F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility documents, resident group meeting, clinical record review, observation and staff interview,
it was determined that the facility failed to accommodate the call bell needs for 19 of 19 residents in
Resident Council on 1/8/26, two of seven Group residents on 1/29/26, and one of seven residents observed
(Resident R41).Findings include:
Residents Affected - Some
Review of the facility policy Accommodation of Needs dated January 2026, the facility's environment and
staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe
independence functioning, dignity and well-being.
Review of the facility document Resident Council Meeting Minutes dated 1/8/26, indicated that during
Resident Council Residents unanimously expressed that staff do not leave their call bells in reach.
During a Resident Group meeting on 1/29/26, at 10:30 a.m. two of seven Group residents indicated call
bells are not always left within their reach. They put it where we can't reach it. This happens a lot.
Review of the admission record indicated Resident R41 admitted to the facility on [DATE].
Review of Resident R41's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/4/26,
indicated the diagnoses of high blood pressure, GERD (gastroesophageal reflux disease- when stomach
acid frequently flows back into the esophagus causing heartburn), and multiple sclerosis (a disease that
affects central nervous system).
Review of Resident R41's care plan intervention dated 8/7/24, indicated to be sure that resident's call light
is within reach and encourage resident to use it for assistance as needed.
During an observation and interview on 1/29/26, at 9:35 a.m. Resident R41 was observed lying in bed with
a call bell beside her head, clipped to her pillow. State Agency (SA) asked Resident R41 how she activates
her call bell, and resident explained that she is unable to move her arms, so she has to use her head to
activate the call bell. Resident R41 then moved her head vigorously from side to side but was not able to
reach the call bell with her head. Resident R41 stated I can give myself whiplash and still not reach it. I
need my pillow to be slide over to the left, so the light is closer.
During an interview and observation on 1/29/26, at 9:36 a.m. Nurse Aide (NA) Employee E26 entered
Resident R41's room, and assisted with moving the resident's pillow to the left. Resident R41 was then able
to activate the call light. NA Employee E26 confirmed that Resident R41 was unable to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 36
Event ID:
395845
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
activate call light when it was in the original position.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 1/29/26, at 2:36 p.m. the Nursing Home Administrator confirmed that the facility
failed to accommodate call bell needs for 19 of 19 Resident Council residents, two of seven Group
residents, and 1 of seven residents observed (Resident R41).
Residents Affected - Some
28 Pa. Code 201.14(a) Responsibility of license28 Pa. Code: 211.10(d) Resident care policies28 Pa. Code:
211.12(d)(1)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 2 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0575
Level of Harm - Potential for
minimal harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy
groups and a statement that the resident may file a complaint with the State Survey Agency.
Based on observations and staff interview, it was determined that the facility failed to post complete contact
information for State Long-Term Care Ombudsman program, and accessible, and complete contact
information for State Survey Agency and Adult Protective Services at the facility as required.Findings
include: During observations completed on 1/28/26 at 11:34 a.m., State Long-Term Care Ombudsman
information posted in the front hallway did not include the Ombudsman's mailing address as required. This
observation also revealed that the State Survey Agency (SSA) and Adult Protective Services (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. During an interview on 1/29/26, at 2:04 p.m.
Regional Director of Clinical Services Employee E2 confirmed that the facility failed to post complete
contact information for the State Long-Term Care Ombudsman program, the State Survey Agency, and
Adult Protective Services as required. 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code:
201.18(e) Management.
Event ID:
Facility ID:
395845
If continuation sheet
Page 3 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that
the facility failed to ensure that residents are free from misappropriation of property for one of five residents
(Resident R155).Findings include: Review of the facility policy Recognizing Signs and Symptoms of
Abuse/Neglect dated January 2026, indicated all types of resident abuse, neglect, exploitation, or
misappropriation of resident property are strictly prohibited. Review of the clinical record indicated that
Resident R155 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic
assessment of care needs) dated 12/9/25, indicated diagnoses of peripheral vascular disease (PVD,
circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), high blood pressure,
and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes
including loss of consciousness). Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a
screening test that aids in detecting cognitive impairment) score of 13 - cognitively intact. Review of facility
provided information dated 1/13/26, at 12:00 p.m. indicated Resident R155 was admitted to the hospital on
[DATE]. On 1/14/26, Resident R155 contacted the facility, stating they were looking for their wallet and
passport that was left at the facility. Resident R155's son claims that a bank card, social security card, and
military ID (identification) were all in this wallet. During the investigation two nurses indicated remembering
the wallet and passport. Both nurses relayed that they last seen the grey bag locked in the narcotic drawer
on the west unit back hall narcotic box for safe keeping. Said medication cart was searched, surrounding
area including the nurses' station, medication room and patient's room with no success in locating the grey
bag. Interview on 1/30/26, at 12:54 p.m. Social Services Director Employee E8 indicated Resident R155's
spouse was in the hospital and the son needed Resident R155's wallet for his mother's funeral, his debit
card, passport, and his military ID for when the dad dies, he'll need it for the funeral. We investigated it. The
last person who saw it was in the narcotic drawer on the [NAME] Unit. We were unable to locate it. Interview
on 1/30/26, at 1:00 p.m. the Director of Nursing confirmed the facility was unable to locate Resident R155's
personal property and that the facility failed to ensure that residents are free from misappropriation of
property for one of five residents (Resident R155). 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.28 Pa.
Code: S 201.18(b)(2) Management
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 4 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of policies and clinical records, observations and staff interviews, it was determined that the facility
failed to develop comprehensive care plans that included specific and individualized interventions to
address the care needs of residents for three of six residents reviewed (Residents R2, R45, and R116).
Findings include:
Review of the facility policy Goals and Objectives, Care Plans dated January 2026, indicated care plan
goals and objectives are defined as the desired outcome for a specific resident problem. Goals and
objectives are entered into the resident's care plan so that all disciplines have access to such information
and are able to report whether the desired outcomes are being achieved.
Review of the facility policy Departmental (Respiratory Therapy)-Prevention of Infection dated January
2026, indicated review the residents care plan to assess for any special circumstances or precaution
related to the resident.
Review of the admission record indicated Resident R2 was admitted to the facility on [DATE].
Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/25,
indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has
trouble controlling blood sugar and using it for energy) and respiratory failure (lungs can't get enough
oxygen). Section O special treatments, procedures, and programs, E1 tracheostomy care coded as
performed while a resident.
During an observation completed on 1/28/26, Resident R2 was in bed with a tracheostomy (trach-a surgical
opening through the neck into the trachea (windpipe) to help you breathe bypassing your nose, mouth and
throat) present.
Review of Resident R2's physician order dated 12/22/25, indicated respiratory tracheotomy assessment six
times a day. Pre -existing trach – 6 Shiley (size and brand of trach tube).
Review of Resident R2's care plan on 1/30/25, failed to include a plan of care for the management and
monitoring of the tracheostomy.
During an interview completed on 1/30/26, at 11:20 a.m. Registered Nurse Employee E5 confirmed a care
plan was not present for Resident R2's tracheostomy care.
Review of the admission record indicated Resident R45 was admitted to the facility on [DATE].
Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/11/26,
indicated the diagnoses of high blood pressure, renal insufficiency (a condition in which the kidneys lose
the ability to remove waste and balance fluids), and diabetes (a long-term condition in which the body has
trouble controlling blood sugar and using it for energy).
