Canterbury House

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of safety for 1 of 1 facility kitchens reviewed. The failure to ensure the kitchen's range vent hood and freezer were kept clean and free of dust, debris, and/or dirt build-up placed residents at risk for ingesting contaminated food and the development of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential equipment (a dishwasher) was kept in safe operating condition for 1 of 1 facility kitchens reviewed. These failures placed the residents at risk for infection from using improperly sanitized dishes and utensils during meals and the development of foodborne illness.

Inspectors wroteBased on interview and record review, the facility: (1) failed to provide the resident and/or the representative a written notice of the facility's bed hold (a process to reserve a resident's current bed when was temporarily absent) policy, at the time of transfer/discharge or within 24 hours, and document in the resident's records for 3 of 4 residents (Residents 9, 27, & 82); and (2) failed to ensure appropriate information was communicated to the receiving health care institution or provider and document in the resident's records for 2 of 4 residents (Residents 9 & 27) reviewed for hospitalizations. These failures placed residents and their representatives at risk of not being informed of their right to, or the cost of ensuring their bed was held for them while hospitalized and unsafe and ineffective transition of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: physician orders were followed for 4 of 18 sampled residents (Residents 55, 1, 9, & 27), failed to notify the physician for refusals of medications for 1 of 5 residents (Resident 27) whose medication regimens were reviewed. These failures left residents at risk for unmet care needs and other negative health outcomes.

Inspectors wroteBased on observation, interview, record review the facility failed to ensure 3 of 5 residents (Residents 5, 9, & 74) reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. The failure to provide hand splinting (Resident 5), Range of Motion (ROM) exercises (Resident 9), and grooming/dressing program (Resident 74) placed residents at risk for pain, contractures (the permanent or severe tightening of muscles resulting to immovable joints), decline in mobility, increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective coordination of care between the facility and hospice staff and failed to implement and develop a coordinated Care Plan (CP) for 2 of 2 residents (Resident 5 & 3) reviewed for hospice services. The failure to implement a system by which consistent communication between the facility and hospice staff occurred placed residents at risk for not receiving necessary care and services, avoidable discomfort, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves and gowns used to prevent exposure to infectious materials) for 1 supplemental resident (Resident 55) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); ensure staff followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 supplemental resident (Resident 88) reviewed for TBP; and ensure respiratory equipment was free from visible debris for 1 of 1 sampled residents (Resident 27) reviewed for respiratory care. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure 2 of 5 Certified Nursing Assistants (CNAs) reviewed for training (Staff H,CNA & Staff I, CNA), received the required in-service training of no less than 12 hours per year. This failure placed residents at risk of receiving care from unqualified staff.

Inspectors wroteBased on interview and record review, the facility failed to 1) review resident rights and the grievance policy in accordance with their process and 2) initiate, investigate and document resolutions for grievances raised during 3 of 3 Resident Council (RC) meetings (11/03/2025, 12/10/2025, and 01/08/2025) reviewed. This failure placed residents at risk of increased feelings of powerlessness, frustration, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete resident assessments within the regulatory timeframes for 2 of 12 sampled residents (Resident 2 & 5) reviewed for assessment completion and timing. The failure to ensure comprehensive admission Minimum Data Set (MDS - an assessment tool) and Quarterly MDS assessments were completed timely delayed the residents' care planning process, hindered necessary Care Plan (CP) revisions, and placed residents at risk for delayed services, unidentified status change and care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status of 3 of 16 sample residents (Residents 67, 3, & 10) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' Care Plans (CPs) were comprehensive and implemented for 1 of 18 (Resident 22) sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs) received the assistance they were assessed to require for 2 of 3 sampled residents (Residents 1 & 29) reviewed for ADLs. The failure to provide bathing and grooming assistance for (Residents 29) and nail care for (Resident 1) left residents at risk for body odors, unmet care needs, and a decreased self-worth and/or quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe water temperatures for 2 of 14 resident room sinks (Rooms 215 & 301) reviewed for water temperatures; and failed to secure potentially hazardous items in 1 of 2 clean utility rooms (West Nursing Station clean utility room) reviewed for accident hazards. These failures placed residents at risk for accidents, injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their abuse and neglect policies and procedures regarding identification, investigation, protecting, and reporting of abuse and neglect incidents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 6 residents (Resident 1, 3, 12, 14, 15 ) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to document identified target behaviors, monitor all target behaviors, document when behaviors occurred, implement and document behavioral interventions before administering medications, assess the effectiveness of the interventions before increasing medications, and to have as needed psychotropic medication (affects behavior, mood, thoughts, or perception) orders with stop dates and physician reassessment for extended use. These failures left residents at risk for unnecessary medications, adverse side effects, unmet needs, and diminished quality of life

