Canterbury of Twinsburg

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff and resident interviews, review of video footage, review of facility investigation, and facility policy review, the facility failed to ensure residents were safely transferred using a Hoyer lift. Actual Harm occurred on 05/08/25 at approximately 2:15 P.M. when Hospice Nurse Aide (HNA) #869 completed a Hoyer lift (a type of mechanical lift used to safely transfer individuals with limited mobility from one surface to another) transfer of Resident #21 without the assistance of a second person, resulting in Resident #21's arm becoming fractured. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #27's call light was responded to in a reasonable amount of time. This affected one resident (#27) of three residents reviewed for call light response times. The facility census was 37.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent a fall for Resident #8 who was completely dependent on staff for fall prevention. This affected one resident (Resident #8) of three residents reviewed for falls. The facility census was 37.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate infection control practices were implemented when Resident #10 was provided incontinence care. This affected one resident (Resident #10) of 37 residents observed for infection control. The facility identified 11 residents (Resident's #10, #12, #13, #14, #15, #17, #18, #25, #26, #30 and #40) as incontinent and residing on the nursing unit of Resident #10. The facility census was 37.

Inspectors wroteBased on staff interview, review of facility policy, review of the employee handbook, and review of photographs taken on a staff member's cell phone, the facility failed to ensure Resident #5 was treated with dignity and respect at all times. This affected one resident (#5) of four residents reviewed for dignity. The facility census was 41.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, resident interview, review of the facility's Self-Reported Incident (SRI) 243880 and related investigation materials, the facility failed to ensure Resident #39 was treated with respect and dignity. This affected one (#39) of three residents reviewed. The facility census was 44. Findings Include: Review of the medical record for Resident #39 revealed an admission date of 01/05/23 with diagnoses including heart failure, muscle weakness, scoliosis, spondylosis with myelopathy, atrial fibrillation, hypertension, cerebral infarction, and age-related osteoporosis. Review of the care plan, revised 08/01/23, revealed Resident #39 required assistance with activities of daily living (ADLs). [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, resident interview, review of the facility's Self-Reported Incident (SRI) 243880 and related investigation materials, the facility failed to protect Resident #18 from abuse by a person who was impersonating a scheduled staffing agency worker. This affected one (#18) of three residents reviewed for abuse. The facility census was 44. Findings Include: Review of the medical record for Resident #18 revealed an admission date of 09/18/23 with diagnoses including congestive heart failure, anxiety disorder, major depressive disorder, and unspecified psychosis. [...]

Inspectors wroteBased on observation, interview, record review, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance the facility failed to maintain and implement an effective infection prevention and control program to prevent the transmission of CRE (carbapenem-resistant enterobacterales), including proper personal protective equipment (PPE) was worn by staff when entering Resident #43's room who was on enhanced barrier isolation for CRE and failed to ensure staff discarded and changed soiled gloves appropriately after providing Resident #43's incontinence care. This had the potential to affect 19 residents (#2, #4, #5, #8, #11, #13, #14, #17, #21, #23, #24, #27, #30, #31, #32, #35, #36, #40, #41) residing on the nursing unit. The facility census was 44.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure a State Tested Nursing Assistant (STNA) #374 accused of staff to resident abuse towards Resident #43 was not immediately suspended pending the outcome of an investigation. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 44.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure Resident #43's allegation of staff-to-resident abuse was reported to the State Agency timely. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 44.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure Resident #43's weights were checked daily according to the physician's orders. This affected one resident (#43) out of three residents reviewed for weights. The facility census was 44.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure Resident #43's physical therapy discharge recommendations were implemented. This affected one resident (#43) out of three residents reviewed for therapy recommendations. The facility census was 44.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #43's incontinence care was completed timely. This affected one resident (#43) out of three residents reviewed for incontinence. The facility census was 44.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #36 did not develop avoidable pressure injuries of the knees. Actual harm occurred when Resident #36 developed a right knee deep tissue injury (Persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.) and a left knee Stage 3 pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss.). This affected one resident (Resident #36) of three residents reviewed for pressure injuries. The census was 49.

Inspectors wroteBased on observation, interview and review of facility policy the facility failed to ensure appropriate hand hygiene was implemented during the medication pass for three residents (Residents #13, #14, #47), during meal time for six residents (Residents #13, #24, #26, #36, #42, #44) and failed to ensure the glucometer for Resident #33 was disinfected after it was used to check a blood sugar. This affected nine out of nine residents reviewed for infection control and had the potential to affect all 28 residents residing on the 300 nursing unit. The facility census was 49.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure a communication book was used for one resident (Resident #48) to communicate in a language the resident understood. This affected one resident (Resident #48) out of three residents reviewed for communication. The facility census was 49.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure one resident's (Resident #22) physician order for a hematology physician appointment was completed. This affected one resident (Resident #22) out of three residents reviewed for physician orders. The census was 49.

Inspectors wroteBased on interview and record review the facility failed to initiate restorative nursing programs per therapy recommendations affecting two residents (Resident #28 and #31) out of two residents (Residents #28 and #31) reviewed for decline in activities of daily living. This had the potential to affect 17 residents (Residents #2, #4, #6, #7, #10, #14, #15, #16, #19, #20, #23, #25, #26, #28, #31, #33, #47) that were recommended to be on a restorative nursing program.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure medications were maintained in a safe and secure manner. This affected two residents (Residents #12 and #43) out of four residents (Residents #3, #12, #18, and #43) reviewed for unsecured medications and had the potential to affect all 49 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurate for Residents #31 and #43. This affected two residents of six residents (Residents #5, #12, #28, #31, #43 and #250) reviewed for nutrition and Activities of Daily Living (ADL).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and sanitary food storage, meal service and equipment. These deficient practices affected 45 residents receiving food from the kitchen (Resident #10, Resident #15 and Resident #18 were identified by the facility as receiving nothing by mouth and did not receive meals from the kitchen). The facility census was 48 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were treated with respect and dignity during care. This affected one resident (Resident #6) of four residents reviewed for dignity. The facility census was 48 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide Resident #195 a copy of her baseline plan of care. This affected one of three new admission residents reviewed. The facility census was 48.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure Resident #35's comprehensive assessment was implemented to ensure the resident used her call light prior to unassisted ambulation. This affected one of 12 residents reviewed for implementation of comprehensive care plans. The facility census was 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #197 catheter tubing was not in contact with floor. This affected one of three residents reviewed for catheter care. The facility census was 48.

Inspectors wroteBased on record review and staff interview the facility failed to have three years of state survey results, including complaint investigations, readily accessible to residents and the general public. This had the potential to affect all 48 residents residing in the building.