Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
14% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of practice regarding the transcription of physician orders on admission for residents.
Findings
The facility failed to ensure that physician orders were transcribed accurately on admission for two of three records reviewed, resulting in incorrect medication dosages being administered and potential harm to residents.
Deficiencies (1)
Failure to ensure physician orders were transcribed accurately on admission for two residents, leading to incorrect medication dosages.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Confirmed failure to ensure accurate transcription of physician orders on admission. |
| Director of Nursing | DON | Confirmed failure to ensure accurate transcription of physician orders on admission. |
Inspection Report
Renewal
Census: 11
Capacity: 78
Deficiencies: 7
Date: Oct 2, 2025
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for Canterbury Place.
Findings
The inspection identified multiple deficiencies including improper food storage, outdated food items, missing annual medical evaluations, medication storage issues, incomplete resident assessments, and incomplete support plan documentation. Plans of correction were accepted and implemented with ongoing audits and education.
Deficiencies (7)
Food was stored in uncovered and undated containers in the walk-in cooler.
Outdated or unsealed food items were found in the walk-in freezer.
A resident's most recent annual medical evaluation was not completed timely.
Medication prescribed for topical pain was not available in the home at the time of inspection.
Resident assessment did not include dental needs information.
Resident's support plan did not document the need, use, and risks of a bedside mobility device.
Resident's support plan was not signed by the staff person who completed it, and resident signature status was not properly indicated.
Report Facts
License Capacity: 78
Residents Served: 11
Staffing Hours: 16
Staffing Hours: 12
Current Residents: 1
Uncovered food items: 3
Hot dogs: 6
Breaded chicken strips: 5
Veggie burgers: 20
Battered cod fillets: 12
Tilapia fillets: 36
Flame broiled burgers: 25
Inspection Report
Deficiencies: 1
Date: Jul 22, 2025
Visit Reason
The inspection was conducted to assess compliance with facility policies and physician orders related to resident care, specifically regarding the management and notification of abnormal glucose readings for residents with diabetes.
Findings
The facility failed to notify a physician of abnormal glucose readings above 400 as per physician's orders for one out of three residents reviewed (Resident R1). This failure was confirmed by the Director of Nursing during an interview.
Deficiencies (1)
Failure to notify a physician of abnormal glucose readings as per order for one out of three residents (Resident R1).
Report Facts
Glucose readings above 400: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed the facility failed to notify a physician of abnormal glucose readings as per order for Resident R1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 3, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding mental abuse of residents through technology and failure to provide safe and appropriate respiratory care, including failure to follow physician orders for a Bipap device and timely action on malfunctioning equipment.
Complaint Details
The complaint investigation found substantiated mental abuse involving staff recording and sharing a video of Resident R1 on social media. The investigation also substantiated failure to follow physician orders and timely action on malfunctioning Bipap equipment for Resident R2, resulting in actual harm and ICU admission.
Findings
The facility failed to protect residents from mental abuse facilitated by staff recording and sharing videos of a resident on social media. Additionally, the facility failed to follow physician orders for a Bipap device and did not act timely on a malfunctioning Bipap machine, resulting in actual harm and ICU admission for one resident.
Deficiencies (2)
Failure to protect residents from mental abuse, including abuse facilitated or enabled through the use of technology for one of five residents reviewed.
Failure to follow physician order for a Bipap device and failure to act on a malfunctioning Bipap in a timely manner for one of three residents, resulting in actual harm and ICU admission.
