the heart medication for the resident.
Failure to Schedule Needed Dental Care
Penalty
Summary
The facility failed to ensure that a dental appointment was scheduled for one resident who required dental services. The resident was admitted to the facility and had diagnoses including peripheral vascular disease, sepsis, and anemia. The contracted dental provider documented that the resident potentially needed surgical extractions and would need to consult with an oral maxillofacial surgeon. Facility progress notes stated that a list of oral surgeons was received from social work and that calls were placed to several providers to schedule the resident for teeth removal. During interview, the Unit Manager stated that no appointment had been set up and that it could take up to two years because the resident needed stretcher transport. The Nursing Home Administrator confirmed that the facility failed to obtain the required dental services for the resident.
Failure to Report Change in Medical Director
Penalty
Summary
The facility failed to notify the State agency of a change in its Medical Director at the time the change occurred. Review of facility data showed Doctor Employee E16 was the Medical Director effective 9/1/22. During an interview on 1/28/26 at 1:00 p.m., the Nursing Home Administrator stated that Doctor Employee E16 no longer worked at the facility and that Doctor Employee E17 became the new Medical Director in June 2025. In the same interview, the Nursing Home Administrator confirmed the facility did not notify the State agency of the Medical Director change when it occurred.
QAA Meeting Lacked Required Committee Member Attendance
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings with all required committee members for one of four quarters, specifically Quarter Two on April 25, 2025. Review of the facility’s Quality Assurance and Performance Improvement (QAPI) Program policy dated January 2026 showed that the Administrator/Executive Director is responsible for assuring the QAPI Program complies with federal, state, and local regulatory agency requirements. Review of Quality Assurance and Performance Improvement sign-in sheets and attendance records for Quarter Two of 2025 showed that the Nursing Home Administrator was not in attendance at the April 25, 2025 meeting. During an interview on 1/28/26 at 11:00 a.m., the Nursing Home Administrator confirmed that the facility failed to conduct QAA meetings with all required committee members for that quarter.
Failure to Offer Flu and Pneumonia Vaccinations
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations after the facility failed to make certain that influenza immunization and pneumococcal immunization were offered to two residents, R45 and R116. Facility policy required that influenza vaccine be offered between October 1 and March 31 unless medically contraindicated or already received, and that pneumococcal vaccines be offered to all residents, with documentation of vaccination details in the medical record. Review of the clinical record for R45 showed admission to the facility and an MDS dated 1/11/26 listing high blood pressure, renal insufficiency, and diabetes, but there was no documented evidence that either the influenza vaccine or pneumococcal vaccine was offered or administered. Review of the clinical record for R116 showed admission to the facility and an MDS dated [DATE] listing anemia, paraplegia, and anxiety, but there was no documented evidence that either the influenza vaccine or pneumococcal vaccine was offered or administered. During interview on 1/30/26 at 12:00 p.m., the Infection Preventionist confirmed the facility failed to make certain that influenza immunization and pneumococcal immunization were offered to these two residents.
Missing Effective Communication Training for Nurse Aide
Penalty
Summary
The facility failed to provide annual in-service training on Effective Communication for one Nurse Aide, Employee E6. Facility policy titled In-Service Training, All Staff dated January 2026 stated that all staff must participate in initial orientation and annual in-service training, including training on effective communication with residents and family. Review of Employee E6’s personnel file showed a hire date of 7/28/24, but the file did not include annual in-service training on Effective Communication for the period from 1/1/25 through 12/31/25. During an interview on 1/31/26, the Director of Nursing confirmed that the facility failed to provide this training for Employee E6.
Missing Resident Rights Training for a Nurse Aide
Penalty
Summary
The facility failed to provide annual Resident Rights training for one of five staff members, Nurse Aide Employee E6. Review of the facility’s In-Service Training policy dated January 2026 showed that all staff must participate in initial orientation and annual in-service training, including resident rights and responsibilities. Review of Employee E6’s personnel file showed a hire date of 7/28/24, but the file did not include annual in-service training on Resident Rights for the period from 1/1/25 through 12/31/25. During an interview on 1/31/26, the DON confirmed that the facility failed to provide this training for Employee E6.
