Canton Oaks

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 26, 2025

  Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 7 resident (Resident #1 and Resident #2) reviewed for accidents and supervision. 1. The facility failed to ensure CNA A appropriately transferred Resident #1 who was identified as a two person assist for bed mobility. Resident #1 was assisted by CNA A for ADL care on [DATE]. CNA A rolled Resident #1 over in the bed, he fell and broke both hips. 2. The facility failed to ensure Resident #2, who could not bear weight and was identified as a Hoyer lift transfer, was transferred using a Hoyer lift. […]

• Immediate jeopardy, isolatedF693Jul 23, 2024

  Based on interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #1) reviewed for enteral feeding. The facility failed to ensure Resident #1's tube feeding was stopped at 7:00 a.m. as ordered. Resident #1 received the tube feeding and water flushes via the pump for approximately an additional 6 and 1/2 hours resulting in an excess volume delivery of 1072mls Resident #1 began vomiting, was found cyanotic (when the skin, lips or nails turn a bluish color) and had an Sp02 ( oxygen saturation level -normal rage is 95-100%) of 52% and was transferred to the hospital where he was diagnosed with aspiration pneumonia ( when food or liquid is… […]

• Immediate jeopardy, isolatedF760Apr 14, 2023

  Based on interview and records review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1's crushed medication and instead administering Resident #1 half of her roommates crushed medications which included Clonidine (medication used to treat high blood pressure), Losartan (medication used to treat high blood pressure), Metoprolol Succinate ER (an extended release medication to treat high blood pressure, chest pain, and heart failure), and Norvasc (medication used to treat high blood pressure) and all of her own crushed medications resulting in Resident #1 being hospitalized . […]

• Actual harm, isolatedF689Feb 16, 2022

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent injury for 1 of 1 resident reviewed for accidents. (Resident #48) The facility did not provide foot pedals to wheelchair prior to transport which resulted in Resident #48 getting a left ankle fracture. This failure could affect residents who required assistive devices when traveling in the facility van at risk for accidents. Findings included: Record review of physician orders dated 01/16/22 to 02/16/22 indicated Resident #48 was a [AGE] year-old male who admitted on [DATE] with diagnoses including dementia without behaviors, fracture to left ankle, depressive disorder, intellectual disability, severe obesity, and [CONDITION(S)] . […]

• No harm, potential for more than minimal, patternF655Feb 16, 2022

  Based on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of admission for 5 of 5 residents reviewed for baseline care plans. (Resident #s 55, 70, 173, 174, and 175) * The facility did not have a baseline care developed and implemented within 48 hours after admission for Resident #s 55, 70, 173, 174, and 175. This failure could place newly admitted residents at risk for no continuity of care, no communication among nursing home staff, and decreased quality of life. Findings included: 1. […]