Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Woods during CMS and state inspections, most recent first.
The facility's fire alarm system was not maintained as required, with batteries not receiving semi-annual load voltage testing. This affected both the North and West Units. The system was inspected annually, but the necessary semi-annual testing was not documented or performed, as confirmed by the Facilities Director.
A Life Safety Code survey identified deficiencies in the smoke barrier walls of an LTC facility's Occupational Therapy/Physical Therapy room and main corridor. The walls were incomplete, lacked fire resistance, and had penetrations, compromising their ability to resist smoke passage. The Facilities Director was unaware of these issues, which were discovered during remodeling.
A resident with severe cognitive impairments was subjected to verbal and physical abuse by a Companion Aide, who restrained the resident against their will. The facility's outdated policies and lack of effective communication and monitoring systems contributed to this deficiency, as Companion Aides were not informed of the prohibition against hands-on care, leading to a failure to protect the resident from potential harm.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairments within the required two-hour timeframe. The incident involved a companion aide forcefully restraining the resident, which was considered abuse by several staff members. The facility's outdated abuse reporting policy contributed to the delay in notifying the State Agency, as the report was submitted the following day.
A resident with pressure ulcers did not receive necessary treatment and services consistent with professional standards. The facility failed to conduct consistent weekly assessments, resulting in conflicting documentation and inadequate monitoring of the resident's condition. Staff interviews revealed a lack of adherence to facility policy and regulatory requirements, with the Registered Nurse Manager expressing a need for further education on pressure ulcer care.
A facility failed to implement enhanced barrier precautions for a resident with pressure ulcers, as required by their infection control policy. The resident had a stage II pressure ulcer and an unstageable pressure ulcer, but no precautionary signage or equipment was present outside their room. During wound care, a nurse did not wear a gown, and both the nurse and the Director of Nursing were unaware that enhanced precautions were necessary, despite the facility's policy. This oversight indicates a lapse in infection control measures.
A survey found that doors with delayed egress locking mechanisms in the West Unit lacked required signage indicating how to open them during emergencies. The Facilities Manager was unaware of the missing signage, and the delayed egress function was reactivated without the Facilities Director's knowledge when a contractor installed a new keypad.
The facility did not post the required nursing staff information, including the resident census and staff hours, in a prominent place for three out of five days reviewed. Observations showed the absence of the necessary form, and interviews revealed that the information was not accessible to residents and families. Staff acknowledged the oversight, and the form was not posted until a later date.
The facility failed to ensure CNAs completed the required in-service training hours, with two CNAs not meeting the six-hour minimum within a six-month period. One CNA completed 5.5 hours and attended four staff meetings, while another completed 3.0 hours and was on leave. Staff interviews revealed a lack of awareness and enforcement of training requirements.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The fire alarm system in the facility was not maintained according to required standards, as the batteries associated with the system were not load voltage tested semi-annually. This deficiency affected both the North Unit and West Unit of the facility. Observations revealed that a fully addressable fire alarm system was installed throughout the facility, and inspection reports indicated that the system was inspected and tested annually. However, the reports did not document semi-annual load voltage testing of the batteries. During an interview, the Facilities Director confirmed that the contractor responsible for inspecting and testing the fire alarm system did not conduct the required semi-annual load voltage testing, and there was no documentation to show that such testing had been performed in 2023 and 2024.
Deficiencies in Smoke Barrier Wall Maintenance
Penalty
Summary
During a Life Safety Code survey, it was observed that the smoke barrier walls in the Occupational Therapy/Physical Therapy room and the main corridor were not maintained as required. Specifically, the smoke barrier walls were incomplete from floor to ceiling deck, lacked a 30-minute fire resistance rating, and were unable to resist the passage of smoke due to penetrations. In the Occupational Therapy/Physical Therapy room, a six-inch by six-inch open penetration and a three-foot by three-foot area of removed gypsum board were found. Additionally, a 22-foot by three-foot section of the smoke barrier wall was missing, exposing an unprotected steel beam. Further observations in the main corridor revealed a two-inch by two-inch penetration around electrical wires filled with orange foam, which the Facilities Director stated was not used by the facility. Another two-inch by two-inch open penetration was found around a gray electrical wire. The Facilities Director was unaware of these issues and stated that the Occupational Therapy/Physical Therapy room was undergoing remodeling. The architectural drawings confirmed that these walls were part of the facility's smoke barrier system, labeled as Smoke Area D, and were intended to provide fire and smoke protection.