Report Facts
Residents reviewed: 5
Residents reviewed: 3
Bipap settings: 18
Bipap settings: 5
Oxygen bleed: 2
Resident R2's BIMS score: 15
Resident R1's BIMS score: 6
Dates of notes: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nurse Aide | Received video of Resident R1 on social media |
| Employee E2 | Nurse Aide | Recorded video of Resident R1 on social media |
| Employee E3 | Registered Nurse | Witnessed and reported video incident involving Resident R1 |
| Employee E5 | Registered Nurse | Witnessed and reported video incident involving Resident R1 |
| Employee E15 | Human Resource Director | Interviewed regarding video incident involving Resident R1 |
| Employee E6 | Licensed Practical Nurse | Documented notes and reported Bipap malfunction issues for Resident R2 |
| Employee E7 | Registered Nurse | Documented notes and reported Bipap malfunction issues for Resident R2 |
| Employee E8 | Licensed Practical Nurse | Documented notes and interviewed about Bipap malfunction procedures |
| Employee E9 | Licensed Practical Nurse | Documented notes on Resident R2's respiratory status |
| Employee E10 | Licensed Practical Nurse | Documented notes on Resident R2's respiratory status |
| Employee E11 | Licensed Practical Nurse | Documented multiple notes on Resident R2's Bipap issues and family interactions |
| Employee E12 | Registered Nurse | Documented hospital transfer and condition of Resident R2 |
| Employee E4 | Registered Nurse | Documented hospital condition of Resident R2 |
| Employee E13 | Infection Preventionist | Interviewed regarding Bipap machine check |
| Employee E14 | Materials Manager | Interviewed regarding Bipap machine check |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with respiratory care standards and overall nursing services, focusing on the provision of appropriate respiratory care to residents.
Findings
The facility failed to provide appropriate respiratory care for two residents, including failure to date and change oxygen nasal cannula tubing as ordered and improper storage of BiPAP and nebulizer equipment. These deficiencies were confirmed through observations, clinical record reviews, staff interviews, and policy review.
Deficiencies (2)
Failure to date and change oxygen nasal cannula tubing per physician orders for Resident R1 and Resident R2.
Failure to properly store BiPAP masks and nebulizer masks in a bag when not in use for Resident R1 and Resident R2.
Report Facts
Oxygen liters per minute: 2
Date of oxygen tubing: Apr 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Licensed Practical Nurse (LPN) | Confirmed deficiencies related to respiratory care for Residents R1 and R2 |
| Director of Nursing | Confirmed facility failed to provide appropriate respiratory care for Residents R1 and R2 |
Inspection Report
Census: 11
Capacity: 78
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 15
Waking Staff: 11
Residents Served: 11
License Capacity: 78
Inspection Report
Routine
Deficiencies: 12
Date: Jan 10, 2025
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including review of policies, clinical records, staff interviews, and observations related to resident care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to perform criminal background checks prior to hire for several employees, incomplete investigations of alleged violations, failure to update care plans accurately, failure to notify physicians of abnormal glucose readings, inadequate pressure ulcer care, incomplete catheter orders and improper catheter care, failure to provide appropriate enteral feeding tube care, inconsistent dialysis communication and care planning, failure to coordinate hospice services, incomplete nurse aide performance evaluations, failure to follow infection prevention protocols including enhanced barrier precautions, and failure to provide timely staff training on abuse, neglect, and exploitation.
Deficiencies (12)
Failed to perform criminal history background checks prior to date of hire for five of six sampled employees.
Failed to conduct a thorough investigation for one resident regarding medication found at bedside.
Failed to update care plans accurately for two residents to reflect current status and care needs.
Failed to notify physician of abnormal glucose readings as per order for one resident.
Failed to provide appropriate pressure ulcer care and prevent new ulcers for two residents.
Failed to ensure physician orders for urinary catheters included size, balloon sizing, and fluid amount; failed to ensure catheter bags were covered for some residents.
Failed to ensure appropriate treatment and services for residents with enteral feeding tubes to prevent complications.
Failed to maintain consistent dialysis communication and accurate care plans for dialysis access sites for several residents.
Failed to ensure coordination of hospice services with facility services for one resident.
Failed to complete annual performance evaluations for three nurse aides.
Failed to follow enhanced barrier precautions for two residents and failed to have proper interventions for one Covid-positive resident.
Failed to provide training on abuse, neglect, and exploitation on date of orientation for one nurse aide.
