Canterbury Center

Inspectors wroteBased on observations, resident interview, and staff interview, the facility failed to ensure the rooms are being kept in a clean/comfortable/homelike environment for four (4) of nine (9) rooms throughout the Long-Term Care Survey Process. Room identifiers: #301, #305, #306. Resident identifier: #4. Facility census: 59.

Inspectors wroteBased on observations, resident interviews, record review and staff interviews. The facility failed to ensure call lights were answered in a timely fashion to ensure residents needs are met, additionally the facility failed to ensure resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed. For five (5) of (22) residents reviewed during the long term care survey process. Facility census 59. Resident indicators.

Inspectors wroteBased on record review and staff interview the facility failed to ensure pharmacist recommendations were acknowledged by the physician. This was true for one (4) of Five (5) residents reviewed for the care area of unnecessary medication. Facility Census: 59. Resident identifiers: #43, #4, #54, and #56. Findings Included: a) Resident #43 The Consultant Pharmacist (CP) completed a Medication Regimen Review (MRR) on 10/21/25. The Consultant Pharmacist (CP) recommended (as Written): The resident was prescribed diclofenac gel 1% to knees twice daily for pain relief. The current order did not specify the amount. Recommended dosing for diclofenac gel.: Upper Extremity: Apply 2g gel each affected area up to 4 times daily (maximum dose per joint is 16g/day) Lower extremity: [...]

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure palatable food. The noon meal on 07/12/26 was served late and cold causing food to be too tough to cut or chew. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #47, #9, #19, #44, #37, #28, #2, #36, #25, #11, #4, #43, #78, #14, #57, #60. Facility Census: 59 Findings Included: a) During the first kitchen visit on 07/12/26 at 11:55 AM, kitchen staff reported that due to being short-staffed, no residents would be served in the dining room at the usual time of 12:00PM. A short time later at 12:10 PM, the kitchen was notified that because the state is here the dining room had to be open. The Dietary Manager had already placed usual dining room resident's meal tickets back in the stack for room delivery. [...]

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This was true for the facility kitchen and nourishment pantry. This had the potential to affect all residents in the facility. Facility census:

Inspectors wroteBased on observation, and staff interview the facility failed to treat each resident with respect and dignity during the lunch dining experience. This was a random opportunity for discovery. Resident Identifier: #54. Facility census:

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure Resident #38 had a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of (22) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #38. Facility census: 59.

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to ensure one (1) of one (1) resident received the assistance needed with activities of daily living. Resident identifier: #4. Facility census: 59. a) Resident #4 During an interview with the State Surveyor (SS) on 07/12/26 at 2:00 PM Resident #4 stated she had not had a shower in three (3) weeks. She stated she was supposed to get a shower every Monday and Friday. She became teary-eyed and stated, My hair is greasy and I cannot do it by myself. Resident #4 had capacity to make medical decisions. On 07/13/26 at 12:08 PM the SS spoke with the Director of Nursing (DON), the Clinical Lead Nurse (CLN) and the Administrator (ADM) about Resident #4 stating that she was not getting showers as she would like to. [...]

Inspectors wroteBased on observations, and staff interviews, the facility failed to ensure the resident environment under its control was as free from accident hazards as possible. An observation of Resident #28's room found a spray bottle of disenfectant cleaner on her bedside dresser. Additionally, observations revealed a housekeeping cart and a treatment cart were left unlocked and unattended, and doors to central supply and the service hall were also found unlocked. These failed practices presented random opportunities for discovery and could affect more than a limited number of residents. Facility census: 59.

Inspectors wroteBased upon record review and staff interview, the facility failed to maintain the accuracy of medical records for its residents. Specifically for wanderguards and their tracking and use. This was discovered during the normal long term survey process and has the ability to affect more than a limited number of residents. Resident identifier: #42. Facility census: 59.

Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to ensure proper levels of staff were maintained to provide for the residents' needs. This was discovered during the normal Long Term Survey Process, while meeting with the resident council and has the ability to affect more than a limited number of residents. Census 59.

