Canterbury Woods

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when:A Kitchen Staff was not wearing hair restraint in the kitchen, andUnlabeled packs of bread were found in the food pantry. These failures had the potential to cause foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that three out of four sampled residents (Residents 9, 23, and 39), who signed the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) understood the BAA prior to signing. This failure posed the risk for the residents to make uninformed decisions regarding the right to file an appeal, if there were any allegations of medical malpractice. During a concurrent interview and record review on 2/25/26 at 2:21 p.m. in the activity room with Resident 9, Resident 9 verified her signature on a BAA signed on 1/22/26. Resident 9 stated she did not know about the BAA and was not aware she signed the agreement. Resident 9 stated she just had a surgery prior to signing the BAA. [...]

Inspectors wroteFindings:Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1 received oxygen therapy with no physician's order and there was no oxygen care plan. These failures had the potential to compromise the resident's health and well-being. Review of Resident 1's medical record indicated he was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (COPD, a progressive, irreversible disease that restricts airflow causing breathing problem); acute respiratory failure with hypoxia (a critical condition where the lungs cannot adequately transfer oxygen to the blood.)Review of Resident 1's Weights and Vital Summary - Vital: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, one of eight sampled residents (Resident 66), was free of significant medication error, when the physician order for the Lasix (a diuretic, used to reduce fluid retention) medication, of Resident 66 was not followed. This failure had the potential to affect the health and general well-being of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were stored in safe and sanitary manner when: 1. Resident foods and food brought by family or visitor stored in the refrigerator at the facility dining area, were readily accessible to all the residents and; 2. Expired food was kept in the cabinet at the facility dining area. These failures had the potential to access the expired food and the food brought by family or visitor in the refrigerator.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (person who routinely visits the facility and advocates for the residents) for one of two sample discharged residents (Resident 14) when Resident 14 was transferred to the acute care hospital. This failure had the potential to result in the resident not having an advocate who could inform them of their admission, transfer, and discharge rights and options.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for one of eight sampled residents (Resident 12) when the resident's communication care plan was not person-centered. This failure had the potential for inaccurate development and implementation of person-centered care plans that would address the residents' identified concerns and needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an activity program that met the resident's needs, interests, and preferences was provided to one of eight sampled residents (Resident 11). This failure had the potential to affect the residents' physical, mental, and psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) assessed and discussed the cause of unplanned weight loss, updated the care plan with a measurable goal and interventions, and provided necessary and timely interventions to maintain the acceptable weights of the residents when there was no follow-up by the IDT after the significant weight loss for one of eight sampled residents (Resident 8). This failure had the potential to result in being unable to evaluate the residents' complete nutritional status and provide necessary interventions timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their bed rails (adjustable rigid bars attached to the side of a bed: side rails, safety rails, and grab/assist bars) policy for one of one sampled resident (Resident 2) when there was no informed consent verification form obtained prior to installing bed rails. This failure had the potential to result in the resident and the resident's responsible parties (RP, individuals designated to make decisions on behalf of the residents) not being fully informed of the use of bed rails.

Inspectors wroteBased on interview and record review, the facility failed to document administration of controlled medications (medications controlled by the government because they may be abused or cause addiction) on the controlled medication accountability sheet (count sheet) for one resident (Resident 8). This failure compromised the facility's ability to ensure accurate administration of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that recipe for making puree was being followed when the executive chef did not follow the recipe for making chicken teriyaki puree. This failure had the potential to result in decreased palatability that could lead to decrease in food intake for the 2 residents with puree diet order out of the skilled nursing facility census of 15.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one out of five sampled residents (Resident 6), who signed the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) understood the BAA prior to signing. This failure posed the risk for the resident to make uninformed decisions regarding the right to file an appeal if there was any allegations of medical malpractice.

Inspectors wroteBased on observation and interview, the facility failed to implement infection control practices for one of eight sampled residents (Resident 165) when staff did not follow the facility's handwashing/hand hygiene policy. This failure had the potential to spread infection in the facility.

Inspectors wroteBased on observations, interview and facility document review, the facility failed to ensure the director of dining services (DDS) comprehensively carried out the functions of the food and nutrition services when the DDS did not perform kitchen audits monthly as scheduled. This failure resulted lapses in the delivery of services associated with food safety and sanitation (cross-reference F812) which had the potential transmission of foodborne illness to 16 residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. The condiments were opened but not labeled or dated, stored beyond used date, label about storage after opening was not followed and one condiment did not have the right cap to cover the bottle tightly; 2. The walk-in freezer's ceiling had ice buildup; 3. Dietary staff did not follow the proper use of hair restraints; 4. A water dispenser was not kept in a sanitary condition; 5. Dishwasher D (DW D) used the expired quat test strips (used to determine that the concentrations of quaternary ammonium [quat-a chemical that kills bacteria, molds, and virus] in sanitizer solutions are at the correct level); 6. There was water pooling in the kitchen floor behind the steamer; 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the wheels on the bed of residents were locked for two of five sampled residents (Resident 4 and Resident 220). This failure had the potential to result in accident and injury.

Inspectors wroteBased on interview and facility's document review, the facility failed to provide a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure had the potential to affect resident's care, health, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling for one of one medication cart. This failure had the potential to result in the administration of outdated or expired medication.

Inspectors wrote3. During an observation, on 7/17/23, at 8:02 A.M., the EST was seen wearing disposable gloves on both hands while cleaning a resident's room. After cleaning, she removed one glove only. She proceeded to hold a plastic bag with soiled rags with the ungloved hand and pushed the cart using the gloved hand towards the end of the hallway. She then went to the dirty utility area carrying the plastic bag. She then came out and opened a closet located in the hallway still with one gloved hand and removed several rolls of toilet paper. After that she then removed the glove. No hand hygiene or hand washing performed. During an interview, on 7/17/23, at 9:26 A.M., EST stated that when cleaning resident rooms, she would perform hand hygiene, wear gloves, use only one rag to mop the floor. She also stated that after cleaning the room, she would remove gloves, rags, garbage and do hand hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an organized and sanitary environment for one non-sampled resident (Resident 14) when the bathroom was disorganized, and the toilet bowl was dirty. These failures created a disorganized and unsanitary environment that could pose safety risks for Resident 14.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (person who routinely visits the facility and advocates for the residents in the nursing homes) when one of two residents (Resident 18 ) was transferred to the hospital. This failure had the potential to result in the resident not being informed of her rights.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) assessment for one of 13 sampled residents (Resident 7) when Resident 7's completed and transmitted quarterly MDS did not reflect Resident 7's hospice care. These omissions in coding resulted in an inaccurate MDS and not addressing the resident needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program that meet the resident's needs, interests, and preferences for one of 13 sampled residents (Resident 11) when Resident 11's activity care plan was not updated and implemented. This failure had the potential to affect the resident's physical, mental, psychosocial well-being, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care for one of one sampled resident (Resident 4) in accordance with professional standards of practice and facility's policy and procedure when a Certified Nursing Assistant A (CNA A) administered oxygen (a colorless and odorless gas that people need to breath) to a resident. This failure had the potential for unsafe oxygen administration and negatively affect the resident's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 7) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 7 received Lorazepam (a medication for anxiety) without documentation of its specific duration in the resident's clinical record. This failure had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical, mental, and psychosocial well-being.