Inspection Reports for
Canterbury Place

No regulatory citations or deficiencies were identified as a result of this inspection.

No regulatory citations or deficiencies were identified as a result of this inspection.

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.

The inspection identified multiple deficiencies including improper food storage, outdated food items, missing annual medical evaluations, medication storage issues, incomplete resident assessments, and incomplete support plan documentation.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.

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.

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.

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.

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.

No regulatory citations or deficiencies were identified as a result of this inspection.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The waiver is granted on the condition that Canterbury Place uses UPMC's 'My Unity' forms in lieu of the Department's specified forms. The Department will review compliance with this waiver during its annual inspection and may terminate the waiver or take licensing action if conditions are not met.

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.

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.

No inspection findings are reported in this document. It only confirms the license renewal and states that an inspection will be conducted within the next year as required by regulation.

The facility was found to have multiple deficiencies related to safety, medical evaluations, medication labeling, and documentation. All plans of correction were implemented as of November 6, 2019, and continued compliance is required.

No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license and outlining future inspection requirements.

Several violations were found including improper food storage, lint accumulation in laundry dryer vents, incomplete fire drills, missing preadmission screening determinations, and unsigned resident support plans. Plans of correction were submitted with partial implementation progress noted.

The inspection was triggered by an incident complaint. The violations were substantiated and related to failure to complete a timely medical evaluation and unsigned support plan for resident #1.

Two violations of 55 Pa. Code Chapter 2600 were found related to medical evaluation and support plan documentation for resident #1. Plans of correction were partially implemented as of June 7, 2018.

No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.

Violations of 55 Pa. Code Chapter 2600 were found related to fire drill evacuation procedures and medication administration documentation. Plans of correction were submitted addressing resident evacuation during fire drills and proper medication administration documentation.

This document does not contain inspection findings but confirms the issuance of a regular license for Canterbury Place following the renewal application.

The Department of Human Services granted the waiver after determining that the non-U.S. educational program submitted is similar to U.S. educational requirements.

Multiple violations of the licensing regulations were found, including failure to post the current license conspicuously, incomplete criminal background checks, unsanitary kitchen conditions, hot water temperature exceeding limits, missing complaint hotline postings, broken furniture posing hazards, lack of thermometers in food storage, overdue fire extinguisher inspection, incomplete fire drill evacuations, missing first aid kit thermometer, and incomplete medication administration records.

The waiver request was returned for additional information because the submitted documentation did not demonstrate equivalency of a non-U.S. high school diploma to U.S. education requirements. Alternatives for meeting the education requirement were provided.

No regulatory violations were identified as a result of this inspection.

The complaint was substantiated based on findings of resident mistreatment and failure to meet training requirements for direct care staff.

Two violations were found: one involving staff verbally abusing a resident and another involving a direct care staff person providing unsupervised direct care without completing required training and competency testing.

No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.

Multiple violations of 55 Pa.Code Chapter 2600 were found, including unsafe storage of poisonous and combustible materials, maintenance issues with doors and lint accumulation, and incomplete resident medical evaluations. Plans of correction were submitted and partially implemented as of the report date.