Below 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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canterbury Villa Of Alliance during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses, including schizophrenia, PTSD, anxiety, psychosis, and dementia, became increasingly agitated and combative during a shower and related care. Despite a care plan noting confusion, behavioral issues, and the need for behavioral interventions such as decreased stimulation and validation, several staff members continued with transfers and showering while the resident yelled, cursed, threatened staff, and attempted to hit and bite. Staff acknowledged they did not stop care or leave and re-approach, even though they recognized this would normally be done for someone with PTSD, and there was no prior documentation of behavioral incidents in the progress notes despite reports of a combative baseline. These actions and omissions led to a deficiency for failing to provide effective and appropriate behavior management during care.
A resident on hospice with multiple wounds to the left great toe and lower leg had physician-ordered daily dressing changes documented as completed on several dates by an RN and an LPN. During wound rounds, the wound NP and wound nurse found the dressings still in place from several days earlier, confirming that the ordered treatments had not been performed despite being signed off on the TAR. Another LPN corroborated this by reporting that the dressings she had applied days before were unchanged, and disciplinary actions were issued for the involved nurses for documenting care that was not provided.
A resident with hemiplegia and multiple comorbidities, who required total mechanical lift assistance for transfers, was being moved from bed to wheelchair by two CNAs when the mechanical lift tipped, causing the resident to hit her head. Staff statements and documentation show the CNAs approached the wheelchair from the side and repositioned the resident by pulling her back while the lift legs were opened, contrary to facility procedure requiring the resident’s weight to remain centered and the resident to face the attendant. The responding LPN found the resident suspended above the wheelchair in a tipped lift, and staff had to stabilize the equipment and assist in safely seating and detaching the resident, after which the resident initially reported a headache but had no observable head injury.
Staff were observed handling ready-to-eat food with bare hands during meal service, including a CNA handling a sandwich and another staff member placing cheese on a burger without gloves. These actions occurred despite facility policy requiring glove use for ready-to-eat foods, and management reportedly instructed staff not to wear gloves during tray line. This practice had the potential to affect all residents receiving food, except two who were NPO.
A resident with diabetes was administered 54 units of rapid-acting insulin instead of the prescribed long-acting insulin at bedtime by an LPN. This error led to the resident experiencing hypoglycemia, requiring emergency department evaluation and intravenous dextrose treatment. The incident was confirmed through facility investigation and staff interviews, with incomplete documentation of the resident's blood sugar at the time of the event.
The facility failed to address fall risks for two residents, leading to harm for one. A resident with cognitive impairment and mobility issues fell and fractured their hip after the facility did not implement a bed alarm despite family and hospice concerns. Another resident was observed without a required pressure sensor alarm. The facility did not update care plans or adhere to fall management policies.
A facility failed to notify a physician in a timely manner when stat lab tests for a resident with dehydration were delayed due to lab issues. The resident, with acute kidney failure and other conditions, experienced declining health, prompting stat orders for a CMP and chest x-ray. Delays in lab work and lack of timely communication with the physician led to the resident being hospitalized with acute kidney injury and hydronephrosis. The facility's lab policy lacked a specific time frame for obtaining stat tests, contributing to the deficiency.
The facility failed to implement their abuse policy and conduct thorough investigations for incidents involving resident-to-resident abuse. Inconsistent and incomplete investigations were noted, and skin checks were not performed immediately as required by the facility's policy. The DON and Administrator acknowledged the deficiencies and the need for additional training.
The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving four residents. Incidents included one resident hitting another multiple times and another resident hitting a peer's hand. The investigations were inconsistent, with incomplete documentation and failure to conduct timely skin checks. The DON and Administrator acknowledged the deficiencies and the need for additional training.
The facility failed to ensure that four residents had drinking water available in their rooms during medication administration. This was confirmed by staff and affected residents with various health conditions, including severe cognitive impairment and chronic diseases.
A facility failed to include the use of a mechanical lift in a resident's care plan despite therapy recommendations, leading to inconsistent documentation and practice. Staff confirmed the use of the lift, but it was not documented in the care plan or physician orders.
A resident with multiple diagnoses, including multiple sclerosis and vascular dementia, required extensive assistance of two staff members for bed mobility. However, the care plan did not specify this, and a nursing assistant provided care alone, accidentally hitting the resident's head on the wall. The resident experienced pain, and the facility's investigation confirmed the incident.
