Canterbury Villa of Alliance

Inspectors wroteBased on observation and interview, the facility failed to ensure staff respected resident dignity by not knocking, announcing themselves, and waiting for permission before entering a shared resident room. This failure affected two residents (Residents #17 and #14) when staff entered their shared room without permission. The facility census was 65.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure timely laboratory services for Resident #10. This deficient practice resulted in significant delays in obtaining Legionella urine antigen testing. This affected one resident (Resident #10) out of two reviewed for laboratory services. The facility census was 65.

Inspectors wroteBased on observation, interview, and review of guidelines for medication administration, the facility failed to ensure proper infection control practices were followed during medication preparation and administration for Resident #11. This affected one resident (Resident #11) out of two observed for medication administration. The facility census was 65.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on interviews, record review and employee file review the facility failed to ensure all wound dressing were completed as ordered. This affected one of three residents (Resident #66) reviewed for wound care. The facility census was 66. Findings Include: Review of the closed medical record for Resident #66 revealed an admission date 10/11/25 and was admitted on hospice. Diagnosis included malignant neoplasm of prostate, chronic obstructive pulmonary disease and history of stroke. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, observation, staff interview and policy review the facility failed to ensure residents were transferred properly while using a mechanical lift This affected one resident (Resident #12) of one residents reviewed for mechanical lift transfer. There were seven residents identified as needing a mechanical lift transfer.

Inspectors wroteBased on observation and staff interview, the facility failed to serve food in a sanitary manner. This had the potential to affect all 70 residents (except Resident #31 and Resident #57 who had orders for nothing by mouth) who received food from the kitchen. The facility census was 72.

Inspectors wroteTHIS IS AN EXAMPLE OF PAST NONCOMPLIANCE SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, emergency room documentation review, review of the facility investigation, interview, review of the Lantus (glargine) Insulin prescribing information, review of www.insulins.lilly.com the facility failed to ensure medications were administered per physician orders resulting in a significant medication error. This affected one resident (Resident #73) of three residents reviewed for medications. Actual harm occurred on 03/14/25 at 10:30 P.M. when Resident #73, a diabetic resident who received insulin with meals and at bedtime, was administered the incorrect type of insulin (short acting instead of long-acting insulin) resulting in the resident having a headache, upset stomach and a blood sugar in low range. [...]

Inspectors wroteBased on observation, medical record review, review of hospice and hospital records, and interview, the facility failed to fully investigate concerns related to falls to ensure risk factors were addressed in the plan of care to prevent falls. The facility also failed to ensure physician orders were implemented for fall intervention. This affected two residents (#42 and #77) of three residents reviewed for falls. Actual Harm occurred on 02/07/25 when Resident #77, who was identified at risk for falls, cognitively impaired, required staff assistance with transfers and had concerns voiced to the facility from family and the hospice provider regarding the resident potentially falling, fell while ambulating unassisted resulting in a right femoral neck fracture. The resident reported complaints of pain following the fall and was transferred to the hospital. [...]

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to notify the physician when they were unable to obtain stat laboratory tests (Stat testing is a category of medical testing that prioritizes speed and efficiency in delivering results. It is reserved for situations where a healthcare provider requires test results as quickly as possible to make immediate clinical decisions.) in a timely manner for one (Resident #77) of three residents reviewed for dehydration.

Inspectors wroteBased on medical record review, review of the facility self-reported incidents (SRIs), staff interview, and review of facility policy, the facility failed implement their abuse policy regarding thoroughly investigating allegations of resident-to-resident abuse for Residents #50, #65, #128, and #129. This affected four residents (#50, #65, #128, and #129) of five reviewed for abuse. The facility census was 78.

Inspectors wroteBased on medical record review, review of the facility self-reported incidents (SRIs), staff interview, and review of facility policy, the facility failed to thoroughly investigate allegations of resident-to-resident abuse for Residents #50, #65, #128, and #129. This affected four residents (#50, #65, #128, and #129) of five reviewed for abuse. The facility census was 78.