Failure to Provide Required QAPI Training
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not provided to one of five staff members, Nurse Aide Employee E6. Facility policy titled In-Service Training, All Staff dated January 2026 stated that all staff must participate in initial orientation and annual in-service training, including training on the elements and goals of the facility QAPI program. Review of Employee E6’s personnel file showed a hire date of 7/28/24, but the file did not include annual in-service training on the QAPI program for the period from 1/1/25 through 12/31/25. During an interview on 1/31/26, the DON confirmed that the facility failed to provide QAPI training for Employee E6.
Missing Infection Control Training for Staff Member
Penalty
Summary
The facility failed to provide annual Infection Control training for one of five staff members, a Nurse Aide identified as Employee E6. Facility policy titled In-Service Training, All Staff, dated January 2026, required all staff to participate in initial orientation and annual in-service training, including training on the infection prevention and control program. Review of Employee E6’s personnel file showed a hire date of 7/28/24, but the file did not include annual in-service training on Infection Control for the period from 1/1/25 through 12/31/25. During an interview on 1/31/26, the DON confirmed that the facility failed to provide Infection Control training for this staff member.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
The facility failed to provide annual in-service training on Compliance and Ethics for one of five staff members, identified as Nurse Aide Employee E6. Facility policy titled In-Service Training, All Staff, dated January 2026, stated that all staff must participate in initial orientation and annual in-service training, including training on the compliance and ethics program. Review of Employee E6’s personnel file showed a hire date of 7/28/24, but the file did not include annual in-service training on Compliance and Ethics for the period from 1/1/25 through 12/31/25. During an interview on 1/31/26, the DON confirmed that the facility failed to provide this training for Employee E6.
Failure to Provide Required Annual Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that one of four sampled Nurse Aides, NA Employee E6, received the required minimum of 12 hours of in-service education per year. Review of the facility’s nurse aide training records showed that NA Employee E6 did not receive 12 hours of in-service training from 1/1/25 through 12/31/25, and the facility was unable to provide documented evidence that the yearly training requirement had been met. During an interview on 1/31/26 at 9:08 a.m., the DON confirmed that the facility failed to ensure NA Employee E6 received the required 12 hours of yearly in-service training.
Incomplete Posting of State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program, the State Survey Agency (SSA), and Adult Protective Services (APS) as required. During observations on 1/28/26 at 11:34 a.m., the Ombudsman information posted in the front hallway did not include the Ombudsman's mailing address. The same observation showed that the SSA and APS information posted in the front hallway did not include the SSA's mailing address and email address and did not include APS's mailing address and email address. On 1/29/26 at 2:04 p.m., the Regional Director of Clinical Services, Employee E2, confirmed that the facility had failed to post complete contact information for the Ombudsman program, SSA, and APS.
Failure to Address Resident Group Concerns About Call Bell Accessibility
Penalty
Summary
The facility failed to consider and act promptly on the recommendations and concerns raised by the resident group regarding call bells not being left within residents' reach. Over a three-month period, Resident Council meeting minutes consistently documented unanimous resident reports that staff did not leave call bells accessible on all units and shifts. Additionally, a resident representative reported being left unattended in a wheelchair without a remote to call for help. During an interview, the DON confirmed that the facility did not effectively address these concerns raised by the resident group.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who reported that his roommate had fondled his leg and groin. The resident, who had diagnoses including high blood pressure, malnutrition, and low back pain, was visibly shaken and expressed fear following the incident. Documentation indicated that the resident had previously reported similar concerns, but felt that no action had been taken. The facility's policy required all allegations of abuse to be thoroughly investigated and documented, including obtaining written, signed, and dated witness statements. Upon review, it was found that the investigation file lacked a written statement from the nurse aide who first responded to the incident, and there was no documentation clarifying the licensed practical nurse's knowledge of any prior sexual abuse allegations. Although the DON stated that a detailed interview was conducted with the LPN regarding prior knowledge, this interview was not documented. The DON confirmed that the facility did not conduct a thorough investigation as required by policy.
Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a registered nurse administered insulin intended for one resident to another resident. The nurse was passing early morning medications and gave the insulin to the wrong resident after the resident answered to the roommate's name and did not question the medication. The nurse failed to properly verify the resident's identity according to facility policy, which requires checking the identification band, photograph, and, if necessary, confirming with other staff. The error was discovered when the nurse realized the mistake and notified the charge nurse, physician, and the resident's family. The resident who received the incorrect medication had a blood sugar check and was given IV dextrose as ordered by the physician. The resident involved had diagnoses including high blood pressure, hyperlipidemia, and a history of falls. Staff interviews revealed that standard practice for medication administration includes verifying the resident's name, checking the medication administration record (MAR), and confirming the resident's picture. However, in this incident, these verification steps were not adequately followed, resulting in the administration of another resident's Lantus insulin. The Director of Nursing confirmed that the facility failed to ensure residents were free from significant medication errors in this case.
Deficiencies in Wander Guard Management and Medication Reconciliation
Penalty
Summary
The facility failed to ensure that residents were provided with appropriate treatment and care by not having physician orders, individualized care plans, and accurate assessments for the use of wander guards for four residents. Specifically, one resident did not have any physician orders for a wander guard despite multiple elopement evaluations indicating no risk, while another resident had orders for a security guard but lacked orders to check the wander guard battery weekly. Additionally, care plans for two residents identified a risk for wandering or elopement but did not include interventions to check the wander guard battery weekly, and physician orders for these residents also omitted this requirement. The Director of Nursing confirmed these omissions and inconsistencies during interviews, and acknowledged that once a resident is identified as an elopement risk, they should remain so unless discharged or bedbound. Another deficiency was identified in the medication reconciliation process upon admission. One resident, who had diagnoses including heart failure, diabetes, and end stage renal disease, was prescribed Calcium Acetate at a specific dose upon discharge from an acute care setting. However, the medication was transcribed incorrectly upon admission to the facility, resulting in the resident receiving only half the prescribed dose. The Certified Registered Nurse Practitioner confirmed that this was a transcription error and that the resident had been receiving the incorrect dose since admission. These findings were based on a review of facility policies, clinical records, and staff interviews. The deficiencies were confirmed by both the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate physician orders, care plan interventions, and accurate medication transcription for the affected residents.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident. According to the facility's policy, residents at risk for wandering or elopement should have specific interventions in place, including orders for a wander guard, regular checks of the device, and quarterly elopement assessments. The resident in question, who had diagnoses of heart failure, diabetes, and cerebral infarction, was assessed as moderately cognitively impaired with a BIMS score of 9. Despite this, the resident's initial elopement evaluation indicated no risk, and appropriate interventions were not implemented. The deficiency was identified when the resident was found outside the facility in the parking lot with her belongings packed, after contacting her husband to pick her up. The receptionist observed the resident outside and assisted her back into the building, notifying nursing staff. At the time of the incident, the resident did not have a wander guard in place, and her care plan lacked resident-specific interventions to address elopement risk. Interviews with the DON and Nursing Home Administrator confirmed that the care plan did not include required checks for the wander guard or battery, and failed to provide adequate supervision to prevent the elopement.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as required by federal regulations. Specifically, a nurse aide physically abused a resident by hitting them multiple times during care. This incident was witnessed by a nurse, who intervened by stepping between the aide and the resident and then escorting the aide out of the room. The facility's own policies, which define abuse and require staff to treat residents with kindness, respect, and dignity, were not followed in this instance. The resident involved had a history of hypertension, aphasia, and right-sided hemiplegia, and was rarely or never understood according to their most recent assessment. The abuse was reported to facility leadership, and the Director of Nursing confirmed that the allegation of physical abuse was substantiated. This event demonstrates a failure to protect a vulnerable resident from physical harm and to adhere to established protocols for resident safety and rights.
