Pennsylvania Department of Health
 CANTERBURY PLACE
Patient Care Inspection Results

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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 two complaints, and an incident completed on June 30, 2026, 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:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on review of facility policy and the Pennsylvania Nursing Practice Act, clinical record review, incidents submitted to the local State field office, and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of clinical practice for one of four residents (Resident R1).

Findings include:

Review of facility policy "Skin Care and Wound Management" dated 12/9/25, indicated assigned/due treatments are assigned in the electronic medical record under the ETAR (Electronic Treatment Administration Record) tab.

Review of the facility "Licensed Practical Nurse (LPN)" job description indicated the LPN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments.

Review of the facility "Registered Nurse (RN)" job description indicated the RN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.18 Standards of nursing conduct (a)(5) indicates the registered nurse shall document and maintain accurate records. 21.18(b)(8) indicates the registered nurse may not falsify or knowingly make incorrect entries into the patient's record or other related documents.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.148 Standards of nursing conduct (a)(5) indicates a licensed practical nurse shall document and maintain accurate records. 21.148 (b)(8) indicates a licensed practical nurse may not falsify or knowingly make incorrect entries into the patient's record or other related documents.

Review of the clinical record indicated Resident R1 was admitted to the facility on 7/25/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Peripheral Vascular Disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).

Review of Resident R1's comprehensive care plan dated 10/14/24, indicated the resident has potential impairment to skin integrity related to immobility, PVD, Sweet syndrome (a rare inflammatory skin disorder characterized by fever and painful, red or purple skin lesions), and incontinence. Interventions include follow facility protocols for treatment of injury.

Review of a facility submitted document dated 6/11/26, indicated the following: "Nurse practitioner (NP) was in to see Resident R1 after nursing staff reported that resident has a dressing placed to LLE (left lower extremity) skin tear on 5/21 with orders for daily xeroform (a medicated gauze dressing that keeps wounds moist and helps prevent infection) dressing. RN and NP assessed area and found the original one area of ulceration was now a few shallow ones, resident denies pain on assessment. On date, during a routine dressing change, the facility nurse identified that resident's LLE skin tear dressing, originally applied on had not been changed since 5/21/26. Review of the electronic medical record showed that multiple licensed nurses documented that the dressing was changed according to the treatment order during this period."

Review of a nursing progress note dated 3/6/26, stated, "Patient has, what appears to be a skin tear (a traumatic wound caused by mechanical forces that partially or fully separates the skin layers, often resulting in a skin flap) on left front tibia (shin), below the knee, measures 0.3 cm (centimeters) x 0.3 cm. Appears to have been scratched since obvious dried blood over skin tear. Patient denies pain. No swelling. Very superficial, band aide applied over area."

Review of a physician order dated 3/11/26, indicated left lower extremity skin tear - cleanse with soap and water, apply xeroform and dry dressing daily every day shift for skin tear.

Review of Resident R1's May 2026 and June 2026 TAR revealed the above treatment documentation:
5/21/26: documented completed5/22/26: blank, no documentation to indicate treatment was completed or refused by resident5/23/26: documented completed5/24/26: documented completed5/25/26: documented completed5/26/26: documented completed5/27/26: documented completed5/28/26: documented completed5/29/26: blank, no documentation to indicate treatment was completed or refused by resident5/30/26: not completed due to "healed"5/31/26: blank, no documentation to indicate treatment was completed or refused by resident6/1/26: documented completed6/2/26: documented completed6/3/26: blank, no documentation to indicate treatment was completed or refused by resident6/4/26: documented completed6/5/26: documented completed6/6/26: documented completed6/7/26: documented completed6/8/26: documented completed6/9/26: documented completed6/10/26: documented completed
Review of a Skin/Wound progress note dated 6/16/26, stated, "Resident seen by wound team this morning. Healing abrasion (scrape) present to LLE. Wound is dry. No drainage. A couple scabbed areas remain. To apply skin prep (a liquid product used to create a protective barrier) QD (every day) and leave OTA (open to air)."

Review of a witness statement dated 6/15/26, completed by LPN Employee E2 stated, "I inadvertently did not do the wound care on Resident R1's medical record and I accidentally signed off the dressing on the MAR (medication administration record). I had asked oncoming nurse to do dressing."

Review of Resident R1's clinical record revealed LPN Employee E2 documented the treatment as completed on 6/10/26.