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 (Resident 1, 12, 3) of 6 residents or resident representatives reviewed were fully informed orally and in writing of the potential risks associated with the use of psychotropic medications (medications that alter the thought process). In addition, based on interview and record review the facility failed to obtain informed consent for devices used for 1 (Resident 1) of 4 residents reviewed for devices. These failures prevented residents and/or legal representatives from making informed decisions about the use of multiple antidepressant medications, and precluded them from exercising their right to refuse/decline the proposed medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently assess and monitor change in condition and implement provider orders timely for 1 of 1 resident (Resident 16) reviewed for significant injury of unknown origin. Resident 16 experienced harm when there was a delay in assessment and treatment by a medical professional and the resident required surgical intervention for a large, expanding hematoma to their right calf, and a blood transfusion for a critically low blood count. These failures placed all residents at risk for delay in treatment, worsening of condition, unmet care needs, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained, and/or implemented, and incorporated into the Care Plan (CP) for 1 of 7 (Resident 23) residents reviewed for PASRR Level II. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 7 (Residents 22, 57, & 13) residents and 2 supplemental residents (Resident 185 & 53) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and/or implement comprehensive Care Plan's (CP) for 6 of 20 sampled residents (Residents 53, 70, 32, 43, 45, & 16) whose CPs were reviewed. The failure to develop comprehensive, individualized, or implement CPs with resident-specific goals and/or interventions, placed residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 4 (Residents 70, 53, 185, & 13) of 20 sample residents whose CPs were reviewed. The facility failed to ensure residents received and/or participated in care conferences that included the Interdisciplinary Team (IDT) for 2 (Residents 21 & 43) residents reviewed. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assistance with Activities of Daily Living (ADL - personal hygiene and other daily routines) was provided for 8 of 11 residents reviewed for ADL (Residents 70, 21, 20, 13, 22, 43, 16, & 45). The failure to provide assistance with getting out of bed, nail care, and bathing placed residents at risk of poor hygiene, diminished sense of self-worth, skin impairment, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 7 residents (Resident 70, 16, & 43) reviewed for Range of Motion (ROM) and 1 supplemental resident (Residents 46) received a Restorative Nursing Program (RNP) as ordered. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility.

Inspectors wrote<Resident 185> According to a 09/24/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 185 had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 185 with no memory impairment. In an interview on 09/30/24 at 9:45 AM, Resident 185 stated they felt the facility did not have enough staff, especially at shift change, on the night shift. Resident 185 stated they would have to wait anywhere from 15 minutes to one hour to get assistance from staff with their toileting needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and followed up timely for 3 of 5 residents (Residents 3, 13, & 23) whose medication regimens were reviewed and 2 supplementary residents (Residents 46 & 16). This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects, and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 (Residents 3 & 23) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 7 of 26 medications for 2 of 5 residents (Resident 72 & 4) observed during medication pass resulted in a medication error rate of 26.92 %. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured, dated when opened, expired medications and biologicals were disposed of timely in accordance with professional standards, medications were stored at beside only for assessed residents, and ensure medication carts were locked and secured when staff were not present for 2 of 4 medications carts, 1 of 2 medication rooms, and 1 shower room. These failures placed residents at risk for receiving expired medications and access to unsecured, prescription medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 4 of 5 residents (Resident 37, 48, 35, & 59) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life.