Plan Of Correction
R3 was immediately assessed by CRNP for injury. Wound team to provide ongoing assessments and skin checks. Social services provided emotional support immediately following the incident. Continued emotional support will be provided. A new trauma assessment was completed and Careplan updated. The facility notified the resident's family, DOH, Area Agency on Aging, and Cranberry Township police. All residents were interviewed regarding abuse and neglect. No other concerns were reported. All residents with a BIMS score of 13 or below had a full body skin check to investigate for any signs/symptoms of abuse or neglect. No concerns were identified. The facility will review/revise the onboarding process, including background checks and licensure. The facility will review/revise the orientation process, specifically regarding abuse and neglect education in orientation. All nursing staff will be educated on abuse and neglect. All nursing staff will be educated on Cognitive Deficits and Behaviors. Social Services will interview 10 residents on abuse and neglect weekly x4 weeks, then 10 residents monthly or until substantial compliance has been reached. Results of interviews will be reviewed during QAPI. Any concerns will be reported to leadership for immediate investigation. The facility will review/revise the onboarding process, including background checks and licensure. The facility will review/revise the orientation process, specifically regarding abuse and neglect education in orientation. All nursing staff will be educated on abuse and neglect. All nursing staff will be educated on Cognitive Deficits and Behaviors. Social Services will interview 10 residents on abuse and neglect weekly x4 weeks, then 10 residents monthly or until substantial compliance has been reached. The DON will interview 5 staff members weekly regarding abuse and neglect x4 weeks then monthly or until substantial compliance has been reached. Results of interviews will be reviewed during QAPI. Any concerns will be reported to leadership for immediate investigation.
Failure to Verify Professional License Prior to Employment
Penalty
Summary
The facility failed to verify the professional license of a nurse aide prior to employment, as required by personnel policies and procedures. Specifically, the personnel record for the nurse aide showed a hire date that preceded the date on which the license verification was completed. The human resource director confirmed during an interview that the license verification inquiry was conducted after the employee had already been hired. This deficiency was identified during a review of new hire files and staff interviews, and it affected one out of two employees reviewed.
Plan Of Correction
The human resource director was educated by the NHA related to timely pulling the staff professional license before the date of hire to ensure the license is valid. The new hire files were reviewed by HR. All new hire files will be audited weekly, the Friday before new hires start, to ensure and maintain compliance by the NHA. An audit was completed on all new hire files for license checks before the start date. I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.
Failure to Properly Date and Store Food Products
Penalty
Summary
The facility failed to properly date and store food products in the main kitchen, as observed during a survey. Specifically, surveyors found that turkey breast lunch meat, ham lunch meat, provolone sliced cheese, and Swiss sliced cheese in a refrigerator/cooler by the tray line were open and lacked an open date. Additionally, in the dry storage room, four bags of open pasta and one container of graham cracker crumbs were found open and without an open date. These findings were in direct violation of the facility's food safety program and standard operating procedures, which require all food to be properly wrapped, labeled, and dated. The deficiency was communicated to the Nursing Home Administrator during the exit interview.
Failure to Complete Weekly Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete comprehensive weekly wound assessments for one resident, as required by its own policies and procedures. The facility's wound care policy and skin care and wound management guidelines specify that wound assessments, including documentation of the wound's color, size, and drainage, must be performed at least weekly and whenever there is a change. Review of the resident's clinical records revealed that comprehensive wound assessments were missing for multiple consecutive weeks, despite physician orders to monitor the wound and provide daily care. The resident involved had multiple diagnoses, including diabetes, COPD, hyperlipidemia, and spinal stenosis, and was under care for a cancerous lesion requiring monitoring for infection and wound care. Staff interviews confirmed that the required weekly comprehensive wound assessments were not completed or documented for the resident over several weeks. The deficiency was acknowledged by both the LPN and RN responsible for wound care, as well as communicated to the Nursing Home Administrator.