Plan Of Correction
Plan of Correction: Approved February 6, 2025 Smoke Barrier walls in identified locations were not completely sealed from ceiling to roof deck. The Facilities Director had both the Facility Manager and Facility Supervisor seal all penetrations identified and sealed the open penetrations with fire sealant that is capable of maintaining the smoke resistance of the smoke barrier and meets the current NFPA standards. The Facilities Director inspected each area to ensure code compliance. All residents have the potential to be affected. The Facilities Director has reviewed requirements regarding smoke barriers. A review of the requirements of smoke barriers was also conducted by the Facilities Director with the Facility Manager and Facility Supervisor. The Facilities Supervisor will inspect all smoke barriers as part of the monthly environmental inspections. The Facilities Director will conduct monthly reviews of the inspection reports completed by the Facility Supervisor. The monthly inspections will be submitted by the Facilities Director at the bi-monthly Quality Assessment & Performance Improvement (i.e., QAPI) Committee meetings. The Facilities Director will be responsible for the ongoing compliance of this plan.
Failure to Protect Resident from Abuse by Companion Aide
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Companion Aide. The incident involved a resident with severe cognitive impairments, including Alzheimer's disease, who required substantial assistance for daily activities. The Companion Aide was witnessed by facility staff restraining the resident by grabbing and crossing their arms against their chest, despite the resident's resistance and distress. This action was contrary to the facility's policy, which prohibited Companion Aides from providing hands-on care. The facility's policies and procedures regarding abuse prevention and the role of Companion Aides were outdated and inadequately implemented. The facility had not revised its abuse prevention protocols since 2016 and lacked an effective system to ensure background checks were completed for all Companion Aides. Additionally, the facility did not effectively communicate its policies to residents, families, and Companion Aides, leading to confusion about the permissible scope of care provided by Companion Aides. Interviews with facility staff and Companion Aides revealed a lack of clarity and enforcement of the facility's policies. Companion Aides were not provided with the nursing home's specific policy prohibiting hands-on care, and there was no formal process for monitoring their activities. The facility relied on staff to report inappropriate behavior, but there was no structured oversight to ensure compliance with the policies, resulting in a failure to protect the resident from potential harm.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required two-hour timeframe. The incident involved a resident with severe cognitive impairments and multiple diagnoses, including Alzheimer's disease and heart failure. On the morning of the incident, a companion aide forcefully restrained the resident by crossing their arms over their chest, which was considered abuse by several staff members. However, the facility did not report the incident to the State Agency until the following day, exceeding the mandated reporting period. The facility's policy on abuse reporting, last revised in 2016, did not include the required two-hour timeframe for reporting allegations of abuse. This oversight contributed to the delay in notifying the appropriate authorities. The incident was initially reported to the facility's administration by various staff members who witnessed or were informed about the event, but the formal report to the State Agency was not submitted until the next day. Interviews with staff members revealed differing opinions on whether the incident constituted abuse, with some staff considering it abuse due to the physical restraint and distress caused to the resident. The administrator, however, did not initially classify the incident as abuse, citing the lack of physical or psychological harm and the absence of police involvement. Despite this, the facility eventually reported the incident, but not within the required timeframe, highlighting a deficiency in their abuse reporting procedures.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. Resident #13, who had diagnoses including dementia, coronary artery disease, and chronic obstructive pulmonary disease, was found to have pressure ulcers on the left heel and left buttock. The facility's policy required complete wound assessments and documentation weekly, but there were inconsistencies in the assessments, including missing staging, measurements, and descriptions of the wounds. Conflicting documentation of treatment instructions and wound measurements further compounded the issue. The medical records and interdisciplinary notes revealed a lack of consistent monitoring and documentation of Resident #13's pressure ulcers. There were several weeks where the pressure ulcers were not observed or documented by the skin team or Medical Director. Additionally, the Registered Nurse Manager and Licensed Practical Nurse #4 failed to provide accurate and consistent documentation, with conflicting measurements and treatment orders noted in the records. The Registered Nurse Manager admitted to not being comfortable with staging pressure ulcers and expressed a need for further education, which was not addressed by the facility. Interviews with facility staff, including the Registered Nurse Supervisor, Medical Director, Director of Nursing, and Administrator, highlighted the lack of adherence to the facility's policy and regulatory requirements for pressure ulcer care. The Director of Nursing and Administrator acknowledged the discrepancies in documentation and the need for accurate and descriptive records to monitor the resident's condition. The Administrator was unaware of the Registered Nurse Manager's request for additional education on pressure ulcer staging and treatment, indicating a communication gap within the facility's management.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of implementation of enhanced barrier precautions for a resident with pressure ulcers. The facility's policy on enhanced barrier precautions, dated May 2024, required the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the spread of multi-drug resistant organisms. However, these precautions were not initiated for Resident #13, who had a stage II pressure ulcer on the left heel and an unstageable pressure ulcer on the left buttock/hip area. Observations and interviews revealed that there were no plastic precaution bins or enhanced barrier precaution signage outside Resident #13's room. During wound care, the Registered Nurse Supervisor did not wear a gown, contrary to the facility's policy. The nurse was unsure if residents with chronic pressure ulcers should be on enhanced barrier precautions and admitted that Resident #13 was not on such precautions, despite the presence of open wounds requiring dressings. Interviews with the Registered Nurse Manager and the Director of Nursing confirmed that enhanced barrier precautions should have been in place for Resident #13. The Director of Nursing, who also served as the facility's Infection Preventionist, acknowledged the oversight and assumed that precautions were in place due to the chronic nature of the resident's pressure ulcers. This deficiency highlights a lapse in the facility's adherence to its own infection control protocols, potentially compromising the safety and health of residents and staff.
