Cranberry Place

Review of Resident R70's clinical record indicated the resident was admitted to the facility on [DATE].

Review of Resident R70's MDS dated [DATE], indicated diagnoses of cancer, depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R70 was given the opportunity to formulate an Advanced Directive.

Review of Resident R77's clinical record indicated the resident was admitted to the facility on [DATE].

Review of Resident R77's MDS dated [DATE], indicated diagnoses of cancer, high blood pressure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

A review of the clinical record failed to reveal a copy of Resident R77's Advanced Directives.

During an interview on 1/24/25 at 12:05 p.m.

Registered Nursed Employee E1 stated, I looked in both residents ' charts and could not find Advanced Directives or documentation that the opportunity was given to formulate them.

During an interview on 1/24/25, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive for two of four residents reviewed (Resident R70, and R77). 28 Pa.

Code: 201.29(b)(d)(j) Resident rights.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024 indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment.

The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R27's admission record indicated the resident was admitted to the facility 7/15/24.

Review of Resident R27's demographic information available in the electronic medical record indicated that Resident R27's daughter was her responsible party.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/17/24, included diagnoses of chronic obstructive pulmonary disease, myopathy (disease of the muscle), and diabetes mellitus (disease that affects how the body uses blood sugar).

Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R27's score to be 11, moderately impairment.

Review of the NOMNC and SNF ABN form dated 8/16/24, revealed that it was signed by Resident R27.

During an interview on 1/24/25, at 8:33 a.m., the Nursing Home Administrator (NHA) confirmed the facility failed to ensure the NOMNC and SNF ABN forms are 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). 28 Pa.

Code 201.14(a) Responsibility of Licensee. 28 Pa.

Code 201.18(b)(2) Management. 28 Pa.

Code 201.29(a) Resident Rights.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

During a tour on 1/23/25, at 9:57 a.m. on 3 nursing units and common areas to include the main dining room, nursing unit lounge areas, failed to have a complete grievance policy and procedure posted and failed to have a posting with the grievance officer address included on the posting, failed to include how to file anonymously, failed to include the process (time frame to get response to grievance).

During observations on 1/23/25, at 10:08 a.m. with Director of Social Service Employee E2, confirmed that there was not information nor a place to file anonymously, that the process for grievances was not posted, facility failed to make certain that a posted grievance policy and procedure met federal guidelines for three of three nursing units and common areas. 28 Pa.

Code 201.29(1) Resident rights. 28 Pa.

Code 201.19( e)(1)Management.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of Resident R115's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transfer, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 1/24/25, at 9:40 a.m. the Nursing Home Administrator stated, We send the paperwork with the resident but as far as documentation to prove what was sent, that we don't have.

During an interview on 1/24/25, at 3:00p.m. the Director of Nursing confirmed 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). 28 Pa.

Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 201.18(a)(b)(3) Management. 28 Pa.

Code: 201.29(b)(d)(j) Resident rights. 28 Pa.

Code: 211.12 (d)(1)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

During an interview on 1/24/25, at 9:40 a.m. the Nursing Home Administrator confirmed the resident or resident's representative were not informed of the facility bed-hold policy at the time of transfer.

Interview on 1/24/25, at 3:00 p.m. the Director of Nursing confirmed 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). 28 Pa.

Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 201.18(a)(b)(3) Management. 28 Pa.

Code: 201.29(b)(d)(j) Resident rights. 28 Pa.

Code: 211.12 (d)(1)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of Social Service progress note dated 1/22/25, at 1:08 p.m. indicate social worker (SW) contacted Resident's mother to inform her that we will not be able to take Resident back a resident at this facility because we can no longer meet his needs. SW stated if she had any further questions or to inquire where he would be going, she could reach out to SW at the hospital.

The mother responded with, You got to be kidding me.

Mother stated did not want facility to give away his stuff and she would be in to pick it up. SW stated that facility would not give his belongings away and would pack it up for her.

Mother stated she did not want facility to touch his belongings. SW stated that respiratory was already willing to assist with packing his belongings.

The phone then went silent.

Mother hung up on SW.

During an interview completed on 1/23/25, at 11:57 a.m. upon asking Social Service Director Employee E2 why Resident R50 is not being permitted to return to the facility she replied, because Resident R50 is refusing all medications, all tube feedings, all care is being refused, we can't care for him.

