Ridgecrest at Cranberry Woods.

“A resident requiring assistance with transferring, toileting, bladder management, and ambulating did not receive this assistance as required, resulting in unwitnessed falls in the home.”

“The support plan does not address the resident's history of attempting to ambulate from bed without assistance at night and history of falls, failing to identify all required physical, medical, social, cognitive, and safety needs.”

“Sanitary conditions not maintained in resident rooms. Fecal matter found on commode rim, shower chair, and floor near commode; strong urine odor present in one room.”

“Staff failed to provide assistance with activities of daily living (level of awareness) according to the resident's support plan. Instead of allowing the resident space to calm when upset, direct care staff physically restrained the resident by holding their wrists and body weight on the bed for 5-7 minutes during continence care.”

“A resident was physically abused when direct care staff held the resident's wrists and used body weight to hold them down on the bed for 5-7 minutes during continence care, despite the support plan indicating the resident should be given space to calm when upset. This is a repeat violation from 5/31/24.”

“Direct care staff applied a manual restraint by holding the resident's wrists and using body weight to hold them down on the bed for 5-7 minutes, restricting the resident's ability to move freely. Manual restraints are prohibited.”

“The resident's assessment and support plan dated 8/2/24 did not reflect significant changes in the resident's condition, including progression of dementia with sundowning and combative behavior in the evening, incontinence of bladder and bowel, and that continence care triggers behavioral responses. The home failed to update the assessment and support plan to address these changed care needs.”

“Resident #6's support plan was not updated to reflect the hiring of a private-duty companion three days per week to provide supervision in the home.”

“Two residents did not have access to a source of light that could be turned on and off at bedside.”

“An unlabeled and undated bag of beans, an unlabeled and undated bag of pierogis, and an unlabeled and undated bag of mixed vegetables were found in the walk-in freezer.”

“The local municipality's emergency management plan was not posted in a conspicuous and public place in the home.”

“The home's posted menus did not include dates.”

“Ondansetron 8mg medication prescribed to Resident #4 was discontinued on 1/23/25 but remained in the medication cart on 1/27/25.”

“Resident #5's Systane eye drops label indicated the medication was to be used as needed (PRN) when the prescription was for 2 drops into both eyes once a day.”

“Approximately 1/4-inch accumulation of lint was found in the lint trap of the 2nd floor resident laundry room dryer, creating a fire hazard. Lint should be removed from lint traps after each use.”

“A resident's assessment indicated a soft diet while the resident's annual medical evaluation indicated a regular diet, creating a discrepancy in documented dietary requirements.”

“The facility failed to conduct additional assessments when the resident's condition significantly changed. Despite documented multiple incidents of verbal and physical aggression, the assessment continued to indicate no mental health needs and no required supervision, and supervision needs were not updated even after a family request for one-on-one care.”

“The facility failed to report incidents to the Department within 24 hours as required. Two incidents involving resident interactions were not timely reported: one involving resident aggression/pushing another resident, and another involving residents engaged in inappropriate contact.”

“Resident was not protected from abuse and neglect. The facility failed to adequately assess resident's mental health needs despite multiple documented incidents of aggression, failed to provide appropriate supervision, and did not implement adequate safeguards. Additionally, another resident was subjected to sexual assault by a roommate when the facility's locked door policy was not properly implemented, resulting in the resident being physically touched inappropriately while sleeping.”

“A deceased resident's record did not include a copy of the official death certificate as required by regulation.”

“The facility failed to report a resident's death to the Department within 24 hours as required. The resident ceased to breathe on the date of death, but the home did not report this incident timely.”

“A resident with dysphagia was admitted to the home and subsequently experienced serious health decline including malnutrition, repeated vomiting, weakness, and weight loss. The facility failed to assist with securing a ordered Gastroenterologist consultation and a hospice consultation, and did not adequately monitor or respond to the resident's declining condition, resulting in the resident's death from aspiration pneumonia and sepsis.”

“An uncovered, unattended garbage can half-full of refuse was found approximately 18 inches from the serving line in the second-floor kitchen.”

“A staff member who moved to Pennsylvania did not have a completed Federal Bureau of Investigations criminal history check on file.”

“Resident #1 had multiple documented falls, but the most recent assessment did not document fall risk as a personal care need requiring assistance.”

“Bedside enablers for Residents #1 and #2 were not properly secured, could move approximately 8 inches, and contained open spaces creating impingement hazards. Resident #1's bed remained adjacent to room wall creating entrapment hazard despite prior incident on 8/29/23.”

“The home's dumpster had an open lid creating a space of approximately 4 x 6 feet, failing to prevent penetration of insects and rodents.”

“Eight 3-gallon ice cream containers were stored on the floor of the second kitchen's walk-in freezer.”

“A half-full, undated plastic container of diced pineapple was found in the second-floor kitchen walk-in cooler.”