Pennsylvania Department of Health
CANTERBURY PLACE
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CANTERBURY PLACE
Inspection Results For:

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CANTERBURY PLACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to a complaint, completed on April 30, 2025, it was determined that Canterbury Place was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R1 and R2).

Findings include:

Review of facility policy "Respiratory Therapy" dated 1/2/25, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. Change the oxygen nasal cannula (a medical device that provides supplemental oxygen to patients through two prongs inserted into the nostrils) every seven days, or as needed. Store the mask and plastic tubing from the nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) in a plastic bag, marked with date and resident ' s name, between uses.

Review of the clinical record indicated Resident R1was admitted to the facility on 7/20/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/20/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and respiratory failure (occurs when the lungs can not properly exchange gases). MDS Section O-Special treatments, procedures and program C1 is marked, indicating oxygen therapy. Section G1 is marked, indicating BiPAP (Bi-level Positive Airway Pressure-a non-invasive ventilation method that uses pressurized air to assist in breathing).

Review of a physician's active orders dated 4/28/25, indicated to administer oxygen at 2 liters per minute per nasal cannula. Change oxygen tubing every week.

Review of a physican's active orders dated 4/28/25, indicated BiPAP with Oxygen at 2 liters per minute. Apply at bedtime and remove in the morning.

During an observation on 4/29/25, at 10:30 a.m. Resident R1 was laying in her bed receiving two liters per minute of oxygen via nasal cannula. No date was present on the oxygen nasal cannula. Two BiPAP masks were laying on the bedside nightstand and failed to be stored in a bag, when not in use.

During an interview on 4/29/25, at 10:45 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that no date was present on Resident R1's nasal cannula tubing and that two BiPAP mask were not properly stored in a bag.

Review of the clinical record indicated Resident R2 was admitted to the facility on 5/12/21.

Review of Resident R2's MDS dated 3/4/25, indicated diagnoses of heart failure, high blood pressure, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). MDS Section O-Special treatments, procedures and program C1 is marked, indicating oxygen therapy.

Review of a physician's active orders dated 7/31/24, indicated to administer oxygen via nasal cannula to maintain pulse ox (a non-invasive method used to measure the percentage of blood that is saturated with oxygen) greater than 90 percent. Change and date oxygen tubing weekly.

Review of a physician's active order dated 3/30/25, indicated to administer Albuterol Sulfate (medication used in a nebulizer machine to help with breathing).

During an observation on 4/29/25, at 10:47 a.m. Resident R2 was laying in her bed receiving two liters per minute of oxygen via nasal cannula. The oxygen tubing was dated 4/18/25. The nebulizer tubing failed to have a date on it, and the nebulizer mask was laying on the bedside nightstand and failed to be stored in a bag, when not in use.

During an interview on 4/29/25, at 11:02 a.m. LPN Employee E1 confirmed that the oxygen tubing was not changed per physician order and that the resident's nebulizer was not properly stored in a bag.

During an interview on 4/29/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for two of two residents (Resident R1 and R2).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 06/06/2025

The tubing for the nasal cannulas and/or the nebulizer masks for residents R-1 and R-2 have been corrected and/or stored on bags while not in use in accordance with facility policy.
Nursing staff will be educated on the importance of changing the nasal cannula tubing weekly and proper storage of the nebulizer masks in a bag when not in use.
Five residents per week will be randomly monitored for a period of four weeks to ensure that their oxygen cannulas are changed and dated and/or that the resident's nebulizer masks are stored in a bag when not in use, both in accordance with the facility policy (weekly).
Any deficient practice will be immediately corrected. All data will be forward to the QAPI committee with the need for additional monitoring to be determined by the committee.

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