Canterbury Health Care Facility

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled Transportation Safety, the facility failed to ensure Resident Identifier (RI) #1 was secured in the wheelchair during a transport on 8/10/23 in the facility van. Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) failed to snuggly secure RI #1's waist and shoulder belts. This resulted in RI #1 sliding from the wheelchair during transportation when the driver abruptly applied the vehicle brakes. This had the potential to affect RI #1, one of three residents sampled for transportation safety. This deficient practice is cited as a result of the investigation of complaint/report number AL00045493.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure one (Resident #40) of 34 sampled residents were assessed to self-administer their albuterol sulfate inhaler.

Inspectors wroteBased on record review, interviews, and review of the Centers for Medicare & [and] Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment within 14 days of the completion date for one (Resident #32) of one resident reviewed for timely submission of MDS assessment.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to complete a new Level I pre-admission screening and resident review (PASARR) after the resident was identified to have a newly evident mental illness diagnosis for one (Resident #2) of one resident reviewed for PASARR requirements.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to complete a discharge summary to include a recapitulation (a concise summary) of the resident's stay for one (Resident #123) of four sampled residents reviewed for discharge requirements.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure one (Resident #25) of three sampled residents reviewed for activities of daily living (ADLs) were shaved and received hair care.

Inspectors wroteBased on interviews, record review, and facility document review, the facility failed to refer a resident to dental services following complaints of tooth pain for one (Resident #57) of two sampled residents reviewed for dental services.

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #154's medical record and review of the facility's investigation file, Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs) failed to follow RI #154's plan of care/care guide when RI #154 was transferred from the wheelchair to the bed on 03/09/21. RI #154 is care planned for a two person assist with transfers using the Hoyer lift. On 03/09/21 on the 3 PM - 11 PM shift, RI #154 was transferred by being picked up under the arms and placed on the side of the bed. Once on the bed, RI #154 slid to the floor. RI #154 was transferred to the ER (Emergency Room) for evaluation. An X-ray from the hospital showed acute fractures of RI #154's left and right distal femurs. This deficient practice affected RI #154, one of 37 sampled residents whose plans of care were reviewed.

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #154's medical record, review of a facility policy titled Lift 4 Care - Safe 4 All Policy, and review of the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs), used a Hoyer lift, as determined necessary by RI #154's assessment, during a transfer on 03/09/21. During the 3:00 PM to 11:00 PM shift on 03/09/21, EI #8 and EI #9 failed to follow RI #154's plan of care when no Hoyer lift was used when RI #154 was transferred from his/her wheelchair to his/her bed. During the two person manual lift transfer, RI #154 slid from the side of the bed and fell to the floor. RI #154 was transferred to the local hospital to be evaluated after the fall. [...]

Inspectors wroteBased on observations, interviews, and a review of facility policies titled, Equipment Cleaning Schedules and Frozen Storage, the facility failed to ensure: 1) dust was not on the ceiling, walls and light fixtures in the kitchen; and 2) food items in the kitchen freezer were labeled. This had the potential to affect 108 of 108 residents receiving meals from the kitchen. Findings Include: 1) A review of a policy titled, Equipment Cleaning Schedules with an Effective Date: August 1, 2012 revealed: . POLICY It is the policy of this facility to assign cleaning schedules on a daily, weekly, and monthly basis. PROCEDURE All equipment will be identified for cleaning. The frequency and position assigned the item should be designated on the schedule. Ceiling As needed. Walls Monthly and weekly as needed. Light fixtures As needed . [...]

Inspectors wroteBased on interview, review of the facility's Record of Medication Destruction forms, and review of a facility policy titled Disposal of Medications Controlled Drug Destruction, the facility failed to ensure the Record of Medication Destruction forms for Controlled Medications contained the required signatures. This was noted on 10 of 10 of the Record of Medication Destruction forms for controlled medications reviewed for the month of March 2021.

Inspectors wroteBased on observations, interviews, and medical record review, the facility failed to ensure the oxygen tubing and humidification bottle for Resident Identifier (RI) #75 was dated. This affected RI #75, one of one resident sampled for respiratory care.

Inspectors wroteBased on observations, interviews, review of a facility policy titled, Food Holding Temperature on Food Service Line, and review of the temperature log for the 2/12/20 lunch meal, the facility failed to ensure: 1. Cordon Bleu Chicken was not stored in the freezer without an open or use by date; and 2. staffed checked the temperatures of the second batch of fish and french fries that were placed on the tray line for meal service on 2/12/20. This had the potential to affect 109 of 109 residents who received meals from the kitchen. Findings Include: 1) On 2/10/20 at 6:06 p.m., Employee Identifier (EI) #1, the Dietary Manager (DM), and the surveyor toured the kitchen. EI #1 and the surveyor observed five Cordon Bleu Chickens in large bag in the freezer. There was no open or use by dates on the Cordon Bleu Chicken. On 2/13/20 at 8:38 a.m., an interview was conducted with EI #1. [...]