Inspectors wrote<Transmission Based Precautions> According to a 09/21/2024 progress note, Resident 34 tested positive for COVID-19 on that date. The note showed necessary precautions were put in place for Resident 34. According a 09/21/2024 progress note Resident 25 was placed on aerosol contact precautions on that date related to their roommate Resident 34 testing positive for COVID-19. A 09/28/2024 progress note showed Resident 25 tested positive for COVID-19 on that date. Observation on 09/30/24 02:23 PM showed an Aerosol Contact Precaution sign outside room [ROOM NUMBER], both residents in that room were isolated. The sign directed anyone entering the room to put on a gown, gloves, eye protection and an N-95 respirator prior to entering the room. The sign directed everyone to remove all their PPE before leaving the room and replace their eye protection and respirator. [...]

Inspectors wrote<Resident 32> Review of Resident 32's records showed an electronically signed form dated 05/24/2021, titled Authorizations and Designations that indicated the resident did not provide an AD to the Facility. Review of Resident 32's notes from the following Care Conferences; 01/10/2024 (admission), 02/01/2024 (quarterly), 04/26/2024 (annual), and 07/29/2024 (quarterly), showed the box indicating a review of Annual and admission paperwork reviewed with resident for AD was not marked for any of the care conferences, indicating a review was not completed with the resident. Review of Resident 32's records showed no AD. According to the 09/07/2024 Quarterly MDS, Resident 32 was understood, had clear comprehension, had multiple medically complex conditions and was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their Grievance policy for 3 of 3 residents (Resident 54, 70, & 53) reviewed for Grievance reporting. The failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievance resolution delayed or incomplete, feelings of frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to report significant injury of unknown origin for 1 of 1 resident (Resident 16) reviewed. The facility's failure to report a large hematoma of unknown origin on Resident 16's right calf, placed Resident 16 and all residents at risk for repeated incidents and unidentified abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and rule out abuse/neglect for 2 of 12 sampled resident's (Resident 16 & 4) reviewed for investigations. Facility failure to complete thorough investigations placed residents at risk for potential abuse and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure residents received required written notices at the time of transfer/discharge for 3 (Residents 65, 16, & 53) of 4 residents and notify the Office of the State Long-Term Care Ombudsman (LTCO) for 2 of 4 residents (Resident 16 & 53) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the Resident's Representative (RR) of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to ensure required LTCO notification was completed, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the Resident's Representative (RR) a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 (Residents 67, 16, & 53) of 4 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision making.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician's orders were clarified for 1 of 21 sample residents (Resident 29), or followed for 2 of 21 sample residents (Residents 4 &3). These failures placed residents at risk for unneeded care and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 1 of 5 sample residents (Resident 32) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of accident hazards for 4 (Residents 41, 57, 43, & 16) supplemental residents reviewed. The failure to ensure residents were free from potential restraints (Resident 41), ensure staff safely used and monitored air mattresses (Residents 57, 16, & 43), ensure sharps (syringe needles, razors etc.), and chemicals were stored safely, placed residents at risk for potential restraints, injury, exposure to soiled medical equipment, and unsafe chemicals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 5 of 5 sample residents (Residents 32, 45, 53, 185, & 22) reviewed for oxygen administration were provided care consistent with professional standards of practice. Failure to provide oxygen treatments and maintain oxygen equipment left residents at risk for respiratory discomfort, oxygen-related accidents, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain management was provided to residents consistent with professional standards of practice including the failure to offer nonpharmacological interventions, identify parameters for administration of as needed (PRN) pain medications, and administer pain medications timely for 1 of 2 residents (Resident 16) reviewed for pain management. These failures placed residents at risk for experiencing untreated pain and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 20 sample residents (Residents 23 & 72) were free from significant medication errors. These failures placed residents at risk for incorrect dosage, adverse side effects, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to obtain timely laboratory services to meet the needs of 1 (Resident 3) of 5 residents reviewed for unnecessary medications. Failure to obtain physician ordered blood tests for residents who were assessed to require this service, placed residents at risk for delayed treatment and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food and drinks served to residents were stored and distributed under sanitary conditions for 1 of 1 facility kitchen. The failure to store canned and frozen food appropriately, ensure food was covered when distributed in the hall, and ensure the ice machine was clean, placed residents at risk for spoiled food and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents records were complete and accurate and readily accessible for 3 of 20 residents (Resident 16, 43, & 45) whose records were reviewed. The facility failed to ensure Task Care Record documentation was complete and accurate. Failure to ensure residents records were complete and accurate placed residents at risk for unmet care needs and inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services in accordance with professional standards of practice. The facility failed to ensure physician orders were followed, implemented timely, or were clarified as needed; Care Plans (CP) developed for 3 (Resident 2, 4, 3) of 3 residents reviewed; medications were not provided as ordered, for 1 (Resident 5) of 3 residents reviewed; and to monitor weights and bowels, act on, or implement their policies for 4 (Residents 3, 2, 1, 4 ) of 4 residents reviewed. These failures placed all residents at risk for unmet care needs, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 3 of 3 (Residents 3, 4, 1) residents reviewed for Pressure Ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, implement wound provider recommendations, and preventative skin measures placed all resident's at risk for deterioration in skin condition(s), pain, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure consistent, timely weights and re-weights, identify significant weight changes timely, notify interested parties timely, and implement Registered Dietician's (RD) recommendations placed the residents at risk for delayed identification of interventions to prevent continued weight loss and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra (an opening that allows urine to leave the body) that drains urine into a bag) were provided catheter care consistent with standards of practice for indwelling catheters, consistent documentation of catheter procedures and resident response, and coordinated referrals to a urologist for evaluation as ordered by a physician for 5 of 5 residents (Resident 3, 2, 1, 4 & 5) reviewed for indwelling urinary catheters. Resident 3 experienced harm when they had redness, swelling, and skin breakdown around the urethra due to catheter friction wear that required a surgical procedure to facilitate urinary function through a tube inserted in the lower abdomen. [...]