During an interview completed on 1/23/24, at 12:40 p.m. upon asking the Director of Nursing why Resident R50 is not being permitted to return to the facility she replied, cause his mom wants to continue giving things by mouth and he wants things by mouth, resident is an aspiration risk, and he is choosing to go against physician orders.

During an interview completed on 1/24/25, at 9:00 a.m. the Nursing Home Administrator confirmed that Resident R50 will not be permitted to return to the facility and 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) 28 PA.

Code 201.14(a)(b) Responsibility of licensee 28 PA.

Code 201.29(c.3) (4) Resident rights 28 PA.

Code 211.12(d)(1) Nursing services

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Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

get 4mg daily.

Recommended nursing to correct.

transcribed incorrectly on admission.

Interview on 1/24/25, at 3:00 p.m. the Director of Nursing confirmed 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 one of five residents (Resident R115). 28 Pa.

Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 201.18(a)(b)(3) Management. 28 Pa.

Code: 211.12 (d)(1)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of Resident R114's progress notes dated 1/18/24, at 4:00 a.m. indicated at around 1:00 a.m. when staff went to check in on resident, he was not in his room or bathroom.

After a thorough search staff realized he was no longer in his room.

Attempts to call resident's phone and sister's phone without success.

Resident had previously expressed interest in leaving the facility.

Review of Resident R114's progress note dated 11/18/24, at 8:30 a.m. indicated resident left the facility in the middle of the night at 11:12 p.m. on 11/17/24, via Uber (ride service).

Resident left AMA.

Review of Resident R114's discharge summary note dated 11/18/24, at 10:13 a.m. indicated was just notified that resident eloped and subsequently will be considered AMA.

Interview with the Nursing Home Administrator on 1/23/25, at 3:30 p.m. indicated the facility 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.

Interview on 1/24/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to provide adequate supervision for two residents resulting in elopement for two of two residents (Residents R42, and R114), and failed to follow a prescribed diet order for one of three residents (Resident R50). 28 Pa.

Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 201.18(a)(b)(3) Management. 28 Pa.

Code: 211.12 (d)(1)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of Resident R317's physician orders dated 1/21/25, indicate monitor indwelling catheter

needed for the catheter balloon (holds the catheter in place in the bladder) securement.

Review of Resident R317's care plan dated 1/21/25, did not include the size of catheter or the amount of fluid needed for the catheter balloon.

During an interview completed on 1/23/24, at 11:40 a.m. RN Employee E7 confirmed the catheter order failed to include the amount of fluid needed for the balloon and the care plan failed to include the size of the catheter or the amount of fluid needed for balloon.

During an interview on 1/21/25, at 3:00 p.m. the Director of Nursing confirmed 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). 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)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

28 Pa.

Code: 211.12(d)(1) Nursing services.

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Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

provide appropriate respiratory care and maintain oxygen equipment for five of six residents (Residents R2, R70, R77, R103, and R317). 28 Pa.

Code: 211.10(c)(d) Resident care policies. 28 Pa.

Code: 211.12(d)(1)(2)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of the facility policy End-Stage Renal Disease, Care of a Resident with dated August 2024, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

Agreements between the facility and the contracted ESRD facility will include how communication between the dialysis provider and facility staff will occur.

Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE].

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/6/24, indicated diagnoses of peripheral vascular disease (progressive disorder that causes narrowing or blocking of the blood vessels outside of the heart), heart failure, and dependence on renal dialysis (blood purifying treatment given when kidney function is not optimal).

Review of current physician orders on 1/24/25, indicated Resident R1 attends dialysis on Tuesday, Thursday, and Saturday each week.

Further review of physician orders indicated to complete pre and post dialysis UDA (User-Defined Assessment) every day and night shift every Tuesday, Thursday, and Saturday.

A review of the clinical record did not include complete communication documentation of User-Defined Assessments for the month of January 2025.

There were five missing communication documentation assessments post dialysis for the following dates: 1/4/25, 1/7/25, 1/11/25, 1/14/25, and 1/18/25; and there were two missing communication documentation assessments for pre and post dialysis for the following dates: 1/2/25, and 1/9/25.

During an interview on 1/24/25, at 9:44 a.m., Registered Nurse (RN) Employee E5 confirmed that the above dates did not include completed communication documentation as required. 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.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of facility policy In-Service Training, Nurse Aide dated August 2024, indicated the facility completes a performance review of nurse aides at least every 12 months.

Review of NA Employee E16's personnel record indicated a hire date of 2/6/23.

