Canterbury Place

Inspectors wroteBased on review of facility policy and the Pennsylvania Nursing Practice Act, clinical record review, incidents submitted to the local State field office, and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of clinical practice for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy and facility job descriptions, clinical record review, incidents submitted to the local State field office, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policies, facility documents, clinical records, and staff interviews it was determined that the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility. This failure created an immediate jeopardy situation (IJ) for sixteen residents identified as an elopement risk. The immediate jeopardy was cited as past noncompliance.

Inspectors wroteBased on review of facility policies, facility submitted documents, facility documentation, clinical record, and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Closed Resident Record CR1) was free of neglect during care which resulted in actual harm of a fracture of their right femur (thigh bone).

Inspectors wroteBased on review of facility policy, facility provided document, observations and staff interview, it was determined that the facility to maintain equipment in a sanitary condition for four of six meal delivery carts (Meal delivery cart 3, 4, 6, and 9)

Inspectors wroteBased on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of six residents (Residents R2 and R3).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility on 4/22/26, which created an immediate jeopardy situation for all residents identified as an elopement risk.

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to one of five direct care facility staff reviewed (Licensed Practical Nurse (LPN) Employee E7).

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Compliance and Ethics training to one of five direct care facility staff reviewed (Licensed Practical Nurse (LPN) Employee E7).

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Behavioral training to one of five direct care facility staff reviewed (Licensed Practical Nurse (LPN) Employee E7).

Inspectors wroteBased on review of facility policy, facility documents, staff and resident interviews it was determined that the facility failed to provide a fully functioning call bell system for one resident resulting in an immediate jeopardy situation for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, facility documentation, clinical record review, staff and resident interviews it was determined that the facility neglected to provide the necessary means and services for a resident to contact staff for help when the call system malfunctioned for one of two trach residents (Resident R1).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents, staff and resident interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in Resident R2 being transferred to the hospital for a hematoma. This failure was determined to be past non-compliance.

Inspectors wroteBased on review of job descriptions, facility and clinical records, and staff interviews it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that the facility provide a fully functioning call bell system for one resident resulting in an immediate jeopardy situation for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents' care plans were updated and revised to reflect the resident's specific care needs for three of six residents (Resident R22, R29, and R31).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide an Assessment Involuntary Movement Scale (AIMS- a widely used tool designed to measure the severity of tardive dyskinesia (TD- a disorder characterized by involuntary movements that can occur as a side effect of long term use of antipsychotic medication) assessment at least quarterly for three of five residents (Resident R30, R36, R102).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for five of seven residents (Resident R21, R30, R33, R36, and R50) and failed to have a current hospice agreement that included the vendors name.

Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of five residents (Resident R64).

Inspectors wroteBased on the review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for one of four residents reviewed (Resident R48).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of five residents (Resident R41).

Inspectors wroteBased on observations, resident and staff interviews it was determined that the facility failed to display (for the residents and family members) the required information on the grievance process for the building.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers/injuries (PU/PI's - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four residents (Resident R11, and R93).

Inspectors wroteBased on observation, review of clinical record, review of facility policy, interview with staff and resident, it was determined the facility failed to provide tracheostomy care consistent with professional standards of practice for one of two residents receiving oxygen (Resident R39).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R36).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in one of two medication rooms ( Renaissance unit), four of four medication carts (First Floor Carts A and B, and Renaissance Hall front and back), and failed to ensure medication carts were secured when not in presence of the nurse.

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarters (January 2025, through March 2025 and July 2025, through September 2025).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to manage airborne isolation for Covid positive infections in one of seven rooms (Resident R37).

Inspectors wroteBased upon review of clinical and hospital records, interviews with staff, and review of facility submitted documents and policies, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to ensure physician orders were transcribed accurately on admission for two of three records reviewed (Closed Record Resident R1 and Resident R2).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings as per order for one out of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for a Bipap device (a positive airway pressure machine when breathing in and breathing out) and failed to act on a malfunctioning Bipap in a timely manner for one of three residents (Resident R2) which resulted in actual harm of dyspnea (difficulty breathing), hypoxemia (a low level of oxygen in the blood), hypercapnia (too much carbon dioxide in the blood stream), requiring an intensive care unit (ICU - specialized hospital department where critically ill patients receive intensive, round-the-clock care) admission for Bipap.

Inspectors wroteBased on review of facility policy, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain residents were free from mental abuse, including abuse facilitated or enabled through the use of technology for one of five residents reviewed (Residents R1).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R1 and R2).

Inspectors wroteBased on review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to implement their written procedures to prohibit and prevent abuse, neglect, and exploitation of residents by failing to perform criminal history background checks prior to the date of hire for five of six sampled records (Registered Nurse (RN) Employee E2, Nurse Aide (NA) Employee E17, Licensed Practical Nurse (LPN) Employee E18, NA Employee E19, and RN Employee E20).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that the physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) included the size of the suprapubic catheter, balloon sizing, and the amount of fluid needed to insert for balloon inflation/securement (the balloon keeps catheter in the bladder) for three out of seven sampled residents (Residents R53, R58, and R316 ) and failed to ensure catheter bags were covered as required for two of seven sampled residents (Residents R58, and R316).

Inspectors wroteBased on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for four of five residents (Residents R14, R22, R58, and R314) and failed to maintain an accurate care plan for dialysis access site for two of five (Resident R22, and R314).

Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of four nurse aide personnel records (Nurse Aide (NA) Employee E10, NA Employee E11, and NA Employee E12).

Inspectors wroteBased on review of facility policy, clinical record, and staff interview it was determined that the facility failed to conduct a thorough investigation for one of three residents (Resident R77).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for two of seven residents (Residents R8 and R316) to accurately reflect the current status of the resident and care needs.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings as per order for one out of three residents (Resident R108).

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers/wounds for two of six residents (Residents R317 and Resident R51).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Residents R14).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of three residents (Resident R59).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for two of seven residents (Residents R22, and R315), failed to have proper interventions carried out by staff for one of two positive Covid residents (Resident R34).

Inspectors wroteBased on review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for one out of five sampled records (Nurse aide Employee E3).

Inspectors wroteBased on a review of facility documents, an audit conducted by the State Ombudsman Office and staff interviews, it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for 30 of 30 months (4/22, 5/22, 6/22, 7/22, 8/22, 9/22, 10/22, 11/22, 12/22, 1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, 2/24, 3/24, 4/24, 5/24, 6/24, 7/24, 8/24, and 9/24) as required.

Inspectors wroteBased on clinical record and interview, it was determined that the facility failed to notify the resident's responsible party of changes in condition for one of six sampled residents (Resident R1).

Inspectors wroteBased on review of facility baseline care plan summary, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan was completed and implemented within 48 hours of admission for four of eight residents (Residents R95, R105, R333, and R262).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs of one of five residents (Resident R69).

Inspectors wroteBased on the review of facility policy, clinical records, and staff interviews it was determined that the facility failed to maintain proper Advanced Directives on one of five residents ( Resident R95).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R69).

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to label open medications with a date in two of four medication carts (2nd Floor Cart A and 3rd Floor High Side).

Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for two of four quarterly meeting (February 2023 thru December 2023). Findings Include: The facility Quality assurance and performance improvement (QAPI) policy dated 10/31/21 and last reviewed 1/3/24, indicated that the facility utilizes a quality assurance and performance improvement program. to comprehensively address systems of care and management practices. The administrator and the Medical director of each facility is responsible for implementation of the QAPI program. [...]