The facility failed to ensure that respiratory care equipment was stored in a protective barrier when not in use for two residents. One resident's aerosol mask was found in a bedside drawer without a barrier, and another resident's oxygen nasal cannula and tubing were found lying on top of the oxygen concentrator. These observations were confirmed by an LPN and verified by the DON.
Failure to Provide Effective Behavior Management During Care for Resident With PTSD and Psychiatric Disorders
Penalty
Summary
The deficiency involves the facility’s failure to provide effective and appropriate behavior management during care for a resident with significant mental health diagnoses and a history of PTSD. The resident was admitted with multiple psychiatric and neurological conditions, including schizophrenia, anxiety disorder, PTSD, panic disorder, psychosis, depression, dementia, and confusional arousals, along with physical conditions such as rhabdomyolysis, muscle weakness, chronic pain, hypertension, hypothermia, and a history of TIA. A PRN order for Olanzapine for agitation was in place, and the care plan identified that the resident could be confused and disoriented, required assistance with ADLs, and preferred showers. The plan of care also documented that the resident was non-compliant with care and treatments and experienced alterations in mood and behavior, including combative and verbally aggressive behaviors such as kicking, hitting, biting, and making false accusations. On the day of the incident, documentation showed that the resident became combative with staff and therapy during care and showering, cursing at staff and attempting to hit them with a closed fist. Redirection was attempted but was ineffective. Despite the resident’s agitation and combative behavior, staff proceeded with the shower and related care. Multiple staff members, including a PTA, COTA, CNA, and RN, were present in the room and shower area. Witness statements described the resident as verbally abusive, threatening to hurt staff if they hurt him, telling them to get out and leave him alone, and stating they were hurting him. Staff reported that these statements were made even before they physically assisted him with transfers. The resident attempted to bite and hit staff, and staff acknowledged that they did not stop care or leave the room to allow the resident time to calm down, even though they recognized that, for someone with PTSD, they would normally leave and re-approach. Staff interviews further revealed that the resident had been yelling, cursing, and swinging at staff, and that he did not like one of the male therapists, becoming more upset when he saw him. The CNA reported that the resident had been refusing to be cleaned, smelled strongly of urine, and had food on him, and that the RN had stated he had to be showered because of his condition and the need to change his bed and mattress. Staff confirmed that they continued with the shower and transfers despite the resident’s ongoing agitation and combative behavior, and that they never paused or left the room to de-escalate the situation. The DON verified there was no documentation in the progress notes of prior behavioral incidents before this date, despite staff describing the resident’s baseline as combative. These actions and omissions demonstrate that the facility did not implement effective, individualized behavior management interventions consistent with the resident’s mental health conditions, PTSD history, and care plan, leading to the cited deficiency. The incident culminated in the resident later alleging physical abuse and food withholding, although he could not provide details or identify an abuser. Staff present during the episode denied any abuse and described their actions as attempts to assist with necessary hygiene and transfers while the resident was verbally and physically aggressive. Nonetheless, the contemporaneous documentation and staff interviews show that the resident’s escalating agitation, threats, and combative behavior were met with continued, uninterrupted care and showering rather than the use of care-plan interventions such as decreasing stimulation, allowing the resident to vent with validation, determining triggers, or stepping away and re-approaching. The facility’s behavior management policy stated that behavior patterns interfering with functional capacity should be addressed to maximize dignity, independence, and self-determination, but the handling of this episode did not reflect effective application of that policy for this resident. Overall, the deficiency centers on the facility’s failure to provide appropriate behavioral and psychosocial interventions during a high-stress care interaction with a resident known to have serious mental disorders and PTSD. Staff recognized the resident’s baseline combative behavior and the need for special handling but did not adjust their approach during the incident, did not document prior behavioral patterns in the progress notes, and did not employ de-escalation strategies such as leaving the room and re-approaching. These documented actions and inactions during the shower and related care encounter form the basis of the cited failure to provide effective and appropriate behavior management services.