Lack of Signage on Delayed Egress Doors
Penalty
Summary
During a Life Safety Code survey, it was observed that doors equipped with delayed egress locking mechanisms in the West Unit of the facility did not have the required signage indicating how the doors could be opened during a fire or other emergency. Specifically, the double doors leading from the Homestead lounge to the West Unit patio were tested, and while the alarm sounded and the door opened in 15 seconds, there was no signage stating: 'Push Unit Alarm Sounds Door Can be Opened in 15 Seconds.' The Facilities Manager was unaware of the absence of signage and mentioned that the doors were checked weekly as part of the wander guard system. Further investigation revealed that the delayed egress function of these doors had been inadvertently reactivated when a contractor installed an electronic keypad on the patio side of the doors. The Facilities Director was not informed of this change by the contractor and was unaware that the delayed egress function had been switched back on. The facility's audit logs confirmed that the doors equipped with wander guard systems were checked weekly, but there was no indication that the signage issue had been addressed during these checks.
Failure to Post Required Nursing Staff Information
Penalty
Summary
The facility failed to ensure that the nursing staff information was posted daily and contained the required information for three out of five days reviewed during the Extended Recertification survey. Specifically, the facility did not post the current resident census, the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place accessible to residents and visitors. Observations on multiple days revealed the absence of the required Report of Nursing Staff Directly Responsible for Resident Care form at the nurse's station, main reception area, or any prominent place. Instead, a Skilled Nursing Assignment Sheet was posted, which did not include the necessary details such as the resident census or the total number and actual hours worked by staff. Interviews with staff and a family member highlighted the lack of transparency and accessibility of staffing information. A family member of a resident noted that the actual staffing was never posted visibly, and the daily assignment sheet did not accurately reflect staff attendance. The Staffing Coordinator and Licensed Practical Nurse Supervisor acknowledged the oversight, stating that the required form was not posted until a later date and was previously kept in a binder behind the nurse's desk, inaccessible to residents and families. The Director of Nursing emphasized the importance of posting this information to ensure residents and family members are aware of the staffing levels in the facility.
Deficiency in CNA In-Service Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) attended the required in-service education to maintain their competence, as mandated by the facility's policy and procedure. Specifically, two CNAs did not complete the minimum required six hours of in-service education within a six-month period. CNA #2 completed only 5.5 contact hours of training and attended four staff meetings, each lasting half an hour, throughout the year 2024. CNA #3 completed only 3.0 contact hours of training and had been on leave for about two months, with their last work date recorded as November 9, 2024. Interviews with facility staff revealed a lack of awareness and enforcement of the training requirements. CNA #2 was unsure of the annual training requirements and relied on passcodes from the Staffing Coordinator to access training modules. The Human Resources Director stated that training compliance was tracked by the Administrator, who would address non-compliance issues. The Staffing Coordinator mentioned scheduling training time for CNAs with outstanding trainings. The Administrator confirmed that CNAs were required to complete a minimum of 12 hours of training annually, with 18-20 hours assigned through a web-based program. Both CNAs were identified as long-term employees, and disciplinary actions were suggested for their non-compliance with training requirements.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Williamsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Williamsville | 0.6 mi | ★★★★★ | 1 | 0 |
| Comprehensive Rehabilitation And Nursing Center At | 2.6 mi | ★★★★★ | 8 | 0 |
| Beechwood Health Care Center, Inc. | 2.8 mi | ★★★★★ | 0 | 0 |
| Harris Hill Nursing Facility, L L C | 3.3 mi | ★★★★★ | 9 | 0 |
| Williamsville Suburban, L L C | 3.3 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.