Canterbury Woods

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00362317) completed on an Extended Recertification survey with an exit date of 1/8/2025, the facility failed to protect the residents rights to be free from verbal and physical abuse by a Companion Aide for one (Resident #22) of six residents reviewed for abuse. Specifically, a Companion Aide was witnessed by facility staff being verbally and physically abusive towards Resident #22. The facility did not review/revise abuse processes/protocols since 2016. In addition, the facility did not consistently implement their protocols regarding Companion Aides. They did not have an effective system to ensure background checks were verified as completed for all Companion Aides prior to starting at the nursing home; [...]

Inspectors wroteBased on interview, and record review conducted during a Complaint investigation (Complaint #NY00362317) completed on an Extended Recertification survey with an exit date of 1/8/2025, the facility did not ensure that all alleged violations involving abuse, neglect, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #22) of six reviewed. Specifically, the facility did not report to the State Agency allegations of abuse within the two-hour required time frame. [...]

Inspectors wroteBased on observation, interview and record review conducted during the Extended Recertification survey completed on 1/8/25, the facility did not ensure that a resident with pressure ulcers (ulcers on the skin due to prolong pressure) received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for one (Resident #13) of one resident reviewed. Specifically, there were lack of consistent weekly pressure ulcer assessments and ongoing monitoring for Resident #13's left heel and left buttock pressure ulcers, the assessments did not consistently include staging, measurements of size (length x width x depth), or a description of the wounds. Additionally, the assessments had conflicting documentation of treatment instructions and wound measurements for the pressure ulcers. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during an Extended Recertification Survey completed 1/8/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for one (Residents #13) of one resident reviewed. Specifically, enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) were not initiated for a resident with pressure ulcers and staff did not wear appropriate personal protective equipment during pressure ulcer care. The finding is: [...]

Inspectors wroteBased on observation and interviews conducted during the Extended Recertification survey completed on 1/8/25, the facility did not ensure the nursing staff information was posted daily and contained the required information for three of five days reviewed. Specifically, the facility did not post daily the current resident census, the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place readily accessible to residents and visitors. The finding is: The policy titled Direct Care Daily Staffing Numbers dated 2/03, documented the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 6/2/23, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for four (Employees A, B, D, and F) of six agency employees reviewed who were hired in the last four months and were subject to the New York State Nurse Aide Registry. Specifically, the facility did not ensure prospective employees were screened through the New York State Nurse Aide Registry prior to their employment. This affected two (North Unit and [NAME] Unit) of two resident units.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 6/2/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one main kitchen had issues with multiple food items in the walk-in coolers and a reach-in cooler that had been removed from the original (mother) container or had been opened and were not dated with the date opened. The reach-in freezer in the kitchen had loose French fries, onion rings and many crumbs of debris on the bottom. In addition, one of one servery, [NAME] #1 was observed serving food without changing gloves during the entire meal service.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 12/30/21, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADL's) receives the necessary services to maintain good nutrition for one (Resident #29) of two residents observed for ADL's. Specifically, Resident #29 with a history of pneumonia (lung infection) and weight loss was not provided with extensive assist with eating at meals as required per their plan of care. The finding is: The policy and procedure (P&P) titled POC Charting and ADLs (undated) defined an extensive assist as resident helps/use muscle and one assist as one staff to help support ADL. 1. [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 12/30/21, the facility did not ensure that each resident received, and the facility provided food prepared by methods that conserve nutritive value, flavor and appearance, and food that was palatable. Specifically, for six of six residents reviewed for pureed food preparation, the recipe for the pureed lunch meal on 12/29/21 was not followed and it affected the nutritive value, flavor, appearance, and palatability of the food. The finding is: According to the facility's undated document titled, Puree Consistency Diet, the puree diet provides a nutritionally adequate diet for the resident with difficulty in swallowing, pureed foods are altered to form a consistency between liquid and soft, and care should be taken to serve pureed food in a colorful, attractive manner. [...]