Failure to Perform and Accurately Document Ordered Wound Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered wound dressings were completed as prescribed for a hospice resident with multiple wounds. The resident was admitted with diagnoses including malignant neoplasm of the prostate, COPD, and a history of stroke, and had impaired skin integrity to the left great toe and left lower shin due to multiple falls. The care plan called for complete skin assessments per facility policy and completion of treatments as ordered. Physician orders directed that the left lower outer leg and left great toe wounds be cleansed with normal saline, dried, and treated with calcium alginate and non-bordered super absorbent dressings, secured and completed on the night shift. The Treatment Administration Record for November showed that these treatments were initialed as completed on three separate dates by nursing staff. However, during wound rounds on a later date, the wound nurse practitioner and wound nurse observed that the dressings on the resident’s left great toe and left outer lower leg had not been changed daily as ordered and were still dated several days earlier, confirming that the treatments had not actually been performed on the dates documented. The DON confirmed that an RN and an LPN had signed the TAR indicating the treatments were done when they had not been provided. Another LPN reported that when she went to perform the dressing change, she found the same dressing she had applied several days before still in place on both the leg and great toe. Personnel records documented disciplinary actions for the involved nurses related to signing off on treatments that were not completed and failure to meet reasonable performance standards.
Improper Mechanical Lift Transfer Leading to Tipped Lift and Head Impact
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred properly using a mechanical (Hoyer) lift, resulting in the lift tipping while the resident was suspended in the sling. The resident had left-sided hemiplegia, atrial fibrillation, seizures, and peripheral vascular disease, and required a total mechanical lift for transfers per her care plan. A quarterly MDS indicated she had no cognitive impairment and needed moderate assistance to total dependence for ADLs. During a morning transfer from bed to wheelchair by two CNAs, the lift tipped and the resident struck her head. According to staff statements and documentation, the CNAs attempted to position the resident into the wheelchair from the side rather than from the front, despite prior instruction not to approach the wheelchair from the side when using the lift. One CNA reported that due to the resident’s size, they chose to approach from the side and opened the legs of the lift; when they pulled the resident back to position her fully in the chair, the lift tipped sideways. The resident hit the back of the wheelchair, which then reclined and contacted a dresser behind it, and the resident reported that the lift hit her head. Staff described having to stand on the lift’s base to keep it from falling onto the resident until additional help arrived. The nurse responding to the incident found the resident in the lift sling above the wheelchair with the lift tipped and called for more assistance so staff could safely seat the resident and detach the lift. Documentation showed the resident initially complained of a headache but later had no complaints, with neuro checks and vital signs completed and no redness, bruising, or edema noted to the forehead. The DON and staff interviews confirmed that two CNAs did not follow facility procedure for mechanical lift use, which required the resident’s weight to remain centered over the base legs, the boom not to be swiveled to either side, and the resident to face the attendant operating the lift at all times.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to serve food in a sanitary manner, as evidenced by staff handling ready-to-eat food with bare hands during meal service. Specifically, a Certified Nursing Assistant was observed handling a sandwich without gloves while assisting residents, and another staff member was seen touching a slice of cheese with her bare hands before placing it on a burger patty during tray line. The staff member confirmed she was instructed by management not to wear gloves during tray line. The facility's Infection Control-Dietary/Food Handling Policy, revised in March 2016, requires staff to wear single-use gloves before handling ready-to-eat food. These actions had the potential to affect all residents receiving food from the kitchen, except for two residents who had orders for nothing by mouth. The deficiency was identified during a review of the Foundations Health Solutions Foodservice Audit and direct observation, and was investigated under a specific complaint number.
Significant Medication Error: Incorrect Insulin Administered
Penalty
Summary
A significant medication error occurred when a diabetic resident, who was prescribed both rapid-acting and long-acting insulin, was administered the incorrect type of insulin. The resident was ordered to receive Humalog (rapid-acting insulin) with meals and insulin glargine (long-acting insulin) at bedtime. On the evening in question, the resident was given 54 units of Humalog instead of the prescribed insulin glargine at bedtime by an LPN. Following the administration of the incorrect insulin, the resident experienced symptoms including headache, upset stomach, and a low blood sugar reading. The physician was notified of the resident's condition and ordered an emergency department transfer for evaluation and treatment. The resident was diagnosed with hypoglycemia in the emergency department and received intravenous dextrose before returning to the facility. The facility's investigation confirmed that the LPN administered the wrong insulin, and