Review of Resident R45's physician order dated 1/14/26, indicated COVID isolation/contact and
dropletPrecautions (Staff must wear N95 respirator, protective eye wear, gowns and gloves). Care and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 5 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
services to be provided in the resident's room every shift for infection prevention.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident R45's care plan on 1/29/26, failed to include a plan of care for the management and
monitoring of Covid isolation.
Residents Affected - Some
Interview on 1/30/26, at 9:00 a.m. Infection Preventionist (IP) Employee E9 confirmed Resident R45's plan
of care failed to include a plan of care for the management and monitoring of Covid isolation.
Review of the admission record indicated Resident R116 was admitted to the facility on [DATE].
Review of Resident R116's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn't have
enough healthy red blood cells), paraplegia (paralysis of legs and lower body), and anxiety.
Review of Resident R116's physician order dated 1/10/26, indicated COVID isolation/contact and
dropletPrecautions. Care and services to be provided in the resident's room every shift for infection
prevention.
Review of Resident R116's care plan on 1/29/26, failed to include a plan of care for the management and
monitoring of Covid isolation.
Interview on 1/30/26, at 9:00 a.m. Infection Preventionist (IP) Employee E9 confirmed Resident R116's plan
of care failed to include a plan of care for the management and monitoring of Covid isolation.
Interview on 1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to develop
comprehensive care plans that included specific and individualized interventions to address the care needs
of residents for three of six residents reviewed (Residents R2, R45, and R116).
28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 6 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and resident and staff interview, it was determined that the facility failed to promote a
multidisciplinary approach with care conferences for four of seven resident's reviewed (Resident R5, R10,
R40, R119).
Findings include:
Review of the clinical record indicated Resident R5 was admitted [DATE].
Review of Resident R5's MDS (minimum data set a periodic review of assessment needs) dated 10/15/25,
indicated diagnosis of heart failure (when the heart muscle can't pump enough blood to meet the body's
needs) and CAD (coronary artery disease - narrowing or blockage of your coronary arteries).
Review of Resident R5's Interdisciplinary Care Plan Conference sign in sheet dated 10/22/25, included the
following disciplinary: social service, dietary, therapy with the resident and family member in attendance.
Review of Resident R5's Interdisciplinary Care Plan Conference sign in sheet failed to include nursing.
Review of clinical record indicated Resident R119 was admitted to the facility on [DATE], with diagnoses
that included progressive multiple sclerosis (disease that causes breakdown of the protective covering of
nerves), bacteremia (bacteria in the bloodstream) and urinary tract infection.
Review of Resident R199's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and
care needs) assessment, dated 1/3/26, indicated the diagnoses remain current.
Progress dated 12/30/25 indicated nursing unavailable during care conference meeting. Review of clinical
record indicated Resident R10 was admitted to the facility on [DATE], with diagnoses that included atrial
fibrillation ( irregular heart rhythm), heart failure and hypertension.
Review of Resident R10's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and
care needs) assessment, dated 12/24/25, indicated the diagnoses remain current.
Progress dated 7/8/25 and 1/28/26 indicated nursing unavailable during care conference meeting.
Review of clinical record indicated Resident R40 was admitted to the facility on [DATE], with diagnoses that
included chronic obstructive pulmonary disease ( ongoing lung condition caused by damage to the lungs),
anxiety and cellulitis (spreading skin infection).
Review of Resident R40's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and
care needs) assessment, dated 12/18/25, indicated the diagnoses remain current.
Progress dated 12/17/25 indicated nursing unavailable during care conference meeting.
During an interview on 1/31/26 at 10:00 a.m. Director of Nursing confirmed there was no nursing in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 7 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
attendance at the care conferences as required.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 211.12(d)(3) Nursing services
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 8 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records and staff interview, it was determined that the facility failed to obtain a physician
order for a wander guard for one of one resident (Resident R40) and failed to obtain a physician order for a
colostomy for one of one resident (Resident R59).Findings include: Review of facility policy Physician
Orders dated January 25, indicated the facility maintains a system for receiving, documenting, verifying,
and carrying out physician orders. Review of the admission record indicated Resident R59 was admitted to
the facility on [DATE], with diagnoses that included peripheral vascular disease (circulatory condition
characterized by narrowed blood vessels), sepsis and anemia. Review of Resident R59''s Minimum Data
Set (MDS - a periodic assessment of care needs) dated 11/3/25, indicated the diagnoses remain current.
Review of most recent plan of care for Resident R59 indicates the need for colostomy management.
Review of Resident R59's physician's orders dated 1/12/26 revealed no orders for a colostomy. Review of
the clinical record indicated Resident R40 was admitted to the facility on [DATE], with diagnoses that
included chronic obstructive pulmonary disease (progressive lung disease characterized by persistent
respiratory symptoms and airflow limitation, atrial fibrillation (irregular and often rapid heart rhythm) and
anxiety. Review of Resident R40's annual MDS assessment (minimum data assessment)- periodic
assessment of resident care needs) dated 12/18/25, indicated the diagnosis remained current. Review of
Resident R40's nurse progress dated 1/13/26 indicated wander guard placed on right ankle. Review of
Resident R40s most recent physician orders indicate no order for wander guard. During an interview on
1/30/26, at 1:12 p.m. Director of Nursing confirmed there was no physician order for the wander guard or
colostomy as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 9 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the
review of professional standards of practice, facility policy, clinical records, observation, and interviews with
staff and resident, it was determined that the facility failed to make certain that residents received the
necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from
prolonged pressure to the skin) for two of three residents (Residents R83 and R156).
Residents Affected - Few
Findings include:
Review of the facility policy Physician Orders last reviewed January 2026, indicated that orders must be
carried out as written and within the timeframe specified.
Review of the admission record indicated Resident R83 was admitted to the facility on [DATE].
Review of Resident R83's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/23/26,
indicated the diagnoses of high blood pressure, quadriplegia (paralysis affecting all four limbs) and
neurogenic bladder (loss of bladder control).
During an observation completed on 1/28/26, at 11:11 a.m. Resident R83 was in bed Prafo boots (boots
that stabilize the ankle and foot helping mange muscle weakness, foot drop and ankle/foot anomalies while
removing pressure from the heel to prevent pressure ulcers) were visualized to her bilateral lower
extremities.
During an observation completed on 1/28/26, at 1:18 p.m. Prafo boots were visualized on both bilateral
lower extremities.
During an observation and interview completed on 1/28/26, at 2:15 p.m. upon asking Resident R83
concerning the schedule for the boots, stated if I am in bed they go on in the morning and then my bunny
boots (medical foot supports designed to prevent heel and toe pressure injuries that provides cushioning
and positioning flexibility while allowing air circulation to reduce skin irritation and promote comfort) go on at
5:00 p.m. I keep track and let the staff know when it is time to change them.
Review of resident R83's physician orders on 1/29/26, failed to include orders or a schedule for Resident
R83's Prafo and bunny boots.
During an interview completed on 1/29/26, at 12:12 p.m. Registered Nurse RN Employee E5 confirmed
there were not any current physician orders or schedule for Resident R83's Prafo and bunny boots.
Review of the admission record indicated Resident R156 was admitted to the facility on [DATE].
Review of Resident R156's MDS dated [DATE], indicated the diagnoses of high blood pressure, malnutrition
(lack of nutrients in the body), and heart failure (a progressive heart disease that affects pumping action of
the heart muscles).
