Canterbury of Twinsburg

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 18, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff and resident interviews, review of video footage, review of facility investigation, and facility policy review, the facility failed to ensure residents were safely transferred using a Hoyer lift. Actual Harm occurred on 05/08/25 at approximately 2:15 P.M. when Hospice Nurse Aide (HNA) #869 completed a Hoyer lift (a type of mechanical lift used to safely transfer individuals with limited mobility from one surface to another) transfer of Resident #21 without the assistance of a second person, resulting in Resident #21's arm becoming fractured. […]

• Actual harm, isolatedF689Jun 12, 2023

  Based on medical record review, interview, review of the fall investigations, and policy review the facility failed to ensure fall prevention interventions were in place to prevent falls for Residents #5, #38, and #50. This resulted in Actual Harm on 04/07/23 when Resident #38 had a fall which resulted in her being sent to the hospital for a laceration to the posterior scalp requiring three staples. In addition, Actual Harm occurred 04/25/23 when Resident #50 had a fall which resulted in a nondisplaced, fractured hip. This affected three residents (#5, #38, and #50) of five residents reviewed for falls. The facility census was 49. Findings include: 1. […]

• Actual harm, isolatedF686Jun 28, 2022

  Based on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #36 did not develop avoidable pressure injuries of the knees. Actual harm occurred when Resident #36 developed a right knee deep tissue injury (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.) and a left knee Stage 3 pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss.). […]

• No harm, potential for more than minimal, widespreadF804Aug 11, 2023

  Based on observation and interview, the facility failed to ensure meals were served at a palatable temperature at point of service. This had the potential to affect all 39 residents who received meals from the kitchen. The facility identified eight residents (#1, #3, #4, #10, #16, #21, #22 and #23) as not receiving meals from the kitchen. The facility census was 47. Findings include: Observation of tray line on 08/11/23 at 12:11 P.M. revealed Dietary Cook #147 was asked by the state surveyor for a test tray at the end of the 100-unit tray cart. At 12:11 P.M. Dietary Cook #147 plated a test tray. The test plate was enclosed by an insulated plate cover and base and placed in a covered uninsulated meal cart. […]

• No harm, potential for more than minimal, widespreadF812Aug 11, 2023

  Based on observation, interview, and facility policy review, the facility failed to ensure all foods in cooler and freezer units were properly labeled and dated. This had the potential to affect 39 residents who received food from the kitchen. The facility identified eight residents (#1, #3, #4, #10, #16, #21, #22 and #23) as receiving nothing by mouth. The facility census was 47. Findings include: Observation of the kitchen on 08/11/23 from 10:00 A.M. to 10:25 A.M. with Registered Dietitian (RD) # 141, Manager in Training #142, and Corporate Dietitian #164 revealed the following concerns: Observation of the three-door reach in freezer located in the dry storage area revealed one opened, resealed half-full bag of peas and carrots that had no date on it. […]