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Cranberry Place

5 Saint Francis Way, Cranberry Township, PA 16066 · Butler County · (724) 772-5350

150 certified beds, about 126 residents a day · Non profit - Corporation · Medicare and Medicaid since 1991

CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 395845 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on January 31, 2026, inspectors cited 26 health deficiencies (the Pennsylvania average is 10, the national average 9.2).

Of 87 health citations since October 2023, 6 were rated as actual harm or immediate jeopardy to residents.

CMS lists 2 fines totaling $43,350 in the last three years; the largest was $34,155, and the latest is dated April 3, 2025.

Nurses and nurse aides worked 3.90 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 1.14 of those hours.

66.3% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).

CMS links it to Upmc Senior Communities, an affiliated group of 6 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 87 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
6G
0H
0I
Potential for more than minimal harm
57D
20E
3F
Potential for minimal harm
0A
0B
1C
April 30, 2026Complaint inspection · 2 citations
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of left femoral neck (hip fracture). This deficiency is cited as past non-compliance.
  2. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on review of facility policy, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective mobility interventions to promote resident safety, resulting in a preventable accident and actual harm when the resident received a fracture of the left femoral neck (hip fracture), for one of two residents reviewed (Resident R1). This deficiency is cited as past non-compliance.
April 1, 2026Complaint inspection · 1 citation
  1. D
    Provide or get specialized rehabilitative services as required for a resident.
    F825 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 15, 2026
    Inspectors wroteBased on review of clinical record, and staff interviews it was determined that the facility failed to identify and or review a change in therapy recommendations for one of three residents (Resident R1). Review of clinical record indicated Resident R1 was admitted on [DATE]. Review of clinical record MDS (minimum data set - a periodic assessment of resident needs) dated 2/8/26, indicated diagnosis of diabetes mellitus, left femur fracture and end stage renal disease (kidneys no longer work well and you need dialysis or a transplant to survive). Review of facility provided documents revealed on 3/5/26 NA was getting Resident R1 up for dialysis. During a transfer of assist x 1 stand and pivot, Resident R1 lost balance and fell. Most recent Kardex indicated Resident R1 is a sit to stand x 2. Xray completed, Resident R1 sent out to the hospital with right distal radius fracture. [...]
March 4, 2026Complaint inspection · 1 citation
  1. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 20, 2026
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Resident R1).
January 31, 2026Standard inspection, Complaint inspection · 26 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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. [...]
  2. F
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  3. E
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  4. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  5. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  6. E
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  7. E
    Provide care or services that was trauma informed and/or culturally competent.
    F699 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  8. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  9. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  10. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  11. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  12. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  13. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  14. D
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    F745 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  15. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  16. D
    Provide routine and 24-hour emergency dental care for each resident.
    F790 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  17. D
    Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
    F844 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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.
  18. D
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    F868 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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. [...]
  19. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  20. D
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    F941 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  21. D
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    F942 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  22. D
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    F944 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  23. D
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    F945 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  24. D
    Provide training in compliance and ethics.
    F946 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  25. D
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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).
  26. C
    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.
    F575 · Resident Rights · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) March 11, 2026
    Inspectors wroteBased 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.
November 21, 2025Complaint inspection · 3 citations
  1. E
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    F565 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2026
    Inspectors wroteBased on review of Resident Council meeting minutes, and staff interview it was determined the facility failed to consider the views of a resident group and act promptly on recommendations concerning issues of resident care and life in the facility for three of three months (September, October, and November 2025).
  2. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2026
    Inspectors wroteBased on review of facility documents, facility policies, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an allegations of abuse for one of two residents (Resident R26).
  3. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2026
    Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R24).
November 19, 2025Complaint inspection · 2 citations
  1. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 9, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to have physician orders, resident specific care plans, and correct complete assessments for wander guards (a bracelet that alarms when close to an exit door) for four of four residents (Resident R4, R5, R6, and R7), and failed to accurately transcribe a medication upon admission for one of three residents (Resident R8).