Review of a witness statement dated 6/12/26, completed by LPN Employee E3 stated, "That wound was healed and her put a dressing on a healed just a pink area wound made it a wound cause the people that seen it and worked there knew it didn't need anything wrong for signing it but never the less it was healed and when you got the whole floor you're busy no excuse but that's the truth."

Review of Resident R1's clinical record revealed LPN Employee E3 failed to document the treatment as completed on 5/31/26, and documented the treatment as completed on 6/7/26.

Review of a witness statement dated 6/12/26, completed by LPN Employee E4 stated, "Last time I seen it was healed nurses before me can witness."

Review of Resident R1's clinical record revealed LPN Employee E4 documented the treatment as completed on 5/25/26, 5/26/26, 5/28/26, 6/1/26, 6/2/26, 6/4/26, 6/5/26, 6/8/26, and 6/9/26. On 5/30/26, LPN Employee E4 documented the treatment as not performed due to the area "healed".

Review of a witness statement dated 6/16/26, completed by RN Employee E5 stated, "There were two dates when RN recorded her initials and did not change dressing. RN either signed while charting with intent to change dressing and forgot or there were two times RN came in to change dressing and had to attend to roommates repositioning and one time when nurse aide refused to clean up roommate who was covered in chocolate. RN will change dressing then sign in chart moving forward."

Review of Resident R1's clinical record revealed RN Employee E5 documented the treatment as completed on 5/23/26, and 6/6/26.

During an interview on 6/30/26, at 12:30 p.m. RN Employee E6 stated, "I would not mark a treatment as completed without actually doing it."

During an interview on 6/30/26, at 1:08 p.m. RN Employee E7 stated, "I would not sign off a treatment if I did not actually complete it."

During an interview on 6/30/26, at 1:10 p.m. RN Employee E8 stated, "I would not sign off a treatment as completed if I did not do it."

During an interview on 6/30/26, at 1:14 p.m. RN Employee E1, RN Employee E9, and RN Employee E10 all stated, "I would not document a treatment a completed without actually completing the treatment."

During an interview on 6/30/26, at 1:45 p.m. the Director of Nursing confirmed that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of clinical practice for Resident R1.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 08/06/2026

For Resident R1 the dressing was changed the day it was reported not changed.
DON/Designee will initiate a house wide skin audit to ensure all existing skin conditions are identified and then 5% weekly x3, bi-weekly x 2 and then monthly x1. UM/RN/LPN will be educated to have skin audits completed weekly and to notify physicians for changes in skin conditions. DON/Designee will present all findings to the QA Committee.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy and facility job descriptions, clinical record review, incidents submitted to the local State field office, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for one of four residents (Resident R1).

Findings include:

Review of facility policy "Skin Care and Wound Management" dated 12/9/25, indicated all residents have head-to-toe skin inspection upon admission/readmission, then completed weekly, and as needed by nursing. It is documented in the electronic medical record "NRSG: Weekly Skin". Assigned/due treatments are assigned in the electronic medical record under the ETAR (Electronic Treatment Administration Record) tab. Wound assessments/observation are required at a minimum weekly and when there is a change.

Review of the facility "Licensed Practical Nurse (LPN)" job description indicated the LPN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments.

Review of the facility "Registered Nurse (RN)" job description indicated the RN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments.

Review of the clinical record indicated Resident R1 was admitted to the facility on 7/25/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Peripheral Vascular Disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).

Review of Resident R1's comprehensive care plan dated 10/14/24, indicated the resident has potential impairment to skin integrity related to immobility, PVD, Sweet syndrome (a rare inflammatory skin disorder characterized by fever and painful, red or purple skin lesions), and incontinence. Interventions include follow facility protocols for treatment of injury.

Review of a facility submitted document dated 6/11/26, indicated the following: "Nurse practitioner (NP) was in to see Resident R1 after nursing staff reported that resident has a dressing placed to LLE (left lower extremity) skin tear on 5/21 with orders for daily xeroform (a medicated gauze dressing that keeps wounds moist and helps prevent infection) dressing. RN and NP assessed area and found the original one area of ulceration was now a few shallow ones, resident denies pain on assessment. On date, during a routine dressing change, the facility nurse identified that resident's LLE skin tear dressing, originally applied on had not been changed since 5/21/26. Review of the electronic medical record showed that multiple licensed nurses documented that the dressing was changed according to the treatment order during this period."

