Cranberry Place

In the surveyor’s words

From the most serious findings on record at Cranberry Place, in the surveyor’s own words.

• Immediate jeopardy, patternF695Sep 27, 2022

  Based on review of facility incident investigations, facility policy, manufacturer's guidelines, clinical record review, resident interview and interviews with staff, it was determined that the facility failed to implement policies to provide ongoing monitoring of equipment and failed to make certain component alarm systems were functioning and clearly audible resulting in actual harm to one resident (Resident R1) and placing eight of eight ventilator dependent residents in Immediate Jeopardy (Residents R1, R2, R3, R4, R5, R6, R7, R8). […]

• Actual harm, isolatedF600Apr 30, 2026

  Based 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. Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed January 2026, indicated all reports of resident abuse (including injuries of unknown origins), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by… […]

• Actual harm, isolatedF689Apr 30, 2026

  Based 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. […]

• Actual harm, isolatedF600Apr 3, 2025

  Based 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). Findings include: The facility's policy Abuse and Neglect - Clinical Protocol dated August 2024, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. […]

• Actual harm, isolatedF689Apr 3, 2025

  Based 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). […]