  2. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 9, 2025
    Inspectors wroteBased on review of facility policy, clinical record reviews, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1).
August 12, 2025Complaint inspection · 1 citation
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 12, 2025
    Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of three residents reviewed (Resident R3).
July 7, 2025Complaint inspection · 2 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · deficient, provider has July 31, 2025
    Inspectors wroteBased on review of facility policies, observations in the main kitchen, and staff interview, it was determined the facility failed to properly date and store food products in a manner to prevent foodborne illness in the main kitchen (Main Kitchen).
  2. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · deficient, provider has July 31, 2025
    Inspectors wroteBased on review of facility policy, resident clinical records, and staff interview, it was determined that the facility failed to complete comprehensive wound assessments weekly for one out of seven sampled residents (Resident R1).
May 28, 2025Complaint inspection · 2 citations
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 25, 2025
    Inspectors wroteBased on a review of facility policy, clinical record, and staff interview, it was determined that the facility staff failed to provide medications and treatments as ordered by the physician for two of 6 residents (Resident R1 and Resident R2).
  2. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 25, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1).
April 3, 2025Complaint inspection · 3 citations
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 7, 2025
    Inspectors wroteBased on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to protect residents from abuse and neglect which resulted in actual harm of abandonment and mental anguish for one of three residents (Resident R1) and resulted in actual harm of a tibial plateau fracture (a break in the upper tibia, the lower leg bone below the knee, that affects the knee joint) for one of three residents (Resident R3).
  2. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 7, 2025
    Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility and transfers to prevent accidents which resulted in actual harm of a head injury for one of four residents (Resident R2) and resulted in actual harm a tibial plateau fracture (a break in the upper tibia, the lower leg bone below the knee, that affects the knee joint) for one of four residents (Resident R3).
  3. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 7, 2025
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for three of three residents to accurately reflect the current status of the residents' needs (Residents R1, R2, and R3).
February 20, 2025Complaint inspection · 1 citation
  1. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 20, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of three residents (Resident R1).
January 24, 2025Standard inspection, Complaint inspection · 24 citations
  1. E
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of four residents sampled with facility-initiated transfers (Residents R70, R76, and R115).
  2. E
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, clinical records, and resident and staff interview, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of four resident hospital transfers (Residents R70, R76, and R115). Findings Include: Review of the facility policy Bed-Holds and Returns dated August 2024, indicated all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospital or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); [...]
  3. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings and lab results as per order for three of six residents (Residents R67, R77, and R167) and failed to follow a physician order for two of five residents (Resdient R67, and Resident R115).
  4. E
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for four of five residents (Residents R40, R53, R70, and R103).
  5. E
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for five of six residents (Residents R2, R70, R77, R103, and R317).
  6. E
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of four nurse aide personnel records (Nurse Aides (NA) Employee E16, NA Employee E17, NA Employee E18, and NA Employee E19).
  7. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of residents clinical record, resident and staff interview it was determined that the facility failed to meet resident rights for one of 10 residents reviewed (Resident R94).
  8. D
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of four residents reviewed (Resident R70, and R77).
  9. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the physician of a resident's refusal of tube feedings for one of four residents (Resident R50).
  10. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R27).
  11. D
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, observations, resident and staff interviews it was determined that the facility failed to make certain that a posted grievance policy and procedure met federal guidelines for three of three nursing units and common areas.
  12. D
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    F626 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to permit one of three residents who transferred to the hospital with the expectation of returning to the facility, return to the facility in a timely manner. (Resident R50)
  13. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for three of ten residents (Residents R1, R50, and R115) to accurately reflect the current status of the resident and care needs.
  14. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for two residents resulting in elopement (resident exited to an unsupervised or unauthorized location without staff's knowledge) for two of two residents (Residents R42, and R114), and failed to follow a prescribed diet order for one of three residents (Resident R50).
  15. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for three of six residents (Resident R3, R62 and R317) and failed to update a care plan for one of three residents (R317) to accurately reflect the current status of the resident and care needs.
  16. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of two dialysis residents (Resident R1).
  17. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    F742 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, resident and staff interview and clinical record review the facility failed to maintain the highest practicable mental and psychosocial well-being for one of three residents (Resident R94).
  18. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (West Medication Room).