Review of Resident R156's clinical record revealed a physician's order dated 12/25/25, to wash coccyx
(tailbone) and peri area/groin twice daily with soap and water and apply zinc based barrier cream (a
protective cream that helps to prevent skin irritation and breakdown in a moist environment)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 10 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
report any decline in wound care, two times a day (morning shift, and evening shift).
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident R156's Treatment Administration Record (TAR) indicated that Resident R156 did not
receive the above treatment on 12/26/25 on the evening shift.
Residents Affected - Few
During an interview on 1/30/26, at 9:48 a.m. the Director of Nursing confirmed that the facility failed to
provide pressure ulcer prevention treatments as ordered for Resident R156.
Interview on 1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to make certain
that residents were monitored, assessed, and received the necessary services to prevent pressure
ulcers/wounds from developing for two of three residents (Residents R83 and R156).
28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 11 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of professional standards of practice facility polices, observations, clinical records, and staff
interview it was determined that the facility failed to make certain that appropriate treatments and services
were provided for the use of a foley catheter (thin tube placed in bladder to drain urine) as required for three
of seven (Resident R64, R83 and R151).
Findings include:
Review of the facility policy Catheter Care dated January 2026, indicated the purpose of this procedure is
to prevent urinary catheter-associated complications, including urinary tract infections. Use aseptic
technique when handling or manipulating the drainage system. Review the resident's care plan to assess
any special needs of the resident. Change catheters and drainage bags based on clinical indications such
as infection, obstruction, or when the closed system is compromised. If the catheter material contributes to
obstruction, notify the physician and change the catheter if instructed.
Review of the facility policy Dignity dated January 2026, indicated each resident shall be cared for in a
manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and
feelings of self-worth and self-esteem. Staff are expected to promote dignity and assist residents by helping
to keep urinary catheter bags covered.
Review of the admission record indicated Resident R64 was admitted to the facility on [DATE].
Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/24/25,
indicated the diagnosis of diabetes (high sugar in the blood), anxiety, and respiratory failure (lungs can't get
enough oxygen).
Observation on 1/28/26, at 10:23 a.m. Resident R64's urinary catheter bag (a medical collection device
attached to a urinary catheter to safely hold urine outside of the body) was hanging on his bed and failed to
have a dignity bag as required.
Interview completed on 1/28/26, at 10:26 a.m. Registered Nurse (RN) Employee E22 confirmed the urinary
catheter bag failed to have a dignity bag as required and stated, it looks like they forgot to put a cover on it.
Review of Resident R64's current physician orders on 1/29/26, failed to include orders for the type of
urinary catheter or urinary catheter care.
Review of Resident R64's current care plan on 1/29/26, failed to include interventions for the type of urinary
catheter or care for the urinary catheter.
Interview completed on 1/29/26, at 9:33 a.m. RN Employee E22 confirmed there were no current orders or
care-plan in place for the urinary catheter.
Review of the admission record indicated Resident R83 was admitted to the facility on [DATE].
Review of Resident R83's Minimum Data Set (MDS - a periodic assessment of care needs) dated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 12 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
1/23/26, indicated the diagnoses of high blood pressure, quadriplegia (paralysis affecting all four limbs) and
neurogenic bladder (loss of bladder control).
Review of Resident 83's physician order dated 4/16/25, indicated to change catheter as needed.
Review of Resident R83's physician ordered dated 1/6/26, indicated indwelling foley catheter (thin tube
placed in bladder to drain urine) due to neurogenic bladder.
Review of Resident R83's care plan with revision on 8/22/24, indicated resident has an indwelling catheter
related to neurogenic bladder, change catheter as per order. Indwelling Foley Catheter size18 French with
5cc balloon (holds tube in place in the bladder).
Review of Resident R83's care plan with revision on 3/1/25, indicated Risk for infection related to foley
catheter. Manage indwelling catheters to minimize risk of infection.
Review of Resident R83's health status note dated 12/28/25, at 8:30 a.m. indicated alerted by resident that
her catheter has been leaking since yesterday as her brief has been wet and her drainage bag empty. This
nurse withdrew 10milliter (ml) from balloon and advanced catheter with a return of medium yellow drainage.
Catheter was flushed with 60ml of sterile water with a return of clear, light-yellow drainage. Resident had no
further complaints.
Review of the admission record indicated Resident R151 admitted to the facility on [DATE].
Review of Resident R151's MDS dated [DATE], indicated the diagnoses of atrial fibrillation, high blood
pressure, and renal failure (a condition in which the kidneys lose the ability to remove waste and balance
fluids).
Review of Resident R151's care plan dated 1/26/26, indicated resident has an indwelling foley catheter
related to urinary retention.
Observation and interview on 1/29/26, at 11:27 a.m. Resident R151 indicated they needed their indwelling
foley catheter adjusted because something was wrong with it. Resident R151's foley catheter failed to have
a dignity bag as required.
During an observation and interview on 1/29/26, at 11:30 a.m. Registered Nurse (RN) Employee E7
confirmed the facility failed to make certain that appropriate treatments and services were provided for the
use of a foley catheter (thin tube placed in bladder to drain urine) required for two of seven (Resident R64,
and R151).
Interview completed on 1/31/26, at 11:40 a.m. upon asking the Director of Nursing (DON) what the protocol
for a urinary catheter that is found to be leaking replied if a catheter was leaking it would be replaced with a
new one. Upon review of the nursing note dated 12/28/25, replied. I believe a new one would have been
warranted, they did not follow the facility protocol and confirmed that the facility failed to make certain that
appropriate treatments and services were provided for the use of a urinary catheter required for three of
seven (Resident R64, R83 and R151).
28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa.
Code: 211.12(d)(1)(2)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 13 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, observations, staff interviews, and clinical record review, it was determined that the
facility failed to provide appropriate respiratory care for two of four residents (Resident R8 and
R34).Findings include: Review of the facility policy Administering Medications through a Small Volume
Handheld Nebulizer dated January 2026, indicated the purpose of this procedure is to safely and
aseptically administer aerosolized particles of medication into the resident's airway. When treatment is
complete, turn off nebulizer, rinse and disinfect the nebulizer equipment according to facility protocol. When
equipment is completely dry, store it in a plastic bag with the resident's name and date on it. Review of the
admission record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's
Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated the diagnosis of
respiratory failure (lungs can't get enough oxygen), Parkinson's disease (progressive brain disorder that
causes muscle stiffness, slowed movement and balance issues) and aphasia (a communicative disorder
that affects the ability to speak and understand). Review of Resident R8's physician orders dated 10/13/25,
indicated average volume assured pressure support (AVAPS-used to treat obstructive sleep apnea) every
night shift. During an observation completed on 1/28/26, at 10:46 a.m. Resident R8's AVAPS mask was
hanging on an IV pole next to his bed not stored in a bag as required. During an interview completed on
1/28/26, at 10:47 a.m. Registered Nurse (RN) Employee E21 confirmed the AVAPS mask was hanging on
the IV pole and not stored in a bag as required. RN Employee E21 stated sometimes the nurse aids take it
off and don't put it in a bag. Review of the admission record indicated Resident R34 was admitted to the
facility on [DATE]. Review of Resident R34's MDS dated [DATE], indicated the diagnosis of heart failure
(heart doesn't pump the way it should), obstructive sleep apnea (breathing stops during sleep) and
hyperlipidemia (high fat in the blood). Review of Resident R34's physician orders dated 1/8/26, indicated
Ipratropium-Albuterol solution 3 milliliter (ml) inhaled via nebulizer every four hours as needed. During an
observation completed on 1/28/26, at 10:56 a.m. Resident R34's nebulizer was sitting on the bedside table
not stored in a bag as required. During an interview completed on 1/28/26, at 11:01 a.m. Licensed Practical
Nurse (LPN) Employee E20 confirmed the nebulizer was sitting on the bedside table and was not stored in
a bag as required. Review of Resident R34's physician orders dated 1/8/26, indicated continuous positive
airway pressure (CPAP-a machine that delivers continuous air pressure while you sleep) at bedtime. The
order failed to have the settings for the device. Review of Resident R34's current care plan on 1/30/26,
failed to have interventions for the CPAP machine. During an interview completed on 1/30/26, at 11:22 a.m.
