Cranberry Place: Residents Escaped Unsupervised - PA
The incidents at Cranberry Place occurred on December 21 and December 23, 2024, when the resident left the building unsupervised despite having a care plan that required supervision for outside patio access. His cognitive assessment scored a 3 out of 15, indicating severe impairment.
On December 21, a nurse returning from lunch found the resident outside in the snow without a coat. Staff brought him back inside, but he became combative, "swinging, scratching and trying to punch staff," according to nursing notes. They needed a male nursing assistant to help restrain him. The facility failed to conduct a medical assessment after the incident or notify his physician.
Two days later, social services staff discovered the same resident outside in the snow again. They brought him inside and notified his father, but again failed to assess his condition or contact medical staff.
The Director of Nursing initially defended the incidents during interviews, stating "We did not treat him going outside to the patio as an elopement because they have the right to go into the courtyard. We encourage them." However, the facility provided no documentation showing staff had observed or approved the resident's outdoor access.
The Licensed Practical Nurse who responded to both incidents acknowledged the resident "was not wearing a coat on both days" and admitted she "did do an assessment but didn't document it." She said the resident "likes to be outside and stated he wanted to stay out in the snow."
A second resident also left the facility undetected. On November 17, staff discovered the resident was missing during routine checks around 1:00 a.m. After searching the building, they realized he had left the facility entirely. The resident had previously expressed interest in leaving against medical advice.
Eight hours later, staff learned the resident had departed via Uber at 11:12 p.m. the previous night. The facility classified this as a discharge against medical advice rather than an elopement requiring investigation and reporting.
The Nursing Home Administrator confirmed during interviews that staff "was not aware Resident R114 was not in the facility, and that the facility did not recognize this as an elopement and called it an AMA discharge."
Federal inspectors found multiple medication safety failures affecting diabetic residents. One resident's blood sugar reached dangerous levels of 403 and 429 mg/dL on separate occasions in January 2025, but staff never notified the physician despite orders requiring immediate contact for readings over 400.
Another diabetic resident experienced nine episodes of low blood sugar between December 2024 and January 2025, including readings as low as 38 mg/dL. Staff documented no interventions and failed to notify physicians despite orders requiring immediate notification for readings below 70. One reading of 38 represents a medical emergency that can cause unconsciousness or seizures.
The Director of Nursing acknowledged during interviews: "I don't see any parameters on the medications, I don't see that anyone notified the doctor, and no documentation to follow up on the low blood sugars."
A third resident with a heart assist device required daily blood tests with results immediately faxed to a specialized cardiac team. When his blood-thinning levels reached a dangerous 4.1 in September 2024, staff failed to contact the required cardiac specialists despite physician orders stating "every shift Call/fax PT/INR results to Hospital Anticoagulation Team."
Care planning failures affected multiple residents with complex medical needs. One dialysis patient with a stage IV pressure ulcer and therapeutic diet requirements had a nutrition care plan that failed to address any of these conditions. The Registered Dietitian confirmed the plan "failed to be updated and identify focused nutritional problems, goals, and interventions specific to resident's nutritional current plan of care."
A quadriplegic resident repeatedly refused tube feedings throughout January 2025, with documented refusals on 13 separate occasions. His care plan contained no interventions for addressing feeding refusals, despite the life-threatening implications for someone dependent on tube nutrition.
A third resident with kidney failure, heart problems, and a specialized IV line had a care plan that completely omitted his PICC catheter care requirements and medication refusal patterns. Physician orders required documenting arm measurements and catheter length with each dressing change, but the care plan included none of these critical monitoring steps.
Infection control violations put residents at risk of preventable complications. Four residents with feeding tubes had unlabeled formula and water bags hanging at their bedsides, violating basic safety protocols for preventing contamination. When nurses discovered the violations during inspections, they immediately wrote dates on the bags.
Respiratory equipment posed additional infection risks. One resident's catheter drainage bag was found lying on the floor, violating fundamental infection prevention standards. Multiple residents had unlabeled or improperly stored oxygen tubing and nebulizer equipment.
The facility's medication management showed serious gaps. Inspectors found a gray plastic basin containing hundreds of discontinued medications sitting unsecured on a counter, including controlled substances like Neurontin, blood thinners, and diabetes medications. The Director of Nursing explained they had "no accountability or disposition forms to fill out" for tracking disposed medications.
Two medication carts had unlocked narcotic compartments, and expired insulin pens remained in active storage areas. One insulin pen had its patient identification blacked out, making it impossible to determine ownership.
Staff supervision failures extended beyond resident care. The facility had not completed annual performance evaluations for four nurse aides, some hired as far back as 2012. One aide hired in February 2023 had never received a required annual review.
Dining service problems affected vulnerable residents with specialized dietary needs. One resident with Parkinson's disease and dementia was served pureed food despite orders for soft, bite-sized meals. The same resident's care plan required a spouted cup, but staff served regular cups instead.
Meal delivery delays reached 27 minutes past scheduled times in some areas, with staff attributing problems to "change in management, and the loss of multiple dietary personnel."
The facility also failed to post required grievance procedures in common areas and nursing units. Residents interviewed by inspectors were unaware of how to file anonymous complaints or the timeframes for receiving responses to grievances.
During interviews, facility leadership acknowledged most violations. The Director of Nursing confirmed failures in medication notification, care planning, infection control, and supervision. The Nursing Home Administrator admitted to medication transcription errors and inadequate elopement recognition.
The inspection found violations affecting resident safety, dignity, and basic care standards across multiple departments, from nursing and dietary services to medication management and staff oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cranberry Place from 2025-01-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Cranberry Place in CRANBERRY TOWNSHIP, PA was cited for violations during a health inspection on January 24, 2025.
His cognitive assessment scored a 3 out of 15, indicating severe impairment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.