Federal inspectors found Resident R151 activated their call light at 11:27 a.m. on January 29, needing assistance with an indwelling foley catheter that "something was wrong with." The monitor at the desk showed the call had been active for 25 minutes when inspectors arrived. By the time staff responded, the resident had been waiting 26 minutes.
"They needed their indwelling foley catheter adjusted because something was wrong with it," inspectors wrote after interviewing the resident.
RN Employee E7 confirmed the desk monitor showed call times of 22 and 25 minutes for the resident during the inspector's visit.
The delayed response was part of broader staffing failures at Cranberry Place. The Director of Nursing confirmed the facility failed to maintain sufficient nursing staff across multiple areas of operation.
Inspectors documented understaffing problems affecting one of four quarters of facility staffing data, specifically Quarter Three. The facility also failed to provide adequate nursing coverage during two of three Resident Council meetings in November 2025 and January 2026.
Six of seven residents in a group meeting experienced insufficient nursing services. The facility couldn't maintain proper staffing for grievance handling in January 2026, affecting one of three months reviewed.
Beyond Resident R151, four other residents experienced inadequate nursing services during the inspection period. Residents R41, R73, R76, and R79 were among five of ten residents observed who didn't receive sufficient nursing care to maintain their highest practicable well-being.
The violation received a minimal harm rating but affected multiple residents throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cranberry Place from 2026-01-31 including all violations, facility responses, and corrective action plans.