  19. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on facility policy review and clinical record review, and staff interview, it was determined that the facility failed to make certain that residents receiving psychotropic medications have adequate indication for use for one of five sampled residents (Resident R108).
  20. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in two of four medication carts (North Front Med Cart, and [NAME] Med Cart) and failed to properly store medical supplies and biologicals in one of two medication rooms (North medication room).
  21. D
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of three residents ordered a soft and bite size diet (Resident R42).
  22. D
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    F809 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility meal delivery times, observations and staff interview, it was determined that the facility failed to deliver meals in a timely manner for one of two meal observations (West Rooms 374-387).
  23. D
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    F810 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of three residents (Resident R42).
  24. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025
    Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents reviewed (Residents R53), failed to prevent cross contamination during a dressing change for one of three residents (Resident R54) and failed to follow enhanced barrier precautions for one of five residents (Resident R54).
April 16, 2024Complaint inspection · 2 citations
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 21, 2024
    Inspectors wroteBased on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of five residents (Resident R1), by failing to follow physicians orders during transfer that resulted in actual harm for Resident R1 of right lower extremity laceration with eleven sutures.
  2. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 21, 2024
    Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision of transfers for one of five residents (Resident R1), which resulted in actual harm for Resident R1 of right lower extremity laceration with eleven sutures.
February 1, 2024Standard inspection · 15 citations
  1. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide a homelike environment for three of three nursing units (North Wing, East Wing, and South Wing).
  2. E
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for three of three residents receiving dialysis (Resident R46, R216, and R218).
  3. D
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    F565 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, Resident Group interviews, Resident Council meeting minutes, grievances, and staff interview it was determined the facility failed to consider the views of a resident and/or family and act promptly on grievances and recommendations concerning issues of resident care and life in the facility for nine of twelve months (January, February, March, April, May, June, July, August and September 2023).
  4. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on clinical record review, staff interview and observations it was determined the facility failed to ensure the privacy of the resident while providing care for two of four residents observed (Resident R26, and R108). Findings Include: Review of facility policy Personal Care and Privacy dated 1/2/24, indicated to maintain privacy and dignity during personal hygiene and/or procedures. Review of the admission record indicated Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/8/23, indicated the diagnoses of diabetes (too much sugar), high blood pressure, and coronary artery disease (narrow arteries decreasing blood flow to the heart). Review of Resident R26's physician order dated 1/5/24, indicated to inject Lantus insulin (medication shot to regulate sugar) every morning. [...]
  5. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to implement the facility abuse policy for one of three abuse allegations (Resident R62).
  6. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of verbal abuse in the required timeframe for one of three residents (Resident R62).
  7. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect for one of three residents (Resident R46).
  8. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions for one of three residents' tube feeding (R102), and one of two residents' (R108) parenteral feeding in order to maintain a resident's highest practicable physical well-being as required.
  9. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility staff failed to follow physician's orders for one of two residents (Resident R62) with a ventricular assist device (VAD - a device that provides support for cardiac circulation, either partially or completely replacing the function of a failing heart).
  10. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide a safe environment resulting in a fall during a transfer for one of three residents (Resident R46).
  11. D
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills necessary to provide care to two of two residents (Resident R62 and R81) with a ventricular assist device (VAD - a device that provides support for cardiac circulation, either partially or completely replacing the function of a failing heart).
  12. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, observation, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R108).
  13. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to label open medications with a date in one of four medication carts (West Back Hall).
  14. D
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    F838 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on staff interviews and a review of the facility's assessment and resident census and condition it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.
  15. D
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2024
    Inspectors wroteBased on a review of facility policy, plans of correction and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
December 8, 2023Complaint inspection · 1 citation
  1. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 4, 2024
    Inspectors wroteBased on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for seven of thirteen residents: three of three residents ordered daily weights (Resident R1, R2, and R3), two of five residents with dressing change orders (Resident R4 and R5), and three of six residents with orders for TED hose (specially designed stockings that help prevent blood clots and swelling in the legs) (R4, R6, and R7).
October 17, 2023Complaint inspection · 1 citation
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 7, 2023
    Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to notify the resident's representative of a change in prescribed medication treatments for one of five resident records (Closed Resident Record CR1).