Inspectors wroteBased on observation and interview the facility failed to ensure the daily nursing posting was completed accurately for two (2) days throughout the long-term care survey process. This was a random opportunity for discovery and had the potential to impact more than an isolated number of residents. Facility census: #59.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a homelike environment by not providing housekeeping and maintenance services to ensure that residents' rooms were being kept in a clean and sanitary condition. Room Identifiers: #103, #104, #108, #110, #302, #304, #307B, #401, #402, #404 #408, 400 Wing hallway, and Shower Room. Resident Identifier: #47. Facility Census: 59. Findings Include: a) Observation of the facility interior upon survey entry on 03/10/25 at 5:30AM: room [ROOM NUMBER] had approximately 3 foot section of section of unfinished drywall above heads of beds The 400 hallway above the resident's room doors had rips in the wall paper borders room [ROOM NUMBER], unfinished dry wall patches on the wall above the head of both resident's beds - Bathroom between rooms [ROOM NUMBERS] had a yellowish stain around base of toilet, and over-flowing trash can. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident environment, over which they had control, was as free from accident hazards as possible in regards to water temperatures. This was a random opportunity for discovery. Room Identifiers: Rooms #101, #107, #202, and #302. Facility census:59. Findings Include: a) Resident #1 During an interview on 03/10/25, at 9:13 AM, Resident #1 stated that the water is too hot for her. She stated that she has never been burnt but must ask the staff to make the water temperature cooler. During an inspection of Resident #1s sink water temperature, this surveyor had to pull my hand back from the sink water due to hot temperatures. b) Water Temperatures During an interview and inspection with the Maintenance Director (MD) #56 on 03/10/25 at approximately 10:30 AM the water temperature was found: [...]

Inspectors wroteBased on record review and staff interview, the Facility failed ensure they had sufficient and competent nurse staffing by failing to complete competency evaluations for Nurse Aides. This is true for five of five Nurse Aide charts reviewed.

Inspectors wroteBased on observation, staff interview, and equipment manual review the facility failed to have a clean, sanitized kitchen, store food in the refrigerator, freezer, and dry storage store food in accordance with professional standards for food service safety. The facility also failed to keep the ice machine in safe operating condition. This has the ability to affect all Residents that get their nutrition from the kitchen, also attends food related activities. Facility Census:

Inspectors wroteBased on observation and interview, facility staff failed to handle, store, process, or transport linens and laundry in a hygienically clean manner, or clean the laundry machine filters. The facility also failed to follow infection control protocols when handling food trays, and trash. In addition, the facility failed to provide residents with hand hygiene before meals. These failed practices allowed for the potential spread of infection throughout the facility. Facility Census: 59 Findings Include: 1) Handling and storage of clean linen (100 Wing, 300 Wing and 400 Wing): a. During an observation of the 100 Wing linen cart on March 10, 2025, at approximately 7:30 AM, Account Manager (AM) #67 was seen replenishing wall boxes with trash bags. While doing this, she pushed a linen cart out of the way with her foot, causing clean linen from the lower rack of the cart to spill onto the floor. [...]

Inspectors wroteb) Resident #58 On 03/10/2025 at 11:03 AM, It was observed Resident #58 in his wheelchair rolling down the hall with his catheter bag in his lap. The catheter bag did not have a bag cover. In an interview with Resident #58, on 03/10/2025 at 11:05 AM, he stated he has never been offered a cover for his catheter bag and would like to have one. In an interview with RN #25 on 03/10/2025, at approximately 11:10 AM, he acknowledged Resident # 58 did not have a cover for his catheter bag. Based on observation and interview, the facility failed to uphold the residents' right to be treated with dignity and respect by leaving urinary catheter bags uncovered and prominently displayed. Resident Identifiers: Residents #28 and #58. Facility Census: 59. Findings Include: a) Resident #28 On 03/10/25, at approximately 1:35 PM, Resident #28 was observed in bed. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that residents had the opportunity to exercise autonomy over important aspects of her life such as choice regarding waking time and morning care. Resident Identifier: Residents #50 and #52 Facility Census: 59. Findings Include: a) Resident #52 During an interview with Resident #52, on 03/10/25, at 1:51 PM, she expressed her preference for waking up early and having her bed made and morning care completed before breakfast. She noted that she does not receive morning care until after 10:00 AM. A family member present during the interview stated that they have raised this issue with the nursing staff multiple times, but no action has been taken. The resident also mentioned that her roommate receives morning care around 7:45 AM each day, while she does not receive assistance until much later. [...]