Failure to Administer Physician-Ordered Medications and Wound Care
Penalty
Summary
Facility staff failed to provide medications and wound care treatments as ordered by physicians for two of six residents. For one resident with diagnoses including rectal cancer, muscle wasting, and diabetes mellitus, physician orders required specific wound care to the buttocks twice daily, including washing, packing with Dakins solution, and applying Calmoseptine, as well as administration of an antidepressant medication. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed multiple missed wound care treatments and several days when the antidepressant medication was not administered due to pending delivery. These omissions were confirmed by the Wound Care Nurse and the Director of Nursing during interviews. Another resident with high blood pressure, low back pain, and bacterial arthritis of the left knee had physician orders for daily wound care to the left knee, ensuring steri strips remained in place and monitoring for infection. The TAR indicated that wound care was not provided on two separate occasions as ordered. The Director of Nursing confirmed these missed treatments during interviews. Facility policies reviewed indicated that medications and treatments are to be administered safely, timely, and as prescribed, with proper documentation and timely reordering of medications. Despite these policies, the facility did not consistently follow physician orders for medication administration and wound care for the two residents, resulting in the identified deficiencies.
Failure to Prevent Significant Medication Error Due to Missed Anticoagulant Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as required by facility policy and state regulations. Review of the clinical record showed that a resident with diagnoses including high blood pressure, cancer, and left knee pain had a physician's order for daily subcutaneous injections of Fondaparinux Sodium, a blood thinner. The resident's Medication Administration Record for May 2025 indicated that the medication was not administered on two consecutive mornings due to the medication being pending delivery. Facility policy required that medications be reordered from the pharmacy at least three days before the last dose to ensure availability, and that all administrations be properly documented. During an interview, the Director of Nursing confirmed that the resident did not receive the ordered medication as required, resulting in a significant medication error for one of the residents reviewed.
Failure to Protect Residents from Abuse and Neglect Resulting in Harm
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in actual harm to two residents. One resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and renal insufficiency, was transported to a medical appointment by a facility driver. On the return trip, the driver deviated from the expected route, stopped at his personal residence in an unfamiliar neighborhood, and left the resident alone in the van for five to ten minutes without explanation. The resident reported feeling terrified, uncertain of her safety, and experienced significant mental anguish during the incident. The driver later admitted to stopping at his home to retrieve his wallet and eat a sandwich, leaving the resident unattended in the vehicle. Another resident, with a history of end stage renal disease, coronary artery disease, and hypertension, required two staff members and a mechanical lift for transfers according to her care plan. Despite this, a nursing assistant transferred the resident alone, without consulting the Kardex for transfer status. During the unassisted transfer, the resident's leg became caught, resulting in severe pain and, upon further evaluation, a fracture of the left tibial plateau. The resident's roommate confirmed hearing the resident scream in pain during the transfer, and the nursing assistant admitted to not checking the Kardex and being unsure of the resident's transfer requirements at the time. Facility documentation and staff interviews confirmed that the required protocols for resident safety and adherence to care plans were not followed in both cases. The incidents resulted in actual harm: mental anguish and fear for one resident, and a significant physical injury for another. The facility's own policies and staff education materials emphasized the importance of following care plans and not leaving residents unattended, yet these were not adhered to, directly leading to the deficiencies identified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility and Transfers Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance for bed mobility and transfers, resulting in actual harm to two residents. One resident with diagnoses including Alzheimer's disease, neurofibromatosis, and chronic pain required assistance for bed mobility. Documentation showed conflicting information regarding the level of assistance needed, with the Minimum Data Set indicating assist of two, while the Kardex indicated assist of one. During incontinence care, the resident was rolled away from the caregiver, contrary to standard procedure, and fell from the bed, sustaining a head laceration that required eight staples. Staff interviews confirmed that the resident was not rolled toward the caregiver as required, and the bed was elevated during care, contributing to the fall. Another resident with end stage renal disease, coronary artery disease, and hypertension required two staff members and a mechanical lift for transfers, as documented in the care plan. Despite this, the resident was transferred by a single nurse aide without the mechanical lift. During the unassisted transfer, the resident's leg became caught, resulting in a tibial plateau fracture. The resident reported severe knee pain following the incident, and subsequent evaluation confirmed the fracture. Staff interviews and witness statements corroborated that the transfer was performed by one aide, who was unsure of the resident's transfer status at the time. The facility's policies required that all accidents be investigated and reported, and that appropriate support and assistance be provided for activities of daily living, including mobility and transfers. However, the facility did not have a specific policy regarding bed mobility, and staff failed to follow established procedures for safe resident handling. These failures led to significant injuries for two residents, including a head injury and a fracture, as a result of inadequate supervision and improper transfer techniques.
