Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canterbury Towers Inc during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to perform hand hygiene between handling soiled and clean dishes, and did not maintain cold liquids like milk at the required temperature before serving. Staff were observed repeatedly touching soiled items and then clean items without washing hands, and milk intended for residents was found at temperatures above 40°F. These actions were inconsistent with the facility's own policies and federal food safety standards.
Surveyors found that three rooms had over-the-toilet seats with visible rust due to lapses in maintenance and cleaning. The Director of Maintenance confirmed that preventative room checks were not being performed, despite existing policies and inspection forms intended to ensure a safe and sanitary environment.
Three residents did not have timely or properly submitted MDS assessments as required, with some assessments missing, incomplete, or not reflecting an accepted status. The MDS Coordinator confirmed these lapses after reviewing records and reports.
Surveyors found that three rooms had over-the-toilet seats with visible rust, indicating a failure to maintain a safe and clean environment. The Director of Maintenance confirmed that preventative room checks were not being performed, despite existing policies and inspection forms outlining such procedures.
Deficient Food Safety and Sanitation Practices in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in food safety and sanitation practices within the facility's dietary department. Staff members operating the dishwashing machine were repeatedly seen handling soiled dishes and equipment with their bare hands, then immediately touching clean dishes and utensils without performing hand hygiene. This practice was observed with several dietary staff, including the cook and dietary aides, over multiple days. The dietary manager was present during some of these observations and did not intervene or remind staff to wash their hands between handling soiled and clean items. Staff interviews confirmed that they were trained on proper handwashing techniques and the facility's policies required handwashing after handling soiled equipment, but staff did not consistently follow these procedures. Additionally, the facility failed to ensure that cold liquids, such as milk, were held at the required temperature of 40 degrees Fahrenheit or below prior to serving to residents. During meal preparation, cartons of milk and other cold items were removed from refrigeration and placed on trays, where they sat in meal carts for at least fifteen minutes before being served. When the temperature of a milk carton was checked, it was found to be 63.2 degrees Fahrenheit, well above the required holding temperature. Further checks of milk stored in the refrigerator also revealed temperatures above the acceptable limit. The refrigerator used for staging food did not have a thermometer present during initial observations, and staff were unaware of its absence. Facility policies reviewed by surveyors clearly outlined the need for proper handwashing and temperature control of cold foods. The policies specified that staff must wash hands after handling soiled equipment and that cold foods should be maintained at or below 40 degrees Fahrenheit. Despite these policies and staff training, the observed practices did not align with the established procedures, resulting in noncompliance with federal food safety requirements.
Plan Of Correction
Specific Corrective Action To ensure staff completed hand hygiene between soiled dish handling and receiving of clean dishes when operating the dish machine, the dietary manager immediately educated all present dishwasher operators on proper hand hygiene and handling of dishes. On 7/31/2025, all kitchen staff that utilize the dishwasher attended an inservice training (Attachments Hand 1). On 7/18/2025, the dietary manager posted educational material near the dishwashing area to remind employees of the importance of proper hand hygiene and the correct way to handle clean dishes (Attachment J). To ensure liquids such as milk were held at a temperature of 40 degrees Fahrenheit and below prior to serving to residents, the dietary manager immediately discarded all beverages deemed outside the proper temperature range during the survey and replaced them with beverages at the proper temperature. The staff member present was educated on when beverages should be placed on the cart and a cool housing was provided to hold beverages before placing on a tray or serving to the residents. The dietary manager also checked that all of the coolers had a thermometer. On 7/18/2025, the dietary manager went over the Taste and Temperature Control Policy with the staff (Attachment K). On 7/31/2025, the dietary manager held an inservice on proper holding temperatures for hot and cold items (Attachments L. and M). Method to Assess Other Residents All residents of this facility have the potential to be affected by these practices. The facility's dietary manager or designee will conduct random weekly inspections to ensure policies and procedures are being followed. Systematic Review Onboarding education for new dietary staff has been updated to include an emphasis on these practices. Annual education of existing staff will stress hand washing procedures and proper holding temperatures. Quality Assurance Dietary Manager or designee will be responsible to ensure compliance of the process to the Administrator. Results of random inspections will be reviewed by the Risk Management/Quality Assurance Committee until such time that consistent substantial compliance has been achieved as determined by the committee. Findings of this process will be discussed with the Resident Council.
Failure to Maintain Safe and Clean Resident Bathroom Equipment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as required by federal regulations. During facility tours, surveyors observed that three resident rooms (112, 113, and 116) had over-the-toilet seats showing visible signs of rust. These observations were made on two separate occasions. The presence of rusted bathroom equipment indicates a lack of proper maintenance and cleaning, which is necessary to ensure a sanitary and comfortable environment for residents. Interviews with the Director of Maintenance revealed that maintenance work orders are managed on paper, with employees responsible for writing up and submitting issues they observe daily. Although a maintenance inspection sheet exists to guide preventative maintenance and room checks, the Director of Maintenance admitted that these room checks were not currently being performed. Review of facility policies and inspection forms showed that procedures for routine cleaning, disinfection, and room inspections were in place, but the lack of implementation contributed to the deficiency.
