Canterbury Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jul 14, 2022

  45171 45173 Based on record review, staff interview and observation, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The state agency determined these failures placed Resident #39's access to smoking supplies and other residents in an immediate jeopardy situation due to potential of serious injury and/or death as a result of burns or fire-related injuries. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 2:59 PM on 07/13/22. The facility submitted a plan of correction (POC) at 4:48 PM. At 5:00 PM the POC was accepted by the state agency. […]

• Actual harm, isolatedF686Jul 14, 2022

  Based on record review and staff interview, the facility failed to ensure two (2) of three (3) residents with a pressure ulcer received treatments per the there need and physician order. Resident #46 did not receive treatments and a wound culture as ordered by the physician. As a result, the wound worsened. The lack of treatment caused physical harm to Resident #46 whose death certificate stated the cause of death was a Stage IV Sacral Decubitis Ulcer. Resident identifiers: #46 and #33. Resident identifier: #33. Facility census: 60. Findings included: a) Resident #46 Resident #46 was admitted to the facility on [DATE]. The resident expired at the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF606Apr 3, 2024

  Based on record review and staff interview the facility failed to ensure all staff had thorough background checks. The state of [NAME] Virginia uses the [NAME] Virginia CARES (Clearance for Access: Registry & Employment Screening) system to determine eligibility to work in a nursing home. Nurse Aide (NA) #17 did not have WV CARES determination on file and had been working at the facility. This was true for one (1) out of five (5) staff reviewed for Nurse Aides reviewed. Staff Identifier: NA #17. Facility census: 58. a) Nurse Aide # 17 A review of the employee file for Nurse Aide (NA) #17 found they do not have a WV Cares eligibility letter on file. NA #17's hire date was 05/08/06. WV CARES became required for all new and current employees beginning in the year 2016. […]

• No harm, potential for more than minimal, widespreadF727Apr 3, 2024

  Based on record review and staff interview, the facility failed to ensure a Registered Nurse was available 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. Facility census: 58. Findings included: a) Eight (8) consecutive hours of RN coverage. A review of the facility staff postings revealed that on 11/19/23 and 12/03/23 no Registered Nurse (RN) was scheduled to work on the above dates. A review of timecards for all staff working on 11/19/23 and 12/03/24 found no RN coverage. During an interview, on 04/03/24 at 8:05 AM, the Director of Nursing reviewed the timecards and stated they were very short staffed.

• No harm, potential for more than minimal, widespreadF732Apr 3, 2024

  Based on observation and staff interview the facility failed to retain the original staff postings for a minimum of 18 months as required. This had the potential to affect all residents currently residing at the facility. Facility census 58. Findings include: a) Staff postings On 03/26/24 at 3:45 PM, the Director of Nursing (DON) was asked for the original Staff Posting Sheets for the first quarter of 2024. On 03/27/24 at 9:10 AM, the DON stated the facility is unable to provide the original Staff Posting Sheets because they cannot find them.