Report Facts
Number of employees without background checks prior to hire: 5
Number of residents with incomplete care plans: 4
Number of nurse aides without annual performance evaluations: 3
Number of incomplete dialysis communication forms: 11
Number of incomplete dialysis communication forms: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 | Registered Nurse | Named in finding for lack of criminal background check prior to hire. |
| Employee E17 | Nurse Aide | Named in finding for lack of criminal background check prior to hire. |
| Employee E18 | Licensed Practical Nurse | Named in finding for lack of criminal background check prior to hire. |
| Employee E19 | Nurse Aide | Named in finding for lack of criminal background check prior to hire. |
| Employee E20 | Registered Nurse | Named in finding for lack of criminal background check prior to hire. |
| Employee E3 | Nurse Aide | Named in finding for failure to provide abuse, neglect, and exploitation training on orientation date. |
| Employee E14 | Registered Nurse | Named in infection control finding for improper donning of gown and failure to follow enhanced barrier precautions. |
| Employee E15 | Nurse Aide | Named in infection control finding for failure to wear appropriate PPE for droplet and airborne precautions. |
| Employee E16 | Infection Preventionist | Confirmed failures in infection prevention and control practices. |
| Employee E6 | Registered Nurse | Confirmed incomplete dialysis communication forms and enteral feeding tube care deficiencies. |
| Employee E7 | Registered Nurse Assessment Coordinator | Confirmed failure to provide appropriate hospice orders and care plans. |
| Employee E8 | Registered Nurse | Confirmed failures in infection control PPE use and signage. |
| Employee E21 | Registered Nurse | Confirmed failure to document wound progression and care. |
| Nursing Home Administrator | Confirmed multiple facility failures including background checks, training, hospice coordination, and care plan deficiencies. | |
| Director of Nursing | Confirmed multiple facility failures including incomplete investigations, care plan updates, abnormal glucose notification, hospice coordination, and infection control. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 31, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with timely notification requirements to the State Ombudsman Office regarding resident transfers and discharges.
Findings
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for 30 consecutive months from April 2022 through September 2024, as confirmed by document review, an audit, and staff interviews.
Deficiencies (1)
Failure to provide timely notification to the resident, resident representative, and ombudsman before transfer or discharge, including appeal rights.
Report Facts
Months of failure to notify: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed failure to report resident transfers and discharges during interview on 10/25/24 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to notify the resident's responsible party of changes in condition for one of six sampled residents.
Complaint Details
The complaint investigation found that the guardian was not notified of changes in condition as required, confirmed by the Nursing Home Administrator during an interview on February 22, 2024.
Findings
The facility failed to notify the resident's guardian of changes in condition as required, including messages left with the power of attorney and the resident's son about physician recommendations and a fall sustained by the resident.
Deficiencies (1)
Facility failed to notify the resident's responsible party of changes in condition for one of six sampled residents.
Inspection Report
Routine
Deficiencies: 6
Date: Jan 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, advanced directives, baseline care plans, respiratory care, medication labeling, and quality assurance processes at Canterbury Place nursing home.
Findings
The facility was found deficient in several areas including failure to accommodate call bell needs for one resident, failure to maintain proper advanced directives for one resident, failure to complete baseline care plans within 48 hours for four residents, failure to provide appropriate respiratory care for one resident, failure to label open medications with dates in two medication carts, and failure to conduct Quality Assessment and Assurance meetings quarterly with all required members.
Deficiencies (6)
Failed to accommodate the call bell needs of one of five residents (Resident R69).
Failed to maintain proper Advanced Directives on one of five residents (Resident R95).
Failed to ensure that a baseline care plan was completed and implemented within 48 hours of admission for four of eight residents (Residents R95, R105, R333, and R262).
Failed to provide appropriate respiratory care for one of three residents (Resident R69) including lack of orders for oxygen use and respiratory tubing changes.
Failed to label open medications with a date in two of four medication carts (2nd Floor Cart A and 3rd Floor High Side).
Failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for two of four quarterly meetings (February 2023 thru December 2023).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Medication carts: 2
Quarterly meetings missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 | Registered Nurse (RN) | Confirmed call light was not accessible for Resident R69 and no date on nasal cannula or nebulizer tubing |
| Employee E5 | Registered Nurse (RN) | Stated waiting for family to sign advanced directives for Resident R95 |
| Employee E3 | Licensed Practical Nurse (LPN) | Confirmed medications not dated on 2nd Floor Cart A |
| Employee E4 | Registered Nurse (RN) | Confirmed medications not dated on 3rd Floor High Side medication cart |
| Director of Nursing | Director of Nursing | Confirmed failures related to call bell needs, advanced directives, baseline care plans, respiratory care, medication labeling |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Confirmed failure to conduct QAA meetings with all required members |
Inspection Report
Follow-Up
Census: 23
Capacity: 78
Deficiencies: 3
Date: Aug 30, 2023
Visit Reason
The inspection was conducted as a partial, unannounced review due to an incident involving allegations of verbal abuse by a staff person against a resident.
Complaint Details
The visit was complaint-related due to an allegation of verbal abuse against a staff person involving resident #1. The allegation was substantiated and investigated, with corrective actions implemented.
Findings
The facility was found to have deficiencies related to failure to immediately report suspected resident abuse, inadequate supervision of a staff person involved in the alleged abuse, and failure to treat a resident with dignity and respect. The submitted plan of correction was determined to be fully implemented.
Deficiencies (3)
Failure to immediately report suspected verbal abuse of a resident by a staff person to the local Area Agency on Aging and Department of Human Services.
Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse, resulting in unsupervised work shifts.
Resident was treated without dignity and respect when staff person called resident a pig after providing incontinence care.
Report Facts
License Capacity: 78
Residents Served: 23
Current Hospice Residents: 3
Residents Age 60 or Older: 23
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 12
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
The inspection was conducted due to complaints and grievances filed by residents and their advocates regarding failure to provide scheduled showers and assistance with activities of daily living (ADL) for nine residents.
Complaint Details
The visit was complaint-related based on grievances filed from 1/2022 through 2/2023 by residents and advocates regarding missed showers and ADL care. The complaint was substantiated as the facility failed to provide scheduled bathing assistance to nine residents.
Findings
The facility failed to provide adequate ADL assistance, specifically bathing and showering, to nine residents as scheduled. Documentation, interviews, and observations confirmed multiple missed showers over several months, resulting in minimal harm or potential for actual harm to residents.
Deficiencies (1)
Failure to provide care and assistance to perform activities of daily living for any resident who is unable, specifically bathing and showering for nine residents.
Report Facts
Missed showers documented: 16
Missed showers documented: 16
Missed showers documented: 18
Missed showers documented: 16
Missed showers documented: 16
Missed showers documented: 15
Missed showers documented: 14
Missed showers documented: 14
Missed showers documented: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nursing Assistant | Indicated the tub doesn't work and has been broken for a while and Resident R10's nails were unkempt; also stated they do the best they can to get showers done. |
| Employee E2 | Nursing Assistant | Indicated not usually on the floor but showers are listed on the assignment sheet. |
| Director of Nursing | Confirmed the facility failed to provide ADL assistance for nine residents. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 9, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide grievance forms for anonymous complaints, incomplete investigations of alleged abuse/neglect, failure to provide assistance with activities of daily living (ADL), and failure to provide residents with the correct diet as ordered.
Complaint Details
The visit was complaint-related, investigating issues including grievance form availability, abuse/neglect investigation, ADL assistance, and dietary compliance. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including failure to make grievance forms available for anonymous complaints on one unit, failure to fully investigate potential abuse/neglect allegations for two residents, failure to provide ADL assistance for nine residents, and failure to provide a resident with the correct diet as ordered.
Deficiencies (4)
Failed to make available grievance forms for filing anonymous grievances on one of three units (Renaissance Unit).
Failed to fully investigate a potential allegation of abuse/neglect for two residents (Resident R12 and R60).