Inspectors wroteThe facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Random opportunity for discovery.

Inspectors wroteBased on observation and staff interview, the facility failed to secure and protect residents' personal and medical information. Specifically, private information was not safeguarded and was found in a clear acrylic wall file located in the residents' hallway. This was a random opportunity for discovery. Facility Census: 59. Findings Include: On 03/18/25 at approximately 8:50 AM, a random opportunity for discovery found multiple documents with resident's identifiable health information in an acrylic wall file holder mounted on the wall outside the nursing office on the 300 wing of the facility. A review of the documents on 03/18/25 at 9:15 AM revealed the following: a) Resident names, Room numbers, Diagnoses, Code status, and Vital signs for twenty-nine (29) residents. b) Prescription information for Resident #221. A new resident admitted on [DATE]. [...]

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure that all written grievance decisions included the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. This was a random opportunity for discovery. Resident identifier: #218. Facility census: 59. a) Resident #218: On 03/17/25 at 03:45 PM, during record review, a grievance form dated 4/10/2024 was not completed for Resident #218. [...]

Inspectors wroteBased on observation, staff interviews, electronic medical record and Operation Policy the facility failed to follow written policy, thorough investigating and reporting to proper agencies of injury of unknow origin and neglect. This is true of two (2) of six (6) residents reviewed for abuse. Resident identifier: #55 and #36. Facility census: 61.

Inspectors wroteBased on observation, staff interview, and operation policy, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This is true for two (2) of six (6) allegations of abuse. Resident identifier: #55 and #36. Facility census: 61.

Inspectors wroteBased on observation, staff interview, and operation policy, the facility failed to take actions to investigate a large bruise of unknow origin and neglect. This was a random opportunity for discovery. Resident identifier #55. Facility Census 61.

Inspectors wroteBased on record review and staff interview the facility failed to accurately document resident's discharge status in Minimum Data Set assessment (MDS). The assessment must represent an accurate picture of the resident's status during the observation period of the MDS. Resident #62.

Inspectors wroteBased on observation, record review, resident, staff interview. The facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for one (1) of four (4) residents reviewed for ADL care. Resident Identifiers: #50. Facility census: 61. Findings Included: a) Resident #50 showers During an interview and observation on 03/10/25 at 10:20 AM Resident #50 stated that she doesn't get her showers or baths as ordered or her preference. She continued to say that I don't like not having a shower when I get visitors. Her hair was observed to be very oily during this interview. A review of Resident #50's ADL documentation found that there was only one (1) shower on 02/21/25 and two bed baths noted on 02/11/25 and 02/14/25 given in 30 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement protocols ensuring that staff conducted incontinence assessments for dependent residents and provided incontinence care at the required intervals throughout the day. Resident Identifier: #51. Facility Census: 59. Findings Include: a) Resident #51 Observation, interview and record review revealed that a dependent resident was not being provided incontinence care in a timely manner. During an interview on 03/10/25, at approximately 1:15 PM, the Medical Power of Attorney (MPOA) for Resident #51 stated that she visits the resident every day. She mentioned that Resident #51 is incontinent and noted that the facility staff has failed to assess the resident for incontinence at regular intervals. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow a physician's order regarding a prescription for oxygen. Resident Identifier: #22. Facility Census: 59 Findings Include: a) Resident #22 During an interview with Resident #22 on 03/10/25, at approximately 9:43 AM, the resident indicated that she was somewhat hard of hearing. She responded to questions about her care, and expressed that she was happy and content with the facility. The resident was observed to be on oxygen therapy. Inspection of the resident's oxygen concentrator revealed that it was set to deliver 4 liters per minute. [...]