Plan Of Correction
Specific Corrective Action A full inspection of all resident rooms was conducted on 7/18/2025, identifying all over the toilet seats that had any rust or damage. Twelve new 3-in-1 over toilet folding commodes were ordered on 7/18/2025 (Attachment A). Three seats arrived the same day and were placed in identified rooms. The remainder of the new equipment arrived on 7/25/2025, with three seats going to replace existing equipment and the remainder going to storage for future utilization. Method to Assess Other Residents A comprehensive survey of all resident rooms was conducted on 7/18/2025 to identify any other equipment of concern (Attachment B). All residents of this facility have the potential to be affected by this practice. Systematic Review The Resident Room Inspection form was updated (Attachment C) to include the 3-in-1 toilet seats. Health Center Maintenance staff were educated on the SNF Room Inspection policy and the new resident room inspection sheet on 7/28/2025 (Attachment D). Quality Assurance The Plant Manager or designee will complete random weekly audits for 3 months during the weeks of 7/28/25 through 9/29/2025 (Attachment E). Validation checklists will be reviewed by the Administrator or designee. Audit records will be reviewed by the Risk Management/Quality Assurance Committee until such time as consistent substantial compliance has been achieved, as determined by the committee.
Failure to Complete and Submit Timely MDS Assessments
Penalty
Summary
The facility failed to conduct and submit timely comprehensive Minimum Data Set (MDS) assessments for three residents out of six reviewed, as required by federal regulations. Specifically, one resident was admitted and discharged within the review period, with MDS assessments completed but not reflecting an 'accepted' status. Another resident had a discharge MDS assessment completed but not submitted, and a third resident did not have a discharge assessment completed at all. These failures were identified through closed record reviews and confirmed by the facility's MDS Coordinator, who acknowledged the missing or unsubmitted assessments. The MDS Coordinator explained that, in one case, the assessment was uploaded to the electronic record keeping platform but the 'accepted' date was not entered, and in two other cases, discharge assessments were either not completed or not submitted. The findings were supported by documentation and photographic evidence. No information was provided regarding the residents' specific medical histories or conditions at the time of the deficiency.
Plan Of Correction
Specific Corrective Action On 07/18/2025 the MDS Nurse completed a Comprehensive Assessments for Residents #2, #35, and #21. Method to Assess Other Residents All residents of this facility have the potential to be affected by this practice. The facility's MOS Nurse will attend an inservice training presented by the MDS Nurse Consultant on 8/19/2025. Systematic Review Internal review of the MDS submittals will be conducted on a monthly basis by the MDS Coordinator, the Director of Nursing, and/or designee per Facility Policy (Attachment F). The Nurse Consultant will review the assessment schedule quarterly to ensure timely completion. Quality Assurance The Director of Nursing, Risk Manager, or designee will be responsible to ensure compliance of the process to the Administrator by implementing and assuring all audits (Attachment G). Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time that consistent substantial compliance has been achieved as determined by the committee. Findings of this audit will be discussed with the Resident Council.
Failure to Maintain Safe and Homelike Environment Due to Rusted Bathroom Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment as required by state regulations. Specifically, during facility tours, it was noted that three resident rooms (112, 113, and 116) had over-the-toilet seats that showed visible signs of rust. These observations were made on two separate occasions, confirming the ongoing presence of the issue. The deficiency was documented through direct observation and photographic evidence. Interviews with the Director of Maintenance revealed that maintenance work orders are managed on paper, with staff responsible for reporting issues daily. Although the facility has a maintenance inspection sheet intended for preventative room checks, the Director of Maintenance admitted that these room checks were not currently being performed. Review of facility policies and inspection forms indicated that procedures for routine cleaning, disinfection, and room inspections exist, but the relevant documents were either unsigned, undated, or not being actively implemented.
Plan Of Correction
Specific Corrective Action A full inspection of all resident rooms was conducted on 7/18/2025, identifying all over-the-toilet toilet seats that had any rust or damage. Twelve new 3-in-1 over-toilet folding commodes were ordered on 7/18/2025 (Attachment A). Three seats arrived the same day and were placed in identified rooms. The remainder of the new equipment arrived on 7/25/2025, with three seats going to replace existing equipment and the remainder going to storage for future utilization. Method to Assess Other Residents A comprehensive survey of all resident rooms was conducted on 7/18/2025 to identify any other equipment of concern (Attachment 8). All residents of this facility have the potential to be affected by this practice. Systematic Review The "Resident Room Inspection" form was updated (Attachment C) to include the 3-in-1 toilet seats. Health Center Maintenance staff were educated on the SNF Room inspection policy and the new resident room inspection sheet on 7/28/2025 (Attachment D). Quality Assurance The Plant Manager or designee will complete random weekly audits for 3 months during the weeks of 7/28/25 through 9/29/2025 (Attachment E). Validation checklists will be reviewed by the Administrator or designee. Audit records will be reviewed by the Risk Management/Quality Assurance Committee until such time as consistent substantial compliance has been achieved, as determined by the committee.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Bayshore Pointe Nursing And Rehab Center | 1.2 mi | ★★★★★ | 1 | 0 |
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| Elon Manor Nursing And Rehabilitation Center | 5 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.