Inspection Reports for
Canterbury-on-the-Lake

The complaint alleged that on 12-15-2025, resident R701 fell out of bed while receiving ADL care and was not assisted properly by the aide. The complaint was substantiated based on interviews, record reviews, and staff disciplinary actions.

The facility failed to ensure proper bed mobility and positioning for resident R701, resulting in a fall and transfer to the hospital. The investigation confirmed insufficient safeguards and improper technique by staff, leading to a written warning and re-education for the involved CNA.

The complaint investigation was triggered by allegations that the facility failed to notify a resident's responsible party of a fall and hospital transfer, failed to administer medications as ordered, had insufficient staffing to meet resident needs, and did not provide proper infection control precautions for a resident with an infection.

The facility failed to notify a resident's responsible party of a fall and hospital transfer, did not ensure timely medication administration for two residents, lacked sufficient nursing staff to meet resident needs, and failed to implement appropriate infection prevention and control measures for one resident with an infection and PICC line.

The facility was found deficient in multiple areas including resident dignity during dining, equipment maintenance, failure to report and investigate abuse/neglect allegations, inconsistent bathing assistance, delayed wound care treatment, medication administration errors, unsafe bed mobility practices, infection control lapses, and ineffective pest control program.

The facility was found deficient in multiple areas including resident rights, care and treatment, medication management, infection control, pest control, and documentation. Several residents experienced neglect, improper care, and inadequate monitoring of conditions and medications.

The complaint was substantiated. It involved grievances from a resident's family about rude nursing staff and the resident being found soiled multiple times. The facility acknowledged the grievances but failed to document corrective actions or outcome satisfaction.

The facility failed to address grievances for one resident, resulting in verbalized frustrations with quality of care. The grievance investigation and corrective actions were incomplete and lacked documentation of resolution or satisfaction.

The complaint involved allegations of misappropriation of property for resident R802, including unauthorized use of her money and purchases. The investigation revealed the facility did not report the allegation as required. Another complaint involved resident R805's repeated falls and inadequate supervision. Medication storage issues were also cited.

The facility failed to report an allegation of misappropriation of property to the Administrator and State Survey Agency. The facility also failed to thoroughly investigate multiple falls for one resident, resulting in repeated falls and injury without adequate supervision or effective interventions. Additionally, medications were not stored properly and expired medications were not discarded as required.

The complaint was substantiated based on review of grievance forms, medical records, treatment administration records, and CNA documentation showing missed showers for resident R902.

The facility failed to ensure that resident R902 received showers twice weekly as ordered, with missed showers documented on 1/2/25 and from 1/14/25 through 1/22/25. The Director of Nursing confirmed lack of documentation for showers after 1/13/25 and acknowledged the resident's discharge on 1/22/25.

The complaint alleged that CNA C physically and verbally abused resident R901 on 10/12/2024. The abuse included punching, kicking, grabbing the neck, and verbal insults. The facility investigation confirmed the abuse, CNA C was suspended and later terminated, and police were notified. Resident R901 was treated at a hospital for injuries and is receiving ongoing care including speech therapy for dysphagia. The facility delayed reporting the abuse to the State Agency and abuse coordinator.

The facility failed to protect resident R901 from physical and verbal abuse by CNA C, resulting in actual harm including pain from being punched, kicked, and verbally abused. The facility also delayed reporting the abuse to the appropriate authorities.

The complaint investigation was triggered by multiple complaints alleging resident-to-resident abuse, failure to provide feeding assistance per plan of care, insufficient nursing staff, and failure to update the facility assessment to reflect current resident needs and staffing requirements. The abuse allegation was substantiated with documented injuries and resident statements. Staffing and care provision concerns were supported by observations, interviews, and record reviews.

The facility failed to protect residents from physical abuse by another resident, did not provide required one-to-one feeding assistance, had insufficient nursing staff to meet resident needs, failed to provide food and drink in the form specified by care plans, and did not update the facility assessment to reflect changes in resident acuity and staffing needs.

The facility had multiple deficiencies including failure to ensure accurate advance directive documentation, resident-to-resident abuse, incomplete PASARR evaluations, incomplete care plans for oxygen and transmission-based precautions, missed showers, delayed wound care treatments, inadequate transfer assistance, missed medication regimen reviews, late and missed seizure medications, delayed physician notification of lab results, insufficient kitchen staffing causing late and incorrect meals, failure to honor resident food preferences, unsanitary kitchen conditions, incomplete infection control practices, and an incomplete antibiotic stewardship program.

The facility was found deficient in protecting residents from abuse, providing adequate assistance with activities of daily living, ensuring safe transfers, maintaining sufficient dietary staffing and honoring food preferences, implementing infection prevention and control protocols, and maintaining an effective antibiotic stewardship program.

The investigation was triggered by complaints from residents R901 and R902 regarding food quality, meal selection not honored, and communication failures such as unanswered phones during critical times. The complaints were substantiated with findings of inadequate documentation and follow-up.

The facility failed to properly document and address grievances related to food service inconsistencies and communication issues, including failure to honor resident food preferences and lack of follow-up on complaints. The facility was also unable to provide concern forms for review due to missing documentation.

The complaint investigation included allegations of unclean facility conditions, failure to report suspected abuse timely, and failure to follow infection control protocols. The abuse allegation was substantiated with findings of delayed reporting and inadequate staff response.

The facility failed to maintain a clean and safe environment with offensive odors, soiled floors, and debris in dining areas. The facility also failed to timely report suspected abuse of a resident and did not ensure proper infection control practices for a resident on enhanced barrier precautions.

The complaint alleged the facility failed to monitor the resident's condition, follow up timely, communicate changes and test results with the guardian, and transfer the resident to the hospital, which was substantiated by the investigation.

The facility failed to consistently monitor a resident with congestive heart failure, did not timely follow cardiologist orders for diuretics, failed to communicate significant weight gain and test results to the guardian, and did not transfer the resident to the hospital in a timely manner, resulting in the resident's death.

The facility was found deficient in multiple areas including resident dignity, safe and clean environment, abuse reporting, care planning, assistance with activities of daily living, change of condition follow-up, safe transfers, medication safety, nutrition assistance, weight monitoring, staff competency evaluations, and psychotropic medication monitoring.

The complaint investigations revealed failures in wound care for resident R806, improper fall risk assessment and mechanical lift use causing injury to resident R808, and inadequate infection control leading to Legionella exposure and illness in resident R810 and missed testing for resident R811.

The facility failed to provide accurate skin assessments and timely preventive interventions for pressure ulcers, failed to properly assess fall risk and train staff on mechanical lift use resulting in resident injury, and failed to maintain an effective water management and infection surveillance program leading to Legionella exposure and inadequate testing of affected residents.

The complaint investigation included allegations of unsafe resident transfers causing injury, failure to prevent resident elopement, failure to complete ordered diagnostic x-rays, and food service issues including late and cold meals. Some complaints were substantiated based on record review and interviews.

The facility was found deficient in ensuring safe resident transfers, preventing elopement, completing physician-ordered x-rays, and providing timely, palatable food at safe temperatures. Multiple residents experienced harm or potential harm due to these failures.