Inspectors wroteBased on record review and staff interview the facility failed to update nurse staff postings to reflect actual hours worked. This is true for five of five days reviewed.

Inspectors wroteBased on record review and staff interview, the facility was unable to provide evidence that the attending physician reviewed any irregularities identified by the pharmacist and either accepted or rejected the recommendations. This was true for two (2) of five (5) residents reviewed under the Unnecessary Medications pathway in the Long-Term Care Survey Process. Resident identifiers: #24 and #2. Facility census: 59.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor, and implement interventions to meet the resident's preferences, as related to the resident's request to have cereal and oatmeal for breakfast. Resident Identifier #52. Facility Census:59. Findings Include: a) Resident #52 During an interview on 03/10/25 at 1:51 PM, resident stated that she had requested cereal and milk for breakfast, but had not received it. Resident's family member stated that she had spoken to the kitchen staff multiple times, and her mother had still not received any cereal with her breakfast. Resident's daughter stated that she would highlight the cereal on her mother's breakfast menu for the next day. On 03/11/25, at approximately 9:15 AM, when interviewed, Resident #52 stated that no cereal had been served to her. [...]

Inspectors wroteBased on resident council interview and staff interview the Facility failed to provide evidence that snacks were offered to resident at bedtime. Resident identifiers #47, #30, #2, #46, #49

Inspectors wroteBased on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 61.

Inspectors wroteBased on record review and staff interview the facility failed to ensure all staff had thorough background checks. The state of [NAME] Virginia uses the [NAME] Virginia CARES (Clearance for Access: Registry & Employment Screening) system to determine eligibility to work in a nursing home. Nurse Aide (NA) #17 did not have WV CARES determination on file and had been working at the facility. This was true for one (1) out of five (5) staff reviewed for Nurse Aides reviewed. Staff Identifier: NA #17. Facility census: 58. a) Nurse Aide # 17 A review of the employee file for Nurse Aide (NA) #17 found they do not have a WV Cares eligibility letter on file. NA #17's hire date was 05/08/06. WV CARES became required for all new and current employees beginning in the year 2016. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Registered Nurse was available 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. Facility census: 58.

Inspectors wroteBased on observation and staff interview the facility failed to retain the original staff postings for a minimum of 18 months as required. This had the potential to affect all residents currently residing at the facility. Facility census 58.

Inspectors wroteBased on observation and staff interview the facility failed to contain waste properly in the dumpster. This had the practice affect more than an isolated number of residents. Facility Census: 58.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to promote and facilitate resident self-determination through the support of resident choices related to showers. This was true for seven (7) out of seven (7) residents reviewed under choices in the Long-Term Care Survey Process. Resident identifiers: #26, #4, #3, #11, #13, #36, and #1. Facility census: 58.

Inspectors wroteBased on record review and staff interview the facility failed to develop and implement a comprehensive resident specific care plan. This was true for five (5) of 19 sampled residents. Resident Identifiers: #19, #24, #50, and #33 Facility Census: #58.

Inspectors wroteBased on record review and staff interview, the facility failed to administer medications as ordered by the physician. Neuro checks were not completed after falls. A critical oxygen level was not reported to the physician. This was found for seven (7) of nineteen residents reviewed. Resident identifiers: #110, #10, #1, #56, #4,#12, and #27. Facility census: 58.

Inspectors wroteBased on observation, staff Interview, and record review the facility failed to ensure the facility was free from accident hazards over which it had control. One (1) medication (med) cart was left unlocked and unattended, allowing access to medications by residents and unauthorized persons. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Facility Census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to monitor for side effects and behaviors associated with an antianxiety (anxiolytic) and antidepressant medication. Resident identifiers: #50, #24 and #10. Facility Census:

Inspectors wroteBased on resident council meeting, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack or the cognitive and/or physical ability to make their way to the nurse's station to request something to eat from the nourishment room. Facility Census: 58.