Registered Nurse (RN) Employee E5 confirmed the orders for the CPAP machine did not include the
settings and the care plan failed to have interventions for the CPAP. During an interview completed on
1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate
respiratory care for two of four residents (Resident R8 and R34). 28 Pa. Code: 201.14(a) Responsibility of
licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing
services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 14 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, resident record review, and staff interviews, it was determined that the facility failed
to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause
re-traumatization of the resident for three of five residents (Resident R7, R9 and R56). Findings include:
Review of the facility policy Trauma-Informed and Culturally Competent Care dated January 2026, indicated
to guide staff in providing care that is culturally competent and trauma informed in accordance with
professional standards of practice. To address the needs of trauma survivors by minimizing triggers and /or
re-traumatization. Develop individualized care plans that address past trauma in collaboration with the
residents and family, as appropriate. Identify and decrease exposure to triggers that may retraumatize the
resident. Review of the facility policy Goals and Objectives, Care Plans dated January 2026, indicated care
plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of
independence. Care plan goals and objectives are defined as the desired outcome for a specific resident
problem. Review of the admission record indicated Resident R7 was admitted to the facility on [DATE].
Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/23/25,
indicated the diagnosis of quadriplegia (paralysis of all four limbs), anxiety, and depression. Observation
completed on 1/28/26, at 9:57 a.m. a sign was noted on the outside of Resident R7's door. The sign stated,
do not knock. Review of Resident R7's care plan on 1/30/26, indicated that Resident R7 had a history of
trauma that affects him negatively. Resident was shot by a gun several times but failed to identify what the
triggers were and how to avoid them. Review of the admission record indicated Resident R9 was admitted
to the facility on [DATE]. Review of Resident R9's MDS dated [DATE], indicated the diagnosis of
quadriplegia (paralysis affecting all four limbs), neurogenic bladder (loss of bladder control) and anemia
(low iron in the blood). Observation completed on 1/28/26, at 9:57 a.m. a sign was noted on the outside of
Resident R9's door. The sign stated, do not knock. Review of Resident R9's care plan on 1/30/26, indicated
that Resident R9 had a history of trauma that affects him but failed to identify what the triggers were and
how to avoid them. Interview completed on 1/28/25, at 10:01 a.m. Registered Nurse (RN) Employee E22
confirmed that both Resident R7 and Resident R9 have do not knock signs on the outside of their doors
and stated, they are both gunshot victims and loud noises are a trigger for them. Review of the admission
record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's MDS dated
[DATE], indicated the diagnosis of hemiplegia (paralysis affecting one side of the body), anxiety and
depression. Review of Resident R56's care plan on 1/30/26, indicated that the resident has a history of
trauma that affects her but failed to identify what the triggers were and how to avoid them. During an
interview completed on 1/30/26, at 11:30 a.m. Registered Nurse RN Employee E5, confirmed that Resident
R56's care plan failed to identify what the triggers were and how to avoid them. RN Employee E5 stated
when she transferred over, we were told she is not to have male caregivers and that is also not included on
the care plan. RN Employee E5 also confirmed that Residents R7 and R9 also did not have care plans that
identified any triggers and how to avoid them. During an interview completed on 1/30/26, at 11:55 a.m.
upon asking Social Service Employee E8, how triggers are identified for residents who have had trauma
stated, we ask the resident if they have any triggers, if they tell us then we will put it on the care plan.
During an interview completed on 1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility
failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may
cause re-traumatization of the resident for three of five residents (Resident R7, R9 and R56). 28 Pa. Code:
201.14(a) Responsibility of
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 15 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
licensee.28 Pa. Code: 201.18(b)(1) Management
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 16 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical record review, review of Resident Representative concerns, review of facility
documents, resident observations, resident and staff interviews, it was determined that the facility failed to
have sufficient nursing staff to provide nursing and related services to attain or maintain the highest
practicable physical, mental, and psychosocial well-being for one of four quarters of facility staffing data
(Quarter Three), two of three Resident Council Meetings (November 2025, and January 2026), six of seven
residents in a Group meeting, one of three months for Grievances (January 2026), and five of ten residents
observed (Residents R41, R73, R76, R79, and R151).
Findings include:
Review of the facility policy Staffing, Sufficient and Competent Nursing dated January 2026, indicated the
facility provides sufficient staff numbers of nursing staff with the appropriate skills and competency
necessary to provide nursing and related care and services for all residents in accordance with resident
care plans and the facility assessment.
Review of Payroll Based Journal (PBJ - a mandatory reporting system for nursing homes in which staffing
information is reported on a quarterly basis) dated 4/1/25, through 6/3/25, indicated that the facility had
excessively low weekend staffing.
Review of 'Resident Council Meeting Minutes dated 11/13/25, and 1/8/26, indicated that Multiple residents
expressed concern with the length of time it takes for call lights to be answered.
Review of Concern and Comment Form dated 1/8/26, indicated during Resident Council Residents
expressed dissatisfaction with meal temperatures- receiving cold items, and review of Facility and
Investigation and Response dated 1/12/26, in response to this concern, indicated Food carts are delivered
to the units and sit for a period of time before trays are passed.
Review of Concern and Comment Form dated 1/11/26, indicated You need more staff. One person covering
is not enough for half a floor. Taking two- two and half hours to get a patient on a bedpan is not acceptable.
Has happened too often, and review of Facility and Investigation and Response dated 1/16/26, in response
to this concern stated Investigation conducted related to short staffing allegations at the facility. Reviewed
schedules, payroll, ratios and interviews with administration and leadership. The investigation determined
that the facility experienced periods of staffing challenges due to ongoing recruitment difficulties and
unexpected absences.
Review of a Resident Representative Concern dated 1/13/26, indicated that residents Go longer than a
week between showers due to insufficient staffing, and Residents are fed cold meals, and Call lights go
unanswered.
Review of a Resident Representative Concern dated 1/22/26, indicated that During Christmas, they had 1
nurse/aide on the floor to take care of 35 residents. This is completely unacceptable, and My mom's food
tray sat in hallway for an hour before I finally went out looking for her food, of course it was ice cold by then
During a Resident Group meeting on 1/29/26, at 10:30 a.m. when asked if they felt the facility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 17 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
maintained enough staff to care for resident needs, six of seven residents indicated it depended on the day,
the shift, and the number of staff that came to work. Indicated if a resident requires a Hoyer lift (a
mechanical lift that moves a body from point A to point B) they would likely not get a shower on days the
staff were short because it takes two people to use the equipment. Three of seven residents indicated they
have missed showers due to lack of staff. Four of seven residents indicated you can wait for assistance on
any given day or shift anywhere from 30 minutes up to two hours.
Interview on 1/29/26, at 11:17 a.m. Nurse Aide (NA) Employee E10 indicated showers that all depends on
how many staff we have, we need two staff for all the Hoyer lift residents who must stay in bed until we find
a second person.