Failure to Revise Care Plans After Significant Resident Events
Penalty
Summary
The facility failed to revise or update care plans for three residents to accurately reflect their current needs following significant events. For one resident with diabetes, hypertension, and renal insufficiency, the care plan did not include monitoring for psychosocial well-being after a traumatic event during a transport, despite the resident expressing fear and distress after being left alone in a van by a driver. Another resident with Alzheimer's disease, neurofibromatosis, and chronic pain was sent to the emergency room for a closed head injury and scalp laceration, but the care plan was not updated to include monitoring for psychosocial well-being following this traumatic event. A third resident with end stage renal disease, coronary artery disease, and hypertension suffered a left lateral tibial plateau fracture during a transfer, resulting in pain, a new brace, and non-weight bearing status. The care plan for this resident was not revised to address psychosocial well-being after the injury, pain management, or skin checks related to brace use. The Director of Nursing confirmed that care plans for all three residents were not updated to reflect these changes in condition and care needs.
Medication Error in Resident's Parkinson's Treatment
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was admitted with a prescription for Carbidopa-Levodopa to be taken as two tablets three times a day. However, the facility's records indicated that only one tablet was administered three times a day throughout the resident's stay. This discrepancy was noted in the discharge orders from the acute hospital stay, but the error was not corrected upon admission to the facility. Interviews with facility staff, including a Certified Registered Nurse Practitioner (CRNP) and the Director of Nursing (DON), confirmed that the resident received only half of the prescribed dosage for 17 days. The CRNP acknowledged that the orders from the discharging facility were not accurately entered into the system, and the DON admitted that multiple checks should have been in place to catch and correct this error at the time of admission. The facility's failure to administer the correct medication dosage resulted in a significant medication error for the resident.
Failure to Obtain Approval for Fire Alarm System Replacement
Penalty
Summary
The facility was found deficient in maintaining general requirements as it failed to submit plans to the State Plan Review and obtain occupancy approval from the Life Safety Division for the replacement of the fire alarm system. This deficiency was identified during an observation on January 29, 2025, at 10:25 a.m., which revealed that the facility had not received the necessary approval for the new fire alarm system, including all devices and the remote annunciator panel. The maintenance supervisor confirmed this deficiency during an interview conducted at the same time as the observation.
Plan Of Correction
Fire panel was replaced. DOH was not notified for plan review. No negative outcomes noted. Maintenance supervisor educated on need for plan review before any changes to current systems. NHA will audit any construction or changes of current systems to ensure compliance. Audits will be completed biweekly. Results will be reviewed at the QAPI meeting.
Deficiencies in Kitchen Hood Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities, specifically the kitchen hood suppression system. During a document review, it was found that there was no documentation of monthly visual inspections being conducted for the kitchen hood suppression system. Additionally, interviews with kitchen staff revealed that they were uncertain about the location and operation of the manual activation for the hood fire suppression system. These deficiencies were confirmed in an interview with the maintenance supervisor.
