Canfield Healthcare Center

In the surveyor’s words

From the most serious findings on record at Canfield Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 24, 2025

  Based on record review, review of a facility self-reported incident (SRI), observation of recorded video, review of a police report, interviews and review of the facility abuse policy, the facility failed to protect Resident #66's right to be free from physical abuse by Housekeeper #582. This resulted in Immediate Jeopardy and Actual Harm on 09/16/25 at approximately 11:15 A.M. when Housekeeper #582 physically abused Resident #66. Housekeeper #582 pushed Resident #66 in his wheelchair causing the resident to fall out of the wheelchair and hit his head on the nurse's medication cart. Housekeeper #582 was then observed by (staff) witnesses and per the resident to put his hand around Resident #66's neck and punch the resident with a closed fist. […]

• Immediate jeopardy, isolatedF627Sep 17, 2025

  Based on observation, record review, review of a facility self-report incident, facility investigation review, police report review, policy review and interviews, the facility failed to provide adequate supervision and/or intervention to prevent resident elopement. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 05/24/25 when Resident #13, who was assessed as an elopement risk, had exit seeking behaviors and was deemed incompetent by the court system, was permitted by staff to leave the facility unattended and without guardian consent. The resident's whereabouts were unknown until the resident was returned to the facility via police escort on this same date. […]

• Immediate jeopardy, isolatedF689Sep 17, 2025

  Based on observation, record review, review of a facility self-report incident, facility investigation review, police report review, policy review and interviews, the facility failed to provide adequate supervision and/or intervention to prevent resident elopement. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 05/24/25 when Resident #13, who was assessed as an elopement risk, had exit seeking behaviors and was deemed incompetent by the court system, was permitted by staff to leave the facility unattended and without guardian consent. The resident's whereabouts were unknown until the resident was returned to the facility via police escort on this same date. […]

• Actual harm, isolatedF697Sep 29, 2023

  Based on observation, record review, review of controlled drug administration records, review of facility policy and interviews, the facility failed to develop and implement a comprehensive and individualized pain management program, including assessment/monitoring of pain and administration of narcotic pain medication (Percocet) to meet Resident #45's needs and prevent severe pain. Actual harm occurred on 09/18/23 when as needed (PRN) Percocet 5-325 milligrams (mg) was not available to administer to Resident #45 as requested and as ordered by the physician. On 09/18/23 at 10:21 A.M. Resident #45 rated her pain level an eight on a scale of zero (no pain) to 10 (severe pain). Resident #45 was administered a dose of Percocet on 09/19/23 at 12:23 P.M. […]

• Actual harm, isolatedF686Jan 19, 2023

  Based on observation, record review, facility policy and procedure review, and interview the facility failed to implement adequate interventions to prevent the development of bilateral deep tissue injury pressure ulcers to Resident #46's bilateral heels. The facility also failed to implement a treatment timely following the identification of the ulcers. Actual harm occurred on 09/22/22 when Resident #46, who had severe cognitive impairment and required extensive two person staff assistance for bed mobility, was found to have bilateral deep tissue injuries (defined as persistent non-blanchable deep red, maroon or purple discoloration, intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to both heels… […]