Canterbury House

In the surveyor’s words

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

• Actual harm, isolatedF684Oct 4, 2024

  Based on observation, interview, and record review the facility failed to consistently assess and monitor change in condition and implement provider orders timely for 1 of 1 resident (Resident 16) reviewed for significant injury of unknown origin. Resident 16 experienced harm when there was a delay in assessment and treatment by a medical professional and the resident required surgical intervention for a large, expanding hematoma to their right calf, and a blood transfusion for a critically low blood count. These failures placed all residents at risk for delay in treatment, worsening of condition, unmet care needs, and decreased quality of life. […]

• Actual harm, isolatedF690Feb 2, 2024

  Based on observation, interview, and record review the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra (an opening that allows urine to leave the body) that drains urine into a bag) were provided catheter care consistent with standards of practice for indwelling catheters, consistent documentation of catheter procedures and resident response, and coordinated referrals to a urologist for evaluation as ordered by a physician for 5 of 5 residents (Resident 3, 2, 1, 4 & 5) reviewed for indwelling urinary catheters. […]

• Actual harm, isolatedF689Feb 3, 2023

  Based on interview and record review the facility failed to assess resident devices to ensure resident safety for 3 (Resident 1, 2 & 3) of 3 residents reviewed for devices and accidents. The failure to thoroughly conduct a device risk assessment for an alternating air mattress and to assess and identify the risk of hazards and injury, evaluate those hazards, and implement interventions to reduce those hazards resulted in harm for Resident 1, who sustained a femur fracture after an unwitnessed fall. This failure placed all residents with an alternating air mattress (AAM-inflates and deflates to alternate pressure) at risk for significant injury, pain, and diminished quality of life. […]

• Actual harm, isolatedF684Sep 9, 2022

  Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 1) of 3 residents reviewed for conditions needing medical attention or follow-up, received the care they required in a timely manner. Resident 1 was transported to a Urology (the function and disorders of the urinary system) appointment, left unattended for at least six hours in the lobby, and not returned to the facility for approximately 11 hours. The resident missed their scheduled [CONDITION(S)] medication and a blood sugar check to determine whether there was a need to give medication. In addition, when the resident was finally seen by the practitioner, they had to have their bladder drained due to urine retention while waiting to be seen. […]

• Actual harm, isolatedF689Aug 2, 2022

  Based on observation, interview and record review, the facility failed to ensure 1 (Resident 1) of 3 residents reviewed for falls was safely positioned in a wheelchair. This failure caused Resident 1 to fall forward, out of the wheel chair, and experience a right forehead hematoma (localized swelling filled with blood) and bruising to both eyes. This failure placed other residents at risk for further falls and associated injuries. Findings included . Review of a 04/29/2022 Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility on [DATE] with medically complex conditions. This MDS showed Resident 1's cognition was severely impaired, required 2 staff to assist with transfers, and used a wheel chair. […]