During an interview on 1/29/26, at 11:17 a.m. NA Employee E26 stated, Staffing is a problem, can't always
do showers, and care gets cut in half, you can't get people out of bed, trays are hard to pass when we're
short. You can't be everywhere. Call lights have to wait sometimes.
During an interview on 1/29/26, at 11:28 a.m. NA Employee E28 stated when staffing is low, Showers don't
get done, we are slow at passing trays, and sometimes call bell take longer.
Interview on 1/29/26, at 11:30 a.m. Registered Nurse (RN) Employee E11 indicated staffing has been a real
struggle.
Interview on 1/29/26, at 11:35 a.m. NA Employee E12 indicated usually the quick showers get done, it's the
residents who require a Hoyer for their showers that are missed or wait longest.
Interview on 1/29/26, at 11:40 a.m. Licensed Practical Nurse (LPN) Employee E13 indicated it is very hard
to get the showers in, especially the Hoyer showers seem to be very bad lately.
Review of the admission record indicated Resident R41 admitted to the facility on [DATE].
Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/4/26,
indicated the diagnoses of high blood pressure, GERD (gastroesophageal reflux disease- when stomach
acid frequently flows back into the esophagus causing heartburn), and multiple sclerosis (a disease that
affects central nervous system).
During an interview on 1/29/26, Resident R41 stated that she is to receive two showers per week but
frequently misses showers. Sometimes the girls say they can't give me one due to staffing, but that's not my
problem.
Review of clinical record revealed Resident R41 is to receive showers every Tuesday and Thursday. Review
of Documentation Survey Report conducted on 1/29/26, revealed that Resident R41 did not receive
showers on 1/6/26, 1/8/26, and 1/28/26 as indicated.
During an interview on 1/29/26, at 1:37 p.m. the Director of Nursing (DON) confirmed that the facility failed
to provide showers as scheduled to Resident R41 on 1/6/26, 1/8/26, and 1/28/26
Review of the admission record indicated Resident R73 admitted to the facility on [DATE].
Review of Resident R73's MDS dated [DATE], indicated the diagnoses of atrial fibrillation (irregular heart
rhythm), high blood pressure and pancreatic cancer.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 18 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident R73's care plan dated 12/16/25, indicated be sure resident's call light is within reach
and encourage the resident to use it for assistance as needed. Resident needs prompt response to all
requests for assistance.
Observation on 1/29/26, at 11:30 a.m. the monitor at the desk indicated Resident R73's call light had been
activated for 17 minutes. Interview on 1/29/26, at 11:31 a.m. Resident R73 indicated they needed a pain
pill. The final time the call light was activated was 22 minutes.
Review of the clinical record revealed Resident R76 was admitted to the facility on [DATE].
Review of Resident R76's MDS dated [DATE], indicated diagnoses of high blood pressure, aphasia (a
language disorder that affects a person's ability to speak, understand, read, and write), and hypokalemia
(low levels of potassium in the blood).Review of Resident R76's clinical record revealed the resident is
scheduled to have shower every Sunday and Wednesday at 6 a.m.
Review of documentation revealed Resident R76 did not receive their shower as scheduled on 1/4/26,
1/11/26, and 1/25/26.
During an interview on 1/29/26, at 10:04 a.m. Resident R76 stated, My roommate is supposed to get a
shower every Monday and Thursday. She did not get one on Monday, she just finally got one on
Wednesday, so now she will not get one today [Thursday]. I have a big mouth; I need to speak up for
residents like my roommate who can't always make their needs known.During an interview on 1/29/26, at
10:21 am. Resident R76 stated, The website for the facility says we're supposed to get an hour of care per
resident every shift. I'm lucky if I get 15 minutes of care a week. I can do a lot for myself, I have balance
issues, I need the staff to help me in the shower room. When I don't get my scheduled showers, they [staff]
like to say they don't have enough staff. I tell them it's not my problem, tell your boss to get more
staff.Review of the clinical record revealed Resident R79 was admitted to the facility on [DATE].
Review of Resident R79's MDS dated [DATE], indicated diagnoses of aphasia, depression, and lack of
coordination.Review of Resident R79's clinical record revealed that the resident is scheduled to have a
shower every Monday and Thursday during the 7 a.m. to 3 p.m. day shift.
Review of documentation revealed Resident R79 did not receive their shower as scheduled on
1/26/26.During an interview on 1/29/26, at 10:23 a.m. when asked if they receive their showers as
scheduled, Resident R79 shook their head no indicating that they do not receive their showers as
scheduled. Resident R79 then pointed to a calendar and indicated they are scheduled to receive showers
every Monday and Thursday.During an interview on 1/29/26, at 1:41 p.m. the DON confirmed that the
facility failed to provider showers as scheduled for Residents R76 and R79.
Review of the admission record indicated Resident R151 admitted to the facility on [DATE].
Review of Resident R151's MDS dated [DATE], indicated the diagnoses of atrial fibrillation, high blood
pressure, and renal failure (a condition in which the kidneys lose the ability to remove waste and balance
fluids).
Review of Resident R151's care plan dated 1/26/26, indicated be sure resident's call light is within reach
and encourage the resident to use it for assistance as needed. Resident needs prompt response to all
requests for assistance.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 19 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Observation on 1/29/26, at 11:27 a.m. the monitor at the desk indicated Resident R151's call light had been
activated for 25 minutes. Interview on 1/29/26, at 11:27 a.m. Resident R151 indicated they needed their
indwelling foley catheter (a thin tube in bladder to drain urine) adjusted because something was wrong with
it. The final time the call light was activated was 26 minutes.
During an interview on 1/29/26, at 11:30 a.m. RN Employee E7 confirmed the monitor at the desk indicated
times of 22 minutes and 25 minutes for Resident R151.
Interview on 1/29/26, at 2:00 p.m. the DON confirmed the facility failed to have sufficient nursing staff to
provide nursing and related services to attain or maintain the highest practicable physical, mental, and
psychosocial well-being for or one of four quarters of facility staffing data (Quarter Three), two of three
Resident Council Meetings (November 2025, and January 2026), six of seven residents in a Group
meeting, one of three months for Grievances (January 2026), and five of ten residents observed (Residents
R41, R73, R76, R79, and R151).
28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(6) Management.28 Pa.
Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(4)(5)(f.1)(i) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 20 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0745
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility documents, clinical record review and staff interview the facility failed to provide sufficient
and timely social services to meet the resident needs for one of three residents reviewed (Resident
R33).Findings include: Review of facility policy dated 01/26, Referrals, Social Service indicated Social
services personnel shall coordinate most resident referrals with outside agencies. Social services will
document the referral in the resident's medical record. Review of facility documentation Social Worker job
description indicated responsibilities document assessment, clinical team meeting minutes, and community
resource referrals. Review of the clinical record indicated resident R33 was admitted [DATE]. Review of
Resident R33's MDS (minimum data set a periodic review of assessment needs) dated 12/18/24, indicated
diagnosis of heart failure and CAD. Review of Resident R33 clinical record psychiatric evaluation note
dated 9/24/25, indicated Resident R33 says his mood is unchanged and he is still frustrated that he is still
unable to find a facility closer to home and he feels like a prisoner at Cranberry. Review of Resident R33
clinical record psychiatric evaluation note dated 1/7/26, indicated Resident R33 says his mood is
unchanged and he is still frustrated that he is unable to go home or to another facility another facility with
better liberty. He realizes people are working on it but he is frustrated. Just frustrated that he is stuck in this
prison. Review of Resident R33 clinical record progress notes indicated the last referrals regarding housing
and placement outside of the nursing care facility were dated July of 2025. During an interview on 1/31/26,
at 12:13 p.m. Social Service Director Employee E8 confirmed that the facility has 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 needs for Resident R33. 28 Pa. Code 201.14(b)Responsibility of licensee.28 Pa. Code
211.16(a)(1) Social services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 21 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical record review, and staff interview it was determined that the facility failed to
identify parameters for heart medication for one of three residents (Resident R5).Findings include: Review
of facility policy Pharmacy Services Overview dated 01/26, indicated: Pharmaceutical services consist of: a.