Inspectors wroteBased on interview, and record review the facility failed to obtain informed consent for residents who were assessed to require a decision maker due to cognitive impairments before performing Covid-19 testing for 5 (Residents 6, 7, 2, 8, 9) of 5 residents reviewed for resident's rights. These failures placed all residents with decision makers unable to exercise their right to be fully informed in a language they could understand and removed their ability to refuse Covid-19 testing.

Inspectors wroteBased on record review and interview the facility failed to ensure residents and/or their Resident Representative (RR) was provided a transfer or discharge notice in writing in a language or manner they understood and send a copy to the State Long-Term Care Ombudsman (SLTCO). The notice must contain the reason for transfer or discharge, location, a statement of appeal rights, and information for contacting the Ombudsman. The failure to provide written transfer/discharge notice to 4 of 4 residents (Resident #28, #32, #33, #60) upon facility-initiated transfer to the hospital prevented residents from inappropriate discharge, provide residents with access to an advocate who can inform them of their options and rights and to ensure the SLTCO is aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents or the Resident's Representative (RR) with a bed-hold notice upon transfer to the hospital for 3 of 4 residents (Resident 28, 33, and 60) reviewed for hospitalization. The failure to provide a copy of the written bed-hold notice and reserve bed payment policy upon transfer to the hospital, regardless of payment source, prevented residents from exercising their rights and choice to return to the facility upon hospital discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications and vaccinations were stored at the appropriate temperature and failed to dispose of expired medications in a timely manner in 2 of 2 medication rooms (East and [NAME] Medication Room) and 1 of 3 medication carts (East Medication Cart) reviewed for medication storage. The failure to dispose of expired medications placed residents at risk for narcotic drug diversion and at risk of administration of expired or discontinued medication. The failure to monitor and document refrigerator temperatures twice daily when storing vaccinations placed residents at risk for administered vaccinations that were no longer useful.

Inspectors wroteBased on observation and interview the facility failed to ensure 3 of 4 nurses (Staff P- Licensed Practical Nurse/LPN, Staff K- LPN, Staff N- LPN) followed hand hygiene procedures when in direct contact with residents. The failure to complete hand hygiene during medication administration placed residents at risk for illness, infections, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered Care Plan (CP), and the resident's choices for 1 resident (Resident 36) of 7 residents reviewed for pain, non-pressure skin, and oxygen management. The failure to assess, care plan, monitor, and follow Physician Orders (PO) placed Resident 36 at risk for overdose of opioid medication, untreated skin issues, worsening medical conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from accidents and hazards for 1 of 1 resident (Resident 54) reviewed for smoking. The failure to assess Resident 54's smoking safety and develop a Care Plan (CP) to monitor and prevent accidents placed Resident 54 at risk for falls, burns, other injuries, and diminished quality of life.