Canterbury Villa of Alliance

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Apr 21, 2022

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 line list, review of facility infection control policies, interviews with staff, observations, interview with the local health department (LHD) and medical record review, the facility failed to implement appropriate infection control practices including appropriate use of personal protective equipment (PPE), social distancing with residents who tested positive for COVID-19 and failed to ensure residents who were exposed to COVID-19 were encouraged to wear appropriate PPE while… […]

• Actual harm, isolatedF760Apr 10, 2025

  THIS IS AN EXAMPLE OF PAST NONCOMPLIANCE SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, emergency room documentation review, review of the facility investigation, interview, review of the Lantus (glargine) Insulin prescribing information, review of www.insulins.lilly.com the facility failed to ensure medications were administered per physician orders resulting in a significant medication error. This affected one resident (Resident #73) of three residents reviewed for medications. Actual harm occurred on 03/14/25 at 10:30 P.M. […]

• Actual harm, isolatedF689Mar 17, 2025

  Based on observation, medical record review, review of hospice and hospital records, and interview, the facility failed to fully investigate concerns related to falls to ensure risk factors were addressed in the plan of care to prevent falls. The facility also failed to ensure physician orders were implemented for fall intervention. This affected two residents (#42 and #77) of three residents reviewed for falls. Actual Harm occurred on 02/07/25 when Resident #77, who was identified at risk for falls, cognitively impaired, required staff assistance with transfers and had concerns voiced to the facility from family and the hospice provider regarding the resident potentially falling, fell while ambulating unassisted resulting in a right femoral neck fracture. […]

• No harm, potential for more than minimal, widespreadF812May 30, 2025

  Based on observation and staff interview, the facility failed to serve food in a sanitary manner. This had the potential to affect all 70 residents (except Resident #31 and Resident #57 who had orders for nothing by mouth) who received food from the kitchen. The facility census was 72. Findings include: Review of the Foundations Health Solutions Foodservice Audit, dated 05/27/25, revealed a Certified Nursing Assistant (CNA) was observed handling a sandwich with bare hands while assisting residents with meal service. Observation on 05/30/25 at 11:49 A.M. of tray line revealed [NAME] #100 touched a slice of cheese with her bare hands and placed it on a burger patty. Interview at the time of observation with [NAME] #100 confirmed she grabbed the cheese with her bare hand. […]

• No harm, potential for more than minimal, widespreadF814Apr 21, 2022

  Based on observations, interviews and review of facility the facility failed to dispose of garbage and refuse properly. This had the potential to affect all 70 residents currently residing in the facility. Findings include: Observations made on 04/11/22 from 10:00 A.M. through 10:30 A.M. revealed six red biohazard trash bags on the ground around the red biohazard trash can with two red bags on top of the lid which was located outside of the exit door (door two) from the COVID-19 unit. There were multiple trash items including used Personal Protective Equipment (PPE) such as surgical masks, gloves, and two N95 masks scattered throughout the grounds of the facility. […]