The process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling,
reconciling, compounding, (e.g. intravenous antibiotics), dispensing, packaging, labeling, disturbing,
administering, monitoring responses to, using and/or disposing of all medications, biologicals,
chemicals;The provision of medication related information to health care professionals and residents;The
process of identifying, evaluation, and addressing medication -related issues including the prevention and
reporting of medication errors; andThe provision, monitoring and/or the use of medication -related
devices.The facility shall contract with a licensed consultant pharmacist to help it obtain an maintain timely
and appropriate pharmacy services that support residents' needs, are consistent with current standards of
practice, and meet state and federal requirements. Review of facility policy Pharmacy Services Overview
dated 01/26, indicated: Screen new medications for orders for key parameters including appropriate
indications proper dose and duration, correct route of administration, potential for adverse consequences
including medication interactions, possible duplicative therapy. Review of facility documentation
carvedilol:Indications: Hypertension, HF (ischemic or cardiomyopathic) with digoxin, diuretics, ace
inhibitors. Left ventricular dysfunction after MI. Action Therapeutic Effect Decreased HR and BP Improved
cardiac output, slowing of the progression of HF and decreasing the risk of death.Assessment Monitor BP
and HR frequently during dose adjustment and periodically during therapy. If HR is down to <55 bpm,
decrease dose.Implementation:PO take HR before administration. If <50 bpm or if arrythmia occurs hold
therapy. Review of the clinical record indicated Resident R5 was admitted [DATE]. Review of Resident R5's
MDS (minimum data set a periodic review of assessment needs) dated 10/15/25, indicated diagnosis of
heart failure (when the heart muscle can't pump enough blood to meet the body's needs) and CAD
(coronary artery disease - narrowing or blockage of your coronary arteries). Review of Resident R5 clinical
record MAR (medication administration record - a record of a resident's medication) for November 2025
indicated: 11/21/25 to 11/30/25:Carvedilol Oral Tablet 6.25MG (Carvedilol)Give 1 tablet by mouth twotimes
a day for HTN-Start Date-11/21/2025 0900Review of Resident R5 clinical record MAR December 2025
indicated:Carvedilol OralTablet 6.25 MG(Carvedilol)Give 1 tablet bymouth two times [NAME] for HTN-Start
Date-11/21/2025 0900Review of Resident R5 clinical record MAR January 2026 indicated:Carvedilol
OralTablet 6.25 MG(Carvedilol)Give 1 tablet bymouth two times [NAME] for HTN-Start Date-11/21/2025
0900 Review of the MAR from 11/21/25 to 11/30/25, and 12/25 and 1/1/26 to 1/23/26 failed to include
parameters for carvedilol. Review of the MAR for January 2026 failed to identify parameters until 1/23/26.
During an interview on 1/31/26, at 11:43 a.m. DON (Director of Nursing) confirmed that the facility failed to
follow manufactures guidelines and identify parameters for heart medication for Resident R33. 28 Pa. Code
201.14 (a) Responsibility of licensee28 Pa. Code 211.9 (a)(1) Pharmacy services
Event ID:
Facility ID:
395845
If continuation sheet
Page 22 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on review of facility policies, observations, and staff interviews, it was determined that the facility
failed to store medications and biologicals in a safe, secure, and orderly manner for three of four medication
carts (North Unit Back Hall, [NAME] Unit Front Hall, and East Unit Front Hall). Findings include:
Review of the facility policy Storage of Medications dated January 2026, indicated that medications and
biologicals are stored safely, securely, and properly.
During an observation on 1/28/26, at 9:31 a.m. of the North Unit Back Hall Medication Cart revealed the
following:
Resident R23's lantus pen (a prefilled pen that injects long-acting insulin under the skin), no open or
expiration date noted.
Resident R80's lantus pen, no open or expiration date noted.
Resident R146's insulin lispro vial (a rapid-acting insulin, stored in a multi-dose vial), no open or expiration
date noted.
During an interview on 1/28/26, at 9:35 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the
above observations and that the facility failed to properly store medications in the North Unit Back Hall
Medication Cart.
Observation of the [NAME] Unit Front Hall medication cart on 1/28/26, at 9:35 a.m. indicated the following
medications opened and not dated as required:- cyclosporine eye drops (used for dry eyes)- eye itch relief
bottle- albuterol sulfate nebulizer solution (used to make breathing easier)
Interview on 1/28/26, at 9:35 a.m. Registered Nurse (RN) Employee E14 confirmed the medications were
open and without a date as required.
Observation of the East Unit Front Hall medication cart on 1/28/26, at 9:42 a.m. indicated the following
medications opened and not dated as required:- budesonide solution (used to make breathing easier) 2
boxes- ipratropium bromide (used to make breathing easier)
Interview on 1/28/26, at 9:42 a.m. LPN Employee E15 confirmed the medications were open and without a
date as required.
Interview on 1/28/26, at 10:00 a.m. the Director of Nursing confirmed the facility failed to store medications
and biologicals in a safe, secure, and orderly manner for three of four medication carts (North Unit Back
Hall, [NAME] Unit Front Hall, and East Unit Front Hall).
28 Pa. Code: 201.14(a)Responsibility of licensee.
28 Pa. Code: 211.9(a)(1) Pharmacy services.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 23 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 24 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0790
Provide routine and 24-hour emergency dental care for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records, and staff and resident interviews, it was determined that the facility failed to
ensure that a dental appointment was scheduled for one of six residents reviewed (Resident R59). Findings
include:Review of the admission record indicated Resident R59 was admitted to the facility on [DATE].
Review of Resident R59''s Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/3/25,
indicated diagnoses of peripheral vascular disease (circulatory condition characterized by narrowed blood
vessels), sepsis and anemia. Documentation by the facility's contracted dental provider dated 11/21/25,
indicated Resident R59 potentially has extraction(s) that are surgical in nature, need to consult with an Oral
MaxillofacialSurgeon. Review of Resident R59's progress notes dated 11/25/25 indicated received list of
oral surgeons from 360 care/ Social work director, calls placed to several to schedule for resident's teeth
removal. During an interview on 1/30/26, at 1:30 p.m. Unit Manager Employee E27 stated there has not
been an appointment set up and it could take up to two years because Resident R59 needs to be
transported via stretcher. During an interview on 1/30/26, at 2:00 p.m. the Nursing Home Administrator
confirmed the facility failed to obtain dental services for Resident R59 as required. 28 Pa. Code
211.12(d)(1)(3)(5) Nursing services28 Pa. Code 211.15(a) Dental Services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 25 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on a review of facility policies, observations and staff interviews it was determined that the facility
failed to properly label and date food products, failed to maintain sanitary conditions in the ice machine,
failed to properly restrain hair, failed to verify proper sanitizing strength in the 3-compartment sink in the
Main Kitchen (Main Kitchen), and failed to properly monitor refrigerator temperatures in three of three
nursing unit kitchenettes (North, East, and West) which created the potential for food borne illness. Findings
Include: Review of the facility policy Food Receiving and Storage last reviewed January 2026, and
previously reviewed indicated that all foods in the refrigerator or freezer will be covered, labeled, and dated.