Inspectors wroteBased on observation, and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection by not following isolation precautions. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #15 and Resident #209. Facility census: 58.

Inspectors wroteBased on observation, resident interview, staff interview and record review, the facility failed to treat Resident #7 with respect and dignity and to care for the resident in a manner that promoted maintenance or enhancement of her quality of life. Secondly, the facility failed to provide meals in the dining room to all residents at a table at the same time. Lastly, the facility failed to ensure Resident #11 was given the right to vote. These were random opportunities for discovery. Resident identifiers: #7 and #11. Facility census:

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to ensure a call light was within reach in Resident #33's room. This was a random opportunity for discovery. Resident identifier: #33. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident's legal representative after the resident experienced a fall. The facility's failure to notify the resident's representative was true for one (1) of four (4) residents sampled for falls in the Long-Term Care Survey Process. Resident identifier: #49. Facility census:

Inspectors wroteBased on observation and staff interview the facility failed to ensure Resident #1's personal privacy was maintained during catheter care. Additionally, three (3) residents personal information was left unattended in the lobby and was accessible to the public and other residents . This was true for one (1) out of one (1) reviewed for catheter care and was a random opportunity for discovery. Resident identifiers: Resident # 1, #49, #23, and #50. Facility census:

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to identify a verbal complaint/concern as a grievance, failed to make prompt efforts to resolve grievances, and to keep the resident informed of progress toward resolution. This was true for one (1) of 19 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #33. Facility census: 58.

Inspectors wroteBased on medical record review and staff interview the facility failed to update Resident #10's Preadmission Screening and Resident Review (PASRR) after they were diagnosed with Major depressive disorder during their stay. This was true for one (1) out of two (2) residents reviewed for Preadmission Screening and Resident Review (PASRR). Resident identifier: #10. Facility censuses 58.

Inspectors wroteBased on record review and staff interview the facility failed to revise the comprehensive care plan in a timely manner. This was found for one (1) of nineteen residents reviewed during the long-term care survey process. Resident Identifier: #19 Facility Census: #58. Findings Include: a) Resident #19 On 03/26/24 at 01:23 PM, record review shows Resident #19 received dialysis three (3) times a week. The current order stated: Dialysis days: Monday, Wednesday, Friday. Time for pick up: 05:30. Transport to: (Name of dialysis center) Transport: PT (patient) via stretcher. She was care planned for the same. On 03/27/24 at 08:00 AM, the resident was in her room. When Registered Nurse #44 was asked why the resident did not go to dialysis, she responded, she doesn't go until 10:00 AM now, they changed her times. [...]

Inspectors wroteBased on observation,record review, and staff interview, the facility failed to ensure a resident received the necessary care and services to maintain good grooming and personal hygiene for dependent residents. Resident #7 had unwanted facial hair. This was a random opportunity for discovery. Resident identifier: #7. Facility census:58.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Resident Identifier: #27 Facility Census:

Inspectors wroteBased on observation, record review, the facility policy, and staff interview the facility failed to use a sterile technique while providing tracheostomy care for Resident #41 and failed to give a breathing treatment to Resident #4 as ordered. This was found for two (2) of four (4) residents reviewed for respiratory care. Resident identifiers; #41 and #4. Facility census: 58.

Inspectors wroteBased on record review and staff interview the facility failed to provide ongoing assessments to ensure the overall quality of care the resident received in regards to dialysis treatment. In addition, the facility failed to follow the physician's order for fluid restriction. Resident identifier: #19. Facility Census: #58.

Inspectors wroteBased on record review and staff interview, the facility failed to monitor for side effects and behaviors associated with an antipsychotic medication. Resident identifiers: #50 and #27. Facility Census:

Inspectors wroteBased on staff interviews and medical record review, the facility failed to develop a discharge plan for a resident. This was true for one (1) of one (1) residents who were reviewed for discharge. Resident identifier: # 17. Facility census: 59.