Review of NA Employee E17's personnel record indicated a hire date of 7/25/22.

Review of NA Employee E18's personnel record indicated a hire date of 7/30/12.

Review of NA Employee E19's personnel record indicated a hire date of 2/7/22.

Review of personnel records did not include annual performance evaluations based on the date of hire for NA Employee E16, NA Employee E17, and NA Employee E18, and NA Employee E19.

Interview on 1/23/25, at 2:21 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations based on date of hire for NA Employee E16, NA Employee E17, NA Employee E18, and NA Employee E19. 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(3) Management

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of the facility policy Social Services dated 8/20/24, indicated: Our facility provides medially-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being.

The social worker/social services staff are responsible for: making referrals and obtaining needed services from outside entities Resident R94 was admitted on [DATE].

Resident R94 MDS (minimum data set - a periodic assessment of resident needs) dated 11/13/24, indicated diagnoses diabetes mellitus (a group of diseases that result in too much sugar in the blood), anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily life).

Review of Resident R94 clinical record indicated the following : Care plans indicated Resident R94 has a mood problem related to depression anxiety: behavioral health consults as needed.

Monitor/record/report to physician, as needed acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills.

Review of the clinical record failed to include any behavioral health consult.

During an interview on 1/23/25, at 10:59 a.m.

Social Service Director Employee E2 confirmed the facility had not sent any referrals for behavioral health services and the facility failed to maintain the highest practicable mental and psychosocial well-being for Resident R94. 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.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

medications that get sent back to pharmacy.

They pick up maybe once a week. We don't have any

reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (West Medication Room). 28 Pa.

Code211.12(d)(1)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of the facility policy Medication and Treatment Orders dated August 2024, indicated orders for medications must include name and strength of the drug, number of doses, dosage and frequency of administration, route, clinical condition for which the medication is prescribed.

Review of the admission record indicated Resident R108 was admitted to the facility on [DATE].

Review of Resident R108's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/5/25, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), high blood pressure, and anxiety disorder.

Review of Resident R108's physician orders dated 12/30/24, indicated quetiapine (an antipsychotic medication) 25 mg (milligrams) twice daily for anxiety.

Review of Resident R108's Medication Administration Record (MAR) dated January 2025, indicated resident was receiving the medication as prescribed.

Interview on 1/24/25, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to have an appropriate diagnosis for the use of the antipsychotic medication quetiapine.

Interview on 1/24/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to make certain that residents receiving psychotropic medications have adequate indication for use for one of five sampled residents (Resident R108). 28 Pa.

Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 201.18(a)(b)(3) Management. 28 Pa.

Code: 211.12 (d)(1)(3)(5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of facility Storage of Medications policy dated 8/24, indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner.

Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control.

Only persons authorized to prepare and administer medications have access to locked medications.

Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Insulin pens are clearly labeled with the resident's name.

During a medication cart review on [DATE], at 9:45 a.m. the narcotic lock box on the North Front medication cart was not locked and there was an expired insulin Lispro (used to treat diabetes - a metabolic disorder in which the body has high sugar levels for prolonged periods of time) pen stored on the cart.

During an interview on [DATE], at 9:45 a.m.

Registered Nurse (RN) Employee E5 confirmed that the narcotic drawer was not locked and there was an expired insulin pen on the cart.

During a medication cart review on [DATE], at 11:00 a.m. it was observed on the [NAME] medicine cart that there was one insulin Lantus (used to treat diabetes) pen on the cart that had the name blackened out and unable to determine whose medication it belonged to.

During an interview on [DATE], at 11:02 a.m.

Licensed Practical Nurse (LPN) Employee E13 confirmed that the insulin pen did not have a legible residents name on.

During an observation completed on [DATE], at 10:32 a.m. the North Hall medication rooms refrigerator contained an opened bottle of [NAME] sweet peach wine.

The wine failed to be labeled with a name or date opened.

During an interview completed on [DATE], at 10:34 a.m. LPN Employee E8 confirmed the wine stored in the refrigerator was not labeled with a name or date opened and that the facility failed to properly store medical supplies and biologicals in one of two medication rooms (North medication room).

During an interview on [DATE], at 3:00 p.m. the Director of Nursing confirmed that the facility failed to properly store medical supplies in two of four medication carts (North Front Med Cart, and [NAME] Med Cart). 28 Pa Code: 211.9 (a) Pharmacy services. 28 Pa code: 211.12 (d) (1) (5) Nursing services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of the facility policy Therapeutic Diets dated 8/24, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A therapeutic diet is considered a diet ordered as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.