Food items and snacks kept on the nursing units must be kept below 41 degrees at the nurse's station and
must be labeled with the resident's name, the item and the use by date. Refrigerator must have a working
thermometer and be monitored for temperature. Review of the facility policy Food Storage Guidelines last
reviewed January 2026, stated that all food supply is marked with the date the item was received by the
department. Review of the facility policy Cleaning and Sanitizing last reviewed January 2026 indicated that
team members maintain the sanitation of the kitchen through compliance with a written, comprehensive
cleaning schedule. Review of the facility policy Personal Hygiene Guidelines last reviewed January 2026,
indicated that hair nets and caps are to be worn at all times. During an observation and interview on
1/28/26, at 10:10 a.m. 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 that it was opened, which was confirmed by Dining Services Director (DSD) Employee
E18. During an observation and interview on 1/28/26, at 10:12 a.m. in the Main Kitchen Dry storage, an
opened bag of egg noodles was not dated with the date that it was opened, which was confirmed by DSD
Employee E18. During an observation and interview on 1/28/26, at 10:15 a.m. in the Main Kitchen, the ice
machine was found to have a black substance on the inside of the lid to the machine, and was confirmed by
DSD Employee E18. During an observation and interview on 1/28/26, at 10:18 a.m. in the Main Kitchen, 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
during the month of January, which is a total of 82 missed opportunities, and was confirmed by DSD
Employee E18. During an observation and interview on 1/28/26, at 11:03 a.m. in the Main Kitchen during
tray line, the DSD Employee E18, and Dining Services Supervisor Employee E19, were noted to have the
front portion of their hair uncovered by a hair net, and was confirmed by DSD Employee E18. During an
observation and interview on 1/30/26, at 10:45 a.m. in the North Hall Kitchenette, two yogurts were noted to
have no label with resident name or date, and was confirmed by Licensed Practical Nurse Employee E4.
Review of the facility documents Refrigerator Inspection Log for January 2026 on 1/30/26, from 10:45 a.m.
through 11:00 a.m., revealed that the North Unit was missing documentation for temperature checks for 19
of 29 days (1/3/26, 1/4/26, 1/9/26, 1/10/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26,
1/19/26, 1/20/26, 1/21/26, 1/24/26, 1/25/26, 1/26/26, 1/27/26, and 1/29/26). The East Unit was missing
documentation for temperature checks for seven of 29 days (1/1/26, 1/17/26, 1/18/26, 1/21/26, 1/22/26,
1/23/26, and 1/29/26. The [NAME] Unit was missing documentation for temperature checks for seven of 29
days (1/7/26, 1/8/26, 1/21/26, 1/22/26, 1/23/26, 1/27/26, and 1/28/26). During an interview on 1/30/26, at
11:00 a.m. The Nursing Home Administrator confirmed that the facility failed to properly monitor refrigerator
temperatures on three of three nursing units (Nort, East, and West). 28 Pa. Code 201.14(a)Responsibility of
licensee.28 Pa. Code 201.18(b)(1) Management.
Event ID:
Facility ID:
395845
If continuation sheet
Page 26 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0844
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Follow rules about disclosure of ownership requirements and tell the state agency about changes in
ownership and/or administrative personnel.
Based on a review of regulations, documents submitted to the State agency and staff interviews, it was
determined that the facility failed to notify the State agency of a change in the facility's Medical Director at
the time of the change. Findings include:Review of the facility's data indicated 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 indicated Doctor Employee E16 no longer worked there, and the new Medical Director was
Doctor Employee E17 effective June 2025.During an interview on 1/28/26, at 1:00 p.m. the Nursing Home
Administrator confirmed the facility failed to notify the State agency of a change in the facility's Medical
Director at the time of the change.PA Code: 201.14(a) Responsibility of licensee.
Event ID:
Facility ID:
395845
If continuation sheet
Page 27 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was
determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings with all
the required committee members for one of four quarters(Quarter Two on April 25, 2025). Findings Include:
The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated January 2026,
indicated the Administrator/Executive Director is responsible for assuring that 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, dated April 25,
2025, failed to indicate the Nursing Home Administrator was in attendance. During an interview on 1/28/26,
at 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality
Assessment and Assurance (QAA) meetings with all the required committee members for one of four
quarters(Quarter Two on April 25, 2025). 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 28 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to
make certain that influenza immunization and pneumococcal immunization were offered to two of five
residents (Residents R45, and R116).Findings include:Review of the facility policy Influenza Vaccine dated
January 2026, indicated between October 1st and March 31st each year, the influenza vaccine shall be
offered to residents and employees, unless the vaccine is medically contraindicated or the resident or
employee has already been immunized. For those who receive the vaccine, the date of vaccination, lot
number, expiration date, person administering, and the site of vaccination will be documented in the
resident's/employee's medical record.Review of the facility policy Pneumococcal Vaccine dated January
2026 indicated all residents are offered pneumococcal vaccines to aid in preventing
pneumonia/pneumococcal infections. For each resident who received the vaccine, the date of vaccination,
lot number, expiration date, person administering, and the site of vaccination will be documented in the
resident's/employee's medical record.Review of the admission record indicated Resident R45 was admitted
to the facility on [DATE].Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care
needs) dated 1/11/26, indicated the diagnoses of high blood pressure, renal insufficiency (a condition in
which the kidneys lose the ability to remove waste and balance fluids), and diabetes (a long-term condition
in which the body has trouble controlling blood sugar and using it for energy).Review of Resident R45's
clinical record failed to provide documented evidence that the influenza vaccine and pneumococcal vaccine
were offered or administered as required.Review of the admission record indicated Resident R116 was
admitted to the facility on [DATE].Review of Resident R116's MDS dated [DATE], indicated the diagnoses of
anemia (the blood doesn't have enough healthy red blood cells), paraplegia (paralysis of legs and lower
body), and anxiety.Review of Resident R116's clinical record failed to provide documented evidence that
the influenza vaccine and pneumococcal vaccine were offered or administered as required.Interview on
1/30/26, at 12:00 p.m. Infection Preventionist (IP) Employee E9 confirmed the facility failed to make certain
that influenza immunization and pneumococcal immunization were offered to two of five residents
(Residents R45, and R116).28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18
(b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5)
Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 29 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of facility documentation, and staff interviews, it was determined that the facility failed
to make certain that equipment was in safe operating condition for three of three crash carts (West Unit,
North Unit, and East Unit).Findings include: Review of facility Emergency Crash Cart Checklist stated the
emergency crash cart (a wheel container carrying equipment for use in emergency resuscitations) always
needs to be ready for emergencies. Complete this checklist at least weekly and after each use to ensure
readiness. [NAME] an X next to each item indicating it is present, clean, in working order, and not expired.
