A list of the most recent deficiencies for Canterbury House. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-08-07 | 2023-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-07 | 2023-09-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-07 | 2023-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-07 | 2023-09-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-07 | 2023-09-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-07 | 2023-09-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-09 | 2023-09-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-09 | 2023-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-09 | 2023-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-09 | 2023-09-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-09 | 2023-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-09 | 2023-09-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-07 | 2023-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-03-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-07 | 2022-10-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-07 | 2022-10-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-09 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-02 | 2022-08-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-11 | 2022-03-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-11 | 2022-03-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-11 | 2022-03-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-11 | 2022-03-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-11 | 2022-03-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-11 | 2022-03-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-11 | 2022-03-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-11 | 2022-03-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-11 | 2022-03-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-11 | 2022-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-02-11 | 2022-03-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-11 | 2022-03-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-11 | 2022-03-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-11 | 2022-03-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-02-11 | 2022-03-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-11 | 2022-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-11 | 2022-03-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-11 | 2022-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-24 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-02-11 | 2022-03-24 | N |
| Respond appropriately to all alleged violations. | Health | 2022-02-11 | 2022-03-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-20 | 2022-02-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-20 | 2022-02-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-20 | 2022-02-10 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-20 | 2022-02-10 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-01 | 2022-02-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-01 | 2022-02-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-01 | 2022-02-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-04 | 2021-10-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-04 | 2021-10-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-04 | 2021-10-22 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-10-04 | 2021-10-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-19 | 2021-05-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-03 | 2019-05-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-03 | 2019-05-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-04-03 | 2019-05-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-03 | 2019-05-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-04-03 | 2019-05-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-03 | 2019-05-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-03 | 2019-05-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-03 | 2019-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-03 | 2019-05-15 | N |
| Post nurse staffing information every day. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-03 | 2019-05-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-03 | 2019-05-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide or obtain dental services for each resident. | Health | 2019-04-03 | 2019-05-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-03 | 2019-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-03 | 2019-05-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