Fire safety inspections

28 fire safety citations on file: 9 on January 31, 2026, 9 on January 24, 2025, 10 on February 1, 2024.

Every fire safety citation28 citations
  1. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · January 31, 2026 · Corrected (the home has a date of correction)
  2. F
    Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
    K 908 · January 31, 2026 · Corrected (the home has a date of correction)
  3. E
    Have proper medical gas storage and administration areas.
    K 923 · January 31, 2026 · Corrected (the home has a date of correction)
  4. C
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · January 31, 2026 · Corrected (the home has a date of correction)
  5. C
    Meet other general requirements.
    K 100 · January 31, 2026 · Corrected (the home has a date of correction)
  6. C
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · January 31, 2026 · Corrected (the home has a date of correction)
  7. C
    Have simulated fire drills held at unexpected times.
    K 712 · January 31, 2026 · Corrected (the home has a date of correction)
  8. C
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · January 31, 2026 · Corrected (the home has a date of correction)
  9. B
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · January 31, 2026 · Corrected (the home has a date of correction)
  10. F
    Meet other general requirements.
    K 100 · January 24, 2025 · Corrected (the home has a date of correction)
  11. F
    Provide properly protected cooking facilities.
    K 324 · January 24, 2025 · Corrected (the home has a date of correction)
  12. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · January 24, 2025 · Corrected (the home has a date of correction)
  13. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · January 24, 2025 · Corrected (the home has a date of correction)
  14. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · January 24, 2025 · Corrected (the home has a date of correction)
  15. D
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · January 24, 2025 · Corrected (the home has a date of correction)
  16. C
    Meet other general requirements.
    K 200 · January 24, 2025 · Corrected (the home has a date of correction)
  17. B
    Have restrictions on the use of highly flammable decorations.
    K 753 · January 24, 2025 · Corrected (the home has a date of correction)
  18. B
    Have proper medical gas storage and administration areas.
    K 923 · January 24, 2025 · Corrected (the home has a date of correction)
  19. F
    Install a two-hour-resistant firewall separation.
    K 133 · February 1, 2024 · Corrected (the home has a date of correction)
  20. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · February 1, 2024 · Corrected (the home has a date of correction)
  21. F
    Provide properly protected cooking facilities.
    K 324 · February 1, 2024 · Corrected (the home has a date of correction)
  22. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · February 1, 2024 · Corrected (the home has a date of correction)
  23. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · February 1, 2024 · Corrected (the home has a date of correction)
  24. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 1, 2024 · Corrected (the home has a date of correction)
  25. D
    Meet other general requirements.
    K 100 · February 1, 2024 · Corrected (the home has a date of correction)
  26. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · February 1, 2024 · Corrected (the home has a date of correction)
  27. B
    Meet requirements for the installation and maintenance of electrical systems.
    K 911 · February 1, 2024 · Corrected (the home has a date of correction)
  28. B
    Ensure proper usage of power strips and extension cords.
    K 920 · February 1, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
April 3, 2025Fine $34,155
April 16, 2024Fine $9,195

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homePennsylvaniaUnited States
All nursing staff (RN, LPN and aides)3.903.893.86
Registered nurses1.140.790.69
All nursing staff on weekends3.313.533.42
Nurse aides2.30
Licensed practical nurses0.47
Nursing staff turnover (share who left in a year)66.3%44.5%45.8%
Registered nurse turnover60.0%39.9%42.9%
Administrators who left0

CMS expects 4.66 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.13 on weekdays and 3.31 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.02 in April to June 2025 to 3.90 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.901.144.133.31 0.0%0 of 90126
Oct to Dec 20254.071.254.283.54 0.1%0 of 92118
Jul to Sep 20254.511.284.684.08 2.9%0 of 92120
Apr to Jun 20254.021.264.233.51 2.4%0 of 91117
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Pennsylvania, Jan to Mar 20263.690.653.823.3411.3%0.1% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Pennsylvania

JobMedianMiddle halfEmployed
Pennsylvania, all employers
CNAs (nursing assistants)$21.44$18.88 to $22.5267,740
LPNs and LVNs$30.74$29.02 to $35.0138,260
Registered nurses$46.36$38.75 to $50.35146,520
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Cranberry Place. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
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Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homePennsylvaniaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
20.616.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.70.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.61.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
0.93.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.51.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
31.517.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
6.64.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
11.717.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
22.822.523.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
12.09.512.0

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Cranberry Place's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (55.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

55.2% this home

No different from the national rate

US median of homes 51.5% · Pennsylvania: 100 better, 108 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 120 eligible stays.

Potentially preventable readmissions

10.9% this home

No different from the national rate

US median of homes 10.7% · Pennsylvania: 3 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 120 eligible stays.

Infections that led to a hospital stay

6.7% this home

No different from the national rate

US median of homes 7.1% · Pennsylvania: 7 better, 5 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 50 eligible stays.

Self-care and mobility at discharge

55.9% this home

Median of homes: Pennsylvania54.4% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 34 residents counted.

Falls with major injury

0.0% this home

Median of homes: Pennsylvania0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 60 residents counted.

New or worsened pressure ulcers

8.5% this home

Median of homes: Pennsylvania2.0% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 60 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Pennsylvania100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 3 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: CRANBERRY PLACE. CMS links this home to Upmc Senior Communities, a group of 6 nursing homes averaging 2.8 stars overall.