Inspectors wroteBased on observation, review of the medical record and interview with staff the facility failed to ensure Resident # 17, #26, #62 and #132 had drinking water available in their rooms. This affected four residents ( Resident # 17, #26, #62 and #132) of five residents observed during medication administration. The facility census was 78.

Inspectors wroteBased on record review and interview the facility did not ensure the care plan included the use of a mechanical lift for transfers for Resident #227. This affected one resident (Resident #227) of 26 residents reviewed for care plans. The facility census was 78. Review of the medical record for Resident #227 revealed an admission date of 03/21/24 with diagnoses including mechanical loosening of internal right knee prosthetic joint, infection, and inflammatory reaction due to internal right knee prosthesis, muscle weakness, depression, cardiomyopathy, hypercholesterolemia, atrial fibrillation, hypertension, osteoarthritis, and fibromyalgia. Resident #227 was transferred to the hospital from an out-patient appointment with her orthopedic surgeon on 04/04/24 and elected to not return to the facility. [...]

Inspectors wroteBased on review of the medical record , review of the facility investigation and interview with staff the facility failed to provide the appropriate level of staff assistance and supervision during resident care for Resident #127 resulting in Resident #127 hitting his head on the wall. This affected one resident ( Resident #127) of seven residents reviewed for accidents. The facility census was 78.

Inspectors wroteBased on observation, review of the medical record and interview with the staff the facility failed to ensure the aerosol mask for Resident # 44 and the oxygen tubing and nasal cannula for Resident #39 were stored in a protective barrier when not in use. This affected two residents (Resident #39 and #44) of four residents reviewed for oxygen therapy. The facility identified 17 residents (Resident #1, #4, #11, #12, #13, #16, #24, #37, #39, #42, #45, #48, #51, #54, #65, #71, and #230) who required use of oxygen and eight residents (#1, #37, #44, #52, #61, #71, #73, and #230) who required aerosol treatments. The facility census was 78.

Inspectors wroteBased on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 line list, review of facility infection control policies, interviews with staff, observations, interview with the local health department (LHD) and medical record review, the facility failed to implement appropriate infection control practices including appropriate use of personal protective equipment (PPE), social distancing with residents who tested positive for COVID-19 and failed to ensure residents who were exposed to COVID-19 were encouraged to wear appropriate PPE while visiting with other residents. [...]

Inspectors wroteBased on observations, interviews and review of facility the facility failed to dispose of garbage and refuse properly. This had the potential to affect all 70 residents currently residing in the facility.

Inspectors wroteBased on medical record review, resident and staff interviews, and review of facility policies and Centers for Medicare and Medicaid (CMS) guidance the facility failed to inform residents, their representatives, and families of those residing in facilities by 5:00 P.M. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new on-set of respiratory symptoms occurring within 72 hours of each other. This affected six (Residents #27, #29, #46, #55, #170, and # 319) of seven residents interviewed and had the potential to affect all residents currently residing in the facility. The facility census was 70.

Inspectors wroteBased on medical record review, interviews, review of facility policy, and review of Centers for Medicare and Medicaid (CMS) guidance and Centers for Disease Control (CDC) guidance in QSO memo 20-38-NH dated 03/10/22 the facility failed to ensure testing residents and staff immediately after identification of each new positive COVID-19 case. This affected six (Resident #27, #29, #46, #55, #170, and #319) of six residents reviewed for testing and had the potential to affect all residents currently residing in the facility. The facility census was 70.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure medications requiring refrigeration were stored appropriately. This had the potential to affect all 70 residents currently residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to provide a written notice of transfer for one former resident's hospitalization, Resident #70. This affected one Resident (Resident #70) of three reviewed for hospitalizations. The facility census was 70.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an accurate Minimum Data Set (MDS) 3.0 assessment to address Resident #9's tobacco use. This affected one (Resident #9) of six residents reviewed for MDS accuracy. The facility census was 70.

Inspectors wroteBased on record review and interview the facility failed to develop an individualized and comprehensive care plan related to Resident #9's tobacco use. This affected one resident (#9) of six residents reviewed for care planning.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure proper treatment to aide one resident (Resident #24) in her ability to hear adequately. The affected one (Resident #24) of one resident reviewed for ancillary services.