Canterbury Health Care Facility

In the surveyor’s words

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

• Actual harm, isolatedF656Apr 23, 2021

  Based on interviews, review of Resident Identifier (RI) #154's medical record and review of the facility's investigation file, Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs) failed to follow RI #154's plan of care/care guide when RI #154 was transferred from the wheelchair to the bed on 03/09/21. RI #154 is care planned for a two person assist with transfers using the Hoyer lift. On 03/09/21 on the 3 PM - 11 PM shift, RI #154 was transferred by being picked up under the arms and placed on the side of the bed. Once on the bed, RI #154 slid to the floor. RI #154 was transferred to the ER (emergency room ) for evaluation. […]

• Actual harm, isolatedF689Apr 23, 2021

  Based on interviews, review of Resident Identifier (RI) #154's medical record, review of a facility policy titled Lift 4 Care - Safe 4 All Policy, and review of the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs), used a Hoyer lift, as determined necessary by RI #154's assessment, during a transfer on 03/09/21. During the 3:00 PM to 11:00 PM shift on 03/09/21, EI #8 and EI #9 failed to follow RI #154's plan of care when no Hoyer lift was used when RI #154 was transferred from his/her wheelchair to his/her bed. During the two person manual lift transfer, RI #154 slid from the side of the bed and fell to the floor. RI #154 was transferred to the local hospital to be evaluated after the fall. […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2021

  Based on observations, interviews, and a review of facility policies titled, Equipment Cleaning Schedules and Frozen Storage, the facility failed to ensure: 1) dust was not on the ceiling, walls and light fixtures in the kitchen; and 2) food items in the kitchen freezer were labeled. This had the potential to affect 108 of 108 residents receiving meals from the kitchen. Findings Include: 1) A review of a policy titled, Equipment Cleaning Schedules with an Effective Date: August 1, 2012 revealed: . POLICY It is the policy of this facility to assign cleaning schedules on a daily, weekly, and monthly basis. PROCEDURE All equipment will be identified for cleaning. The frequency and position assigned the item should be designated on the schedule. Ceiling As needed. […]

• No harm, potential for more than minimal, patternF755Apr 23, 2021

  Based on interview, review of the facility's Record of Medication Destruction forms, and review of a facility policy titled Disposal of Medications Controlled Drug Destruction, the facility failed to ensure the Record of Medication Destruction forms for Controlled Medications contained the required signatures. This was noted on 10 of 10 of the Record of Medication Destruction forms for controlled medications reviewed for the month of March 2021. Finding include: Review of facility policy titled Disposal of Medications Controlled Drug Destruction, dated 03/11, revealed: 4.4: CONTROLLED DRUG DESTRUCTION . Procedures . 7. […]

• No harm, potential for more than minimal, isolatedF689Oct 4, 2023

  Based on interviews, resident record review, and review of a facility policy titled Transportation Safety, the facility failed to ensure Resident Identifier (RI) #1 was secured in the wheelchair during a transport on 8/10/23 in the facility van. Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) failed to snuggly secure RI #1's waist and shoulder belts. This resulted in RI #1 sliding from the wheelchair during transportation when the driver abruptly applied the vehicle brakes. This had the potential to affect RI #1, one of three residents sampled for transportation safety. This deficient practice is cited as a result of the investigation of complaint/report number AL00045493. […]