Plan Of Correction
Kitchen and Maintenance were educated on visually inspecting the Kitchen hood suppression system monthly. Dietary employees were also educated on what the suppression system is, what it does, and when to pull the alarm. Audits will be done weekly for 6 weeks. Results will be reviewed at QAPI meeting.
Failure to Maintain Fire Alarm System Components
Penalty
Summary
The facility failed to maintain its fire alarm system components, which affected the entire facility. During a document review and interview on January 29, 2025, it was revealed that the facility could not provide documentation for several critical inspections and tests. These included the annual inspection/testing, semi-annual visual inspection, smoke detector sensitivity testing, battery-operated smoke detector checks, and six-month battery replacement and policy. The maintenance manager confirmed the absence of this documentation and noted that the fire alarm system had been recently replaced.
Plan Of Correction
We have no battery powered smoke detectors; all are hard wired in. Paperwork was located for annual testing and semi-annual visual inspection. All smoke detectors were replaced on 9/25/2024. Education completed with Maintenance department on timely receipt of paperwork. Audits will be monthly. Results will be reviewed at the QAPI meeting.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain compliance with sprinkler system regulations as evidenced by two key deficiencies. Firstly, during a document review, it was found that the facility did not provide documentation for the required three-year full flow trip test of the sprinkler system. This deficiency was confirmed through an interview with the maintenance supervisor. Secondly, an observation revealed that six sprinkler heads in the laundry room were covered with dust and lint and showed signs of corrosion. This build-up of material can insulate the sprinkler's thermal element, potentially impacting its temperature activation and response time, and may lead to inadequate spray coverage. The maintenance supervisor confirmed these deficiencies during an interview.
Plan Of Correction
The sprinkler heads were cleaned on 1/31/25 in the laundry. The maintenance director received an education regarding the importance of sprinkler heads being dust-free. The sprinkler heads will be randomly monitored monthly for 4 months. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI. The three-year flow test is scheduled to be completed by vendor Granu. Report will be kept on file. The maintenance department were educated on timeliness of receiving testing and paperwork. Audit will be yearly after test completed. Results will be reviewed at QAPI for further recommendations.
Generator Documentation Deficiency
Penalty
Summary
The facility failed to meet the electrical system requirements for its generator, as evidenced by the absence of necessary documentation. During a document review on January 29, 2025, it was found that the facility could not provide records for the monthly battery-specific gravity or conductance test. Additionally, the facility lacked documentation for the three-year, four-hour load test, which is a critical component of ensuring the generator's reliability and compliance with NFPA standards. An interview with the maintenance supervisor on the same day confirmed that the required documentation was unavailable at the time of the survey. This deficiency indicates a lapse in the facility's maintenance and testing protocols for its essential electrical systems, which are crucial for ensuring the safety and functionality of the generator in emergency situations.
Plan Of Correction
4-hour full-load Generator run was completed on 11/3/2024. This was in response to a power outage that lasted 16 hours. The Nursing home administrator educated the maintenance director on ensuring the Generator testing to be completed timely. The NHA will monitor system compliance monthly. Results will be reviewed at the QAPI meeting. The generator at Cranberry Place is a battery specific gravity. The maintenance department was educated on where the battery read out is and record it as per regulation. The testing was completed until August 2024, then was missed. The battery specific gravity test has been recorded. Audits will be weekly for 4 weeks. Results will be reviewed at QAPI for further recommendations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,159 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cranberry Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sherwood Oaks | 1.7 mi | ★★★★★ | 8 | 1 |
| Harmony Hills Healthcare And Rehabilitation Center | 3.5 mi | ★★★★★ | 1 | 0 |
| St John Specialty Care Center | 4.5 mi | ★★★★★ | 4 | 0 |
| Perry Health & Rehab Center | 7 mi | ★★★★★ | 29 | 0 |
| Concordia At Villa St Joseph | 7.5 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cranberry Place.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.