Canterbury Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 3, 2026

  Based on review of facility policies, facility documents, clinical records, and staff interviews it was determined that the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility. This failure created an immediate jeopardy situation (IJ) for sixteen residents identified as an elopement risk. The immediate jeopardy was cited as past noncompliance. Findings include: Review of the facility policy Wandering and Elopements dated 12/9/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. […]

• Immediate jeopardy, isolatedF919Feb 13, 2026

  Based on review of facility policy, facility documents, staff and resident interviews it was determined that the facility failed to provide a fully functioning call bell system for one resident resulting in an immediate jeopardy situation for one of three residents (Resident R1). Findings include: Review of facility policy Answering the Call Light dated 1/2/26, indicated: The purpose of this procedure is to ensure timely responses to the residents requests and needs. General Guidelines - Be sure that the call light is plugged in and functioning at all times. Some residents may not be able to use their call light. Be sure you check these residents frequently. Review of admission Record indicated Resident R1 was admitted on [DATE]. […]

• Actual harm, isolatedF600Jun 3, 2026

  Based on review of facility policies, facility submitted documents, facility documentation, clinical record, and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Closed Resident Record CR1) was free of neglect during care which resulted in actual harm of a fracture of their right femur (thigh bone). Findings include: Review of facility policy Recognizing Sign and Symptoms of Abuse/Neglect, dated 12/9/25, indicated all types of resident abuse, neglect, exploitation or misappropriation of resident property are strictly prohibited. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Sign of neglect: accidents among residents who need supervision. […]

• Actual harm, isolatedF695Jun 3, 2025

  Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for a Bipap device (a positive airway pressure machine when breathing in and breathing out) and failed to act on a malfunctioning Bipap in a timely manner for one of three residents (Resident R2) which resulted in actual harm of dyspnea (difficulty breathing), hypoxemia (a low level of oxygen in the blood), hypercapnia (too much carbon dioxide in the blood stream), requiring an intensive care unit (ICU - specialized hospital department where critically ill patients receive intensive, round-the-clock care) admission for Bipap. […]

• Actual harm, isolatedF600Nov 17, 2022

  Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (fracture of fibula-lower leg) for one of two residents reviewed (Resident R1). Findings include: A review of the facility policy Abuse Neglect Exploitation General Policy dated January 2022 indicated the facility will provide a safe environment where residents are protected from all forms of abuse to include neglect. Residents must not be subjected to abuse/neglect by anyone including facility staff. […]