Review of the clinical record revealed that Resident R42 was admitted to the facility on [DATE].

Review of Resident R42's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/6/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking).

Review of Resident R42's physician's orders on 1/16/25, indicated that resident was ordered a soft and bite size diet.

During an observation on 1/21/25, at 12:43 p.m.

Resident R42 was observed in the dining room with a lunch tray that was pureed food (soup like) consistency.

Resident R42's meal ticket stated he should have received a soft and bite size food consistency diet for lunch.

Resident R42 was also missing his milk on his tray.

During an interview on 1/21/25, at 12:47 Nursing Assistant Employee E6 stated that Resident R42's tray looked like it was pureed food consistency, did not match what he was ordered, and stated I should have called the kitchen to tell them to bring him another lunch tray.

During an interview on 1/21/25, at 12:55 p.m. the Dietary Manager Employee E3 confirmed 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). 28 Pa.

Code: 211.6(d) Dietary services.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Based on review of facility meal delivery times, observations and staff interview, it was determined

Rooms 374-387).

Findings include: Review of the facility provided tray schedule, indicated lunch start time is at 11:00 a.m.

More specifically, [NAME] 2 (Rooms 374-387) cart number 8 is 12:05 p.m.

During dining/meal observations on 1/21/25, at 12:00 p.m. of the [NAME] Hallway Rooms 374-387, it was revealed that the lunch trays did not arrive until 12:32 p.m.

Trays arrived 27 minutes late.

Interview on 1/21/25, at 12:33 p.m.

Nurse Aide (NA) Employee E20 confirmed the time of tray arrival to be 12:32 p.m.

Interview on 1/21/25, at 12:40 p.m.

Registered Nurse (RN) Employee E21 indicated tray arrival time varies since the change in management, and the loss of multiple dietary personnel.

During an interview on 1/24/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to deliver meals in a timely manner for one of two meal observations (West Rooms 374-387). 28 Pa.

Code: 201.18(e)(4) Management 28 Pa.

Code: 201.29(i) Resident Rights

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

Review of the admission record indicated Resident R42 admitted to the facility on [DATE].

Review of Resident R42's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/6/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking).

Review of Resident R42's current physician orders indicated a soft and bite size diet with thin liquids.

Review of Resident R42's care plan dated 1/20/25, indicated to use a two handled sippy cup with spout, sippy lid.

During an observation on 1/22/25, at 12:15 p.m.

Resident R42 was in the dining room set up for lunch and was eating.

The meal ticket indicated spouted cup.

During an interview and observation on 1/22/25, at 12:17 p.m.

Dietary Director Employee E3 indicated a spouted cup was not served as ordered on the tray, one regular cup was present.

During an interview on 1/22/25, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide adaptive feeding devices for one of three residents (Resident R42). 28 Pa.

Code: 211.6(a) Dietary services. 28 Pa Code: 201.29 (d) Resident rights.

395845 01/24/2025

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

During an interview completed on 1/22/25 at 10:54 a.m. LPN Employee E8 confirmed not cleansing the bedside stand after completion of the dressing change and not utilizing enhanced barrier precautions during the dressing change and that the facility failed to prevent cross contamination during a dressing change for one of three residents and failed to follow enhanced barrier precautions for one of five residents (Resident R54).

During an interview completed on 1/22/25 at 11:28 Registered Nurse Infection Preventionist Employee E11 stated that enhanced precautions were not ordered for Resident R54, and that the facility failed to follow enhanced barrier precautions for one of five residents (Resident R54). 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.

During a tour on 1/23/25, at 9:57 a.m. on 3 nursing units and common areas to include the main dining room, nursing unit lounge areas, failed to have a complete grievance policy and procedure posted and failed to have a posting with the grievance officer address included on the posting, failed to include how to file anonymously, failed to include the process (time frame to get response to grievance).

During observations on 1/23/25, at 10:08 a.m. with Director of Social Service Employee E2, confirmed that there was not information nor a place to file anonymously, that the process for grievances was not posted, facility failed to make certain that a posted grievance policy and procedure met federal guidelines for three of three nursing units and common areas.

28 Pa.

Code 201.29(1) Resident rights.

28 Pa.

Code 201.19( e)(1)Management.

395845

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 395845 B.

Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066