Failed to provide Activity of Daily Living (ADL) assistance for nine residents (Residents R10, R52, R88, R61, R5, R4, R32, R35, and R27).
Failed to ensure a resident (Resident R47) received the correct diet as ordered, specifically providing a can of soda with a straw despite orders for nectar thick liquids and no straws.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 9
Residents affected: 1
Subcutaneous hematoma measurement: 87
Subcutaneous hematoma measurement: 21
Subcutaneous hematoma measurement: 103
BIMS score: 1
BIMS score: 3
BIMS score: 9
BIMS score: 12
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E10 | Social Service Employee | Confirmed failure to make grievance forms available for anonymous grievances |
| Employee E1 | Nursing Assistant | Indicated tub was broken and Resident R10's nails were unkempt; also stated efforts to get showers done |
| Employee E2 | Nursing Assistant | Indicated not usually assigned but showers are listed on assignment sheet |
| Employee E11 | Nurse Aide | Observed giving Resident R47 a can of soda with a straw, failing to follow diet order |
| Director of Nursing | Confirmed failure to fully investigate abuse/neglect allegations and failure to provide ADL assistance for nine residents |
Inspection Report
Renewal
Census: 22
Capacity: 78
Deficiencies: 8
Date: Sep 27, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons.
Findings
Multiple deficiencies were identified including hot water temperatures exceeding 120°F, incomplete medical evaluations, unsecured medications, improper medication labeling, transportation safety issues, and incomplete resident assessments. Plans of correction were accepted and implemented with follow-up audits and education scheduled.
Deficiencies (8)
Hot water temperature in areas accessible to residents exceeded 120°F at multiple locations.
Resident #1's medical evaluation lacked pulse rate, cognitive functioning, and license number of medical professional.
During transportation, resident #2 fell backwards in wheelchair due to unsecured wheelchair straps.
Resident #3's topical medication was unlocked in their bedroom despite not being assessed capable to self-administer medications.
Resident #4's medication label indicated incorrect dosage frequency compared to prescription.
Resident #1's glucometer was not set to the correct date and time.
Resident #1's medication administration record did not document units of insulin administered from 9/1/22 through 9/28/22.
No initial assessment was completed for resident #1 within 15 days of admission.
Report Facts
License Capacity: 78
Residents Served: 22
Staffing Hours: 24
Waking Staff: 18
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 2
Residents 60 Years or Older: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Care | Director of Resident Care | Named in multiple findings related to medical evaluation, medication management, and resident assessments. |
| Activity Director | Activity Director | Named in transportation safety deficiency and related corrective actions. |
| Maintenance Director | Maintenance Director | Named in hot water temperature deficiency and corrective actions. |
Inspection Report
Renewal
Capacity: 78
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
The document is a renewal license issued in response to the facility's March 4, 2021 renewal application to operate the Personal Care Home. The Department advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department has issued a regular license for Canterbury Place following the renewal application. No findings of noncompliance are stated in this document, but the Department notes that if noncompliance is found during the upcoming inspection, enforcement action will be taken.
Report Facts
Maximum licensed capacity: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
Inspection Report
Renewal
Census: 25
Capacity: 78
Deficiencies: 3
Date: Apr 5, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of Canterbury Place on April 5 and 6, 2021.
Findings
The facility was found to have deficiencies related to resident personal equipment and additional assessments. The submitted plan of correction was accepted and determined to be fully implemented.
Deficiencies (3)
Multiple cracks in the vinyl exposing the underlying fabric on both of resident #1's wheelchair armrests, posing a skin tear hazard.
The assessment for resident #2 did not include several diagnoses as indicated on the medical evaluation.
The assessment for resident #3 did not include diagnoses of depression, anxiety, and mood disorder as indicated on the medical evaluation.
Report Facts
License Capacity: 78
Residents Served: 25
Total Daily Staff: 31
Waking Staff: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Signed letters regarding inspection results and plan of correction | |
| Director of Resident Care | Responsible for reviewing wheelchair audits and assessments to ensure compliance |
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