Review of facility Crash Cart Daily Signature Log stated to complete this form daily to ensure that the
emergency crash cart is in order and ready to use in case of emergency. During an observation on [DATE],
at 10:10 a.m. of the [NAME] Unit crash cart revealed the following expired supplies:Two (2) intravenous
secondary tubing sets, expired [DATE]Two (2) intravenous short-term kits, expired [DATE]Four (4) 21-gauge
blood collection needle and tubing sets, expired [DATE]Five (5) 23-gauge blood collection needle and
tubing sets, expired [DATE]Nine (9) povidone-iodine (a broad-spectrum antiseptic used for skin disinfection)
swab sticks, expired [DATE]. During this observation, a clipboard was located on top of the crash cart with a
Crash Cart Daily Signature Log for [DATE]. Review of the check list sheet documentation failed to reveal
that the cart was checked on [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE],
at 10:29 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the above observations and that the
facility failed to make certain equipment was in safe operating condition for the [NAME] Unit crash
cart.During an observation on [DATE], at 10:38 a.m. of the North Unit crash cart revealed the following
expired supplies:One (1) 21-gauge blood collection needle and tubing set, expired [DATE]One (1) StayFIX
fixation device (a needleless catheter securement device that prevents migration, movement, and
accidental removal of a catheter), expired [DATE].One (1) nonconductive suction tubing set (tubing
connected to a suction device), expired [DATE]. During an interview on [DATE], at 10:53 a.m. LPN
Employee E4 confirmed the above observations and that the facility failed to make certain equipment was
in safe operating condition for the North Unit crash cart. During an observation on [DATE], at 11:00 a.m. of
the East Unit crash cart revealed the following expired supplies:Two (2) intravenous short-term kits, expired
[DATE]Four (4) povidone-iodine swab sticks, expired [DATE]Adult nonrebreather (a medical device used to
deliver high concentrations of oxygen during emergencies) mask and tubing kit, expired [DATE] During an
interview on [DATE], at 11:15 a.m. Registered Nurse Employee E5 confirmed the above observations and
that the facility failed to make certain equipment was in safe operating condition for the East Unit crash cart.
During an interview on [DATE], at 2:39 p.m. information was disseminated to the Director of Nursing that
the facility failed to make certain that equipment was in safe operating condition for three of three crash
carts (West Unit, North Unit, and East Unit). 28 Pa. Code: 201.14(a) Responsibility of licensee.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 30 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0941
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Develop, implement, and/or maintain an effective training program that includes effective communications
for direct care staff members.
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it
was determined that the facility failed to provide training on Effective Communication for one of five staff
members (Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All
Staff dated January 2026, indicated all staff must participate in initial orientation and annual in-service
training. Required training topics include the following: effective communication with residents and family,
resident rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident
property, elements and goals of the facility QAPI (Quality Assurance and Performance Improvement)
program, the infection prevention and control program, behavioral health, and the compliance and ethics
program. Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA
Employee E6's personnel file did not include annual in-service training on Effective Communication from
1/1/25 through 12/31/25. During an interview on 1/31/26, at 19:08 a.m. the Director of Nursing confirmed
that the facility failed to provide training on Effective Communication for one of five staff members (NA
Employee E6). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff
development.
Event ID:
Facility ID:
395845
If continuation sheet
Page 31 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0942
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for
its residents.
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it
was determined that the facility failed to provide training on Resident Rights for one of five staff members
(Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All Staff dated
January 2026, indicated all staff must participate in initial orientation and annual in-service training.
Required training topics include the following: effective communication with residents and family, resident
rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident property,
elements and goals of the facility QAPI (Quality Assurance and Performance Improvement) program, the
infection prevention and control program, behavioral health, and the compliance and ethics program.
Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA Employee
E6's personnel file did not include annual in-service training on Resident Rights from 1/1/25 through
12/31/25. During an interview on 1/31/26, at 19:08 a.m. the Director of Nursing confirmed that the facility
failed to provide training on Resident Rights for one of five staff members (NA Employee E6). 28 Pa. Code:
201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.
Event ID:
Facility ID:
395845
If continuation sheet
Page 32 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0944
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement
Program.
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it
was determined that the facility failed to provide training on the Quality Assurance and Performance
Improvement (QAPI) program for one of five staff members (Nurse Aide (NA) Employee E6).Findings
include:Review of facility policy In-Service Training, All Staff dated January 2026, indicated all staff must
participate in initial orientation and annual in-service training. Required training topics include the following:
effective communication with residents and family, resident rights and responsibilities, preventing abuse,
neglect, exploitation or misappropriation of resident property, elements and goals of the facility QAPI
(Quality Assurance and Performance Improvement) program, the infection prevention and control program,
behavioral health, and the compliance and ethics program. Review of NA Employee E6's personnel file
indicated a date of hire on 7/28/24. Review of NA Employee E6's personnel file did not include annual
in-service training on the QAPI program from 1/1/25 through 12/31/25. During an interview on 1/31/26, at
19:08 a.m. the Director of Nursing confirmed that the facility failed to provide training on the QAPI program
for one of five staff members (NA Employee E6). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa.
Code: 201.20(a)(d) Staff development.
Event ID:
Facility ID:
395845
If continuation sheet
Page 33 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0945
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Include as part of its infection prevention and control program, mandatory training that includes written
standards, policies, and procedures for the program.
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it
was determined that the facility failed to provide training on Infection Control for one of five staff members
(Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All Staff dated
January 2026, indicated all staff must participate in initial orientation and annual in-service training.
Required training topics include the following: effective communication with residents and family, resident
rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident property,
elements and goals of the facility QAPI (Quality Assurance and Performance Improvement) program, the
infection prevention and control program, behavioral health, and the compliance and ethics program.
Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA Employee
E6's personnel file did not include annual in-service training on Infection Control from 1/1/25 through
12/31/25. During an interview on 1/31/26, at 19:08 a.m. the Director of Nursing confirmed that the facility
failed to provide training on Infection Control for one of five staff members (NA Employee E6). 28 Pa. Code:
201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.
Event ID:
Facility ID:
395845
If continuation sheet
Page 34 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0946
Provide training in compliance and ethics.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it
was determined that the facility failed to provide training on Compliance and Ethics for one of five staff
members (Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All
Staff dated January 2026, indicated all staff must participate in initial orientation and annual in-service
training. Required training topics include the following: effective communication with residents and family,
resident rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident
property, elements and goals of the facility QAPI (Quality Assurance and Performance Improvement)
program, the infection prevention and control program, behavioral health, and the compliance and ethics
program. Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA
Employee E6's personnel file did not include annual in-service training on Compliance and Ethics from
1/1/25 through 12/31/25. During an interview on 1/31/26, at 19:08 a.m. the Director of Nursing confirmed
that the facility failed to provide training on Compliance and Ethics for one of five staff members (NA
Employee E6). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff
development.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395845
If continuation sheet
Page 35 of 36
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395845
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/31/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cranberry Place
5 Saint Francis Way
Cranberry Township, PA 16066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0947
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in
dementia care and abuse prevention.
Based on review of facility policy, personnel files and staff interview it was determined that the facility failed
to ensure that one of four sampled Nurse Aides (NA) received a minimum of 12 hours of in-service
education per year (NA Employee E6).Findings include: Review of facility nurse aide training records
revealed that NA Employee 6 did not receive 12 hours of in-service training from 1/1/25, through 12/31/25.
The facility was unable to provide documented evidence that NA Employee E6 had received a minimum of
12 hours of in-service training yearly. During an interview on 1/31/26, at 9:08 a.m. the Director of Nursing
confirmed that the facility failed to ensure NA Employee E6 received the required 12 hours of yearly
in-servicing training. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff
development.
Event ID:
Facility ID:
395845
If continuation sheet
Page 36 of 36