Review of a nursing progress note dated 3/6/26, stated, "Patient has, what appears to be a skin tear (a traumatic wound caused by mechanical forces that partially or fully separates the skin layers, often resulting in a skin flap) on left front tibia (shin), below the knee, measures 0.3 cm (centimeters) x 0.3 cm. Appears to have been scratched since obvious dried blood over skin tear. Patient denies pain. No swelling. Very superficial, band aide applied over area."

Review of a physician order dated 3/11/26, indicated left lower extremity skin tear - cleanse with soap and water, apply xeroform and dry dressing daily every day shift for skin tear.

Review of Resident R1's May 2026 and June 2026 TAR revealed the above treatment documentation:
5/21/26: documented completed5/22/26: blank, no documentation to indicate treatment was completed or refused by resident5/23/26: documented completed5/24/26: documented completed5/25/26: documented completed5/26/26: documented completed5/27/26: documented completed5/28/26: documented completed5/29/26: blank, no documentation to indicate treatment was completed or refused by resident5/30/26: not completed due to "healed"5/31/26: blank, no documentation to indicate treatment was completed or refused by resident6/1/26: documented completed6/2/26: documented completed6/3/26: blank, no documentation to indicate treatment was completed or refused by resident6/4/26: documented completed6/5/26: documented completed6/6/26: documented completed6/7/26: documented completed6/8/26: documented completed6/9/26: documented completed6/10/26: documented completed
Review of a Skin/Wound progress note dated 6/16/26, stated, "Resident seen by wound team this morning. Healing abrasion (scrape) present to LLE. Wound is dry. No drainage. A couple scabbed areas remain. To apply skin prep (a liquid product used to create a protective barrier) QD (every day) and leave OTA (open to air)."

Review of a witness statement dated 6/15/26, completed by LPN Employee E2 stated, "I inadvertently did not do the wound care on Resident R1's medical record and I accidentally signed off the dressing on the MAR (medication administration record). I had asked oncoming nurse to do dressing."

Review of Resident R1's clinical record revealed LPN Employee E2 documented the treatment as completed on 6/10/26.

Review of a witness statement dated 6/12/26, completed by LPN Employee E3 stated, "That wound was healed and her put a dressing on a healed just a pink area wound made it a wound cause the people that seen it and worked there knew it didn't need anything wrong for signing it but never the less it was healed and when you got the whole floor you're busy no excuse but that's the truth."

Review of Resident R1's clinical record revealed LPN Employee E3 failed to document the treatment as completed on 5/31/26, and documented the treatment as completed on 6/7/26.

Review of a witness statement dated 6/12/26, completed by LPN Employee E4 stated, "Last time I seen it was healed nurses before me can witness."

Review of Resident R1's clinical record revealed LPN Employee E4 documented the treatment as completed on 5/25/26, 5/26/26, 5/28/26, 6/1/26, 6/2/26, 6/4/26, 6/5/26, 6/8/26, and 6/9/26. On 5/30/26, LPN Employee E4 documented the treatment as not performed due to the area "healed".

Review of a witness statement dated 6/16/26, completed by RN Employee E5 stated, "There were two dates when RN recorded her initials and did not change dressing. RN either signed while charting with intent to change dressing and forgot or there were two times RN came in to change dressing and had to attend to roommates repositioning and one time when nurse aide refused to clean up roommate who was covered in chocolate. RN will change dressing then sign in chart moving forward."

Review of Resident R1's clinical record revealed RN Employee E5 documented the treatment as completed on 5/23/26, and 6/6/26.

During an interview on 6/30/26, at 12:30 p.m. RN Employee E6 stated, "I would not mark a treatment as completed without actually doing it."

During an interview on 6/30/26, at 1:08 p.m. RN Employee E7 stated, "I would not sign off a treatment if I did not actually complete it."

During an interview on 6/30/26, at 1:10 p.m. RN Employee E8 stated, "I would not sign off a treatment as completed if I did not do it."

During an interview on 6/30/26, at 1:14 p.m. RN Employee E1, RN Employee E9, and RN Employee E10 all stated, "I would not document a treatment a completed without actually completing the treatment."