NameRoleTypeShareSince
Upmc Senior Communities Inc5% or greater direct ownership interestOrganization100%09/09/2002
Upmc5% or greater indirect ownership interestOrganization100%09/09/2002
Beckwith III, GeorgeManaging control - governing bodyIndividual01/01/2023
Blum, EvaManaging control - governing bodyIndividual06/12/2014
Borgo, AngelaManaging control - governing bodyIndividual08/10/2020
Caplan, DebraManaging control - governing bodyIndividual01/01/2020
Cestello, LouisManaging control - governing bodyIndividual10/18/2023
Clagette, VaughnManaging control - governing bodyIndividual07/01/2019
Covert, JamesManaging control - governing bodyIndividual07/01/2019
Davis, LeslieManaging control - governing bodyIndividual08/01/2021
Dick, DouglasManaging control - governing bodyIndividual06/01/2021
Gabel, JohnManaging control - governing bodyIndividual07/17/2023
Ghubril, SaleemManaging control - governing bodyIndividual09/20/2023
Haley, LisaManaging control - governing bodyIndividual09/20/2023
Humphrey, KathyManaging control - governing bodyIndividual09/20/2023
Jegasothy, MicheleManaging control - governing bodyIndividual04/01/2004
Lucido, EleniManaging control - governing bodyIndividual12/01/2022
Lyons, MichaelManaging control - governing bodyIndividual07/01/2019
Montler, RobertManaging control - governing bodyIndividual07/01/2013
Neidich, DouglasManaging control - governing bodyIndividual02/07/2019
Pepperman, AnnManaging control - governing bodyIndividual10/01/2016
Raimy, MarkManaging control - governing bodyIndividual10/22/2017
Scott, GregoryManaging control - governing bodyIndividual07/01/2024
Shekhar, AnanthaManaging control - governing bodyIndividual06/01/2020
Shipley, SusanManaging control - governing bodyIndividual07/01/2015
Solomon, JeffreyManaging control - governing bodyIndividual07/01/2024
Stilley, JohnManaging control - governing bodyIndividual01/01/2021
Surma, JohnManaging control - governing bodyIndividual01/01/2015
Verbanac, JohnManaging control - governing bodyIndividual07/01/2024
Wells, MichaelManaging control - governing bodyIndividual07/01/2020
Brodine, DeborahCorporate directorIndividual05/03/2005
Hamilton, RichardCorporate directorIndividual01/01/2025
Joy, MargaretCorporate directorIndividual01/01/2025
Nace, DavidCorporate directorIndividual01/01/2025
Simmons, EileenCorporate directorIndividual01/01/2025
Wesley, BryantCorporate directorIndividual01/01/2025
Borgo, AngelaCorporate officerIndividual08/10/2020
Brodine, DeborahCorporate officerIndividual01/01/2025
Joy, MargaretCorporate officerIndividual01/01/2025
Simmons, EileenCorporate officerIndividual01/01/2025
Wesley, BryantCorporate officerIndividual01/01/2010
Oakdale Seniors Alliance LLCOperational/managerial controlOrganization08/01/2024
Walter, AnnOperational/managerial controlIndividual12/01/2021
Baker Tilly Us LLPAdp of the SNFOrganization05/13/2025
Oakdale Seniors Alliance LLCAdp of the SNFOrganization07/30/2025
UpmcAdp of the SNFOrganization09/09/2002
Walter, AnnAdp of the SNFIndividual12/01/2021

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 26 problems in this area, most recently on April 30, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 17 problems in this area, most recently on March 4, 2026: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 10 problems in this area, most recently on January 31, 2026: "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."
  4. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 9 problems in this area, most recently on April 30, 2026: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.31 hours per resident per day, below the Pennsylvania average of 3.53.

Other nursing homes nearby

Pennsylvania contacts for a concern about a nursing home

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Common questions

What is Cranberry Place's Medicare star rating?
CMS rates Cranberry Place 1 out of 5 stars overall, with 1 for health inspections, 2 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Cranberry Place get at its last inspection?
26 health deficiencies at the standard inspection on January 31, 2026. The Pennsylvania average is 10.
Has Cranberry Place been fined?
Yes. CMS lists 2 fines totaling $43,350 in the last three years.
Does Cranberry Place accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Cranberry Place?
CMS lists 47 owners and managers, and links the home to Upmc Senior Communities. Legal business name: CRANBERRY PLACE.

Sources

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