Review of Resident R1's clinical record failed to include documentation that a weekly skin assessment was performed for the following weeks:
4/5/26 - 4/11/264/12/26 - 4/18/264/19/26 - 4/25/264/26/26 - 5/2/265/3/26 - 5/9/265/17/26 - 5/23/265/31/26 - 6/6/266/7/26 - 6/13/26
During an interview on 6/30/26, at 1:45 p.m. the Director of Nursing (DON) confirmed that the facility failed to complete and document a weekly skin assessment for Resident R1 on the above-mentioned dates.

During an interview on 6/30/26, at 1:45 p.m. the DON confirmed that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for Resident R1.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.5(f) Medical records.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 08/06/2026

For Resident R1 the dressing was changed the day it was reported not changed.
DON/Designee will audit all treatment records for all identified wounds initially and then 5% weekly x3, bi-weekly x2, and then monthly x1.

Staff Development Coordinator/Designee will educate licensed staff (RN/LPN) to have skin audits completed weekly and to notify physicians about changes in skin conditions.

DON/MDS/Designee will audit The treatment record for completion of treatments as ordered.  and then 5x weekly x3, bi-weekly x2, and then monthly x1.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 10 residents during the day shift for one of 21 days (6/28/26) and one nurse aide per 11 residents on evening shift for one of 21 days (6/20/26).

Findings include:

Review of facility census data and nursing time schedules from 6/9/26 through 6/29/26, revealed the following NA staffing shortages.

Day Shift:
6/28/26, Census 104, 9.19 Full-Time Equivalents (FTEs) present, 10.40 FTEs required.

Evening Shift:
6/20/26, Census 109, 8.44 FTEs present, 9.91 FTEs required.

During an interview on 6/30/26, at 3:03 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift and one nurse aide per 11 residents on evening shift as required with no additional excess higher-level staff to compensate this deficiency.







 Plan of Correction - To be completed: 08/06/2026

NHA/DON/Designee will audit the HRPD daily to ensure the NA ratios per 10 residents for the day shift, 11 residents per NA evening shift, and 15 residents per NA nightly, weekly x4, bi-weekly x2, and then monthly. DON/Staffer/Designee will audit the daily staffing Hours per Resident Day (HRPD) weekly x4, bi-weekly x2 and then monthly x1. Recruiting efforts are advertising for jobs, establishing a weekly open interview day and shift pick up bonus. Clinical Support Educator will educate the DON, Staffer, and Supervisors on state minimum staffing ratios and hours per resident per day. Administrator/DON will report all findings to the QA committee.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on one of 21 days (6/21/26).

Findings include:

Review of facility census data and nursing time schedules from 6/9/26, through 6/29/26, revealed the following LPN staffing shortages.

Day Shift:
6/21/26, Census 109, 3.81 Full-Time Equivalents (FTEs) present, 4.36 FTEs required.

During an interview on 6/30/26, at 3:03 p.m. the Nursing Home Administrator confirmed the staffing shortages and that the facility failed to provide one LPN per 25 residents during the day shift as required with no additional excess higher-level staff to compensate this deficiency.






 Plan of Correction - To be completed: 08/06/2026

NHA/DON/Designee will audit the HRPD daily to ensure the LPN ratios per 25 residents for the day shift, 30 residents per LPN evening shift, and 40 residents per LPN nightly, weekly x4, bi-weekly x2, and then monthly. DON/Staffer/Designee will audit the daily staffing Hours per Resident Day (HRPD) weekly x4, bi-weekly x2 and then monthly x1. Recruiting efforts are advertising for jobs, establishing a weekly open interview day and shift pick up bonus. Clinical Support Educator will educate the DON, Staffer, and Supervisors on state minimum staffing ratios and Hours per Resident per day. Administrator/DON will report all findings to the QA committee
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on one of 21 days (6/20/26).

Findings include:

Review of facility census data and nursing time schedules 6/9/26 through 6/29/26, revealed that the facility failed to maintain 3.20 hours of general nursing care (PPD) to each resident in a 24-hour period on the following dates:

6/20/26, Census 109, PPD 3.18

During an interview on 6/30/26, at 3:03 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on one of 21 days as required.






 Plan of Correction - To be completed: 08/06/2026

DON/Staffer/Designee will audit the daily staffing Hours per Resident Day (HRPD) weekly x4, bi-weekly x2 and then monthly x1. Administrator will educate the DON/Staffer/Supervisor on state minimum staffing ratios and Hours per Resident Day (HRPD). Recruiting efforts are advertising for jobs, establishing a weekly open interview day and shift pick up bonus. Administrator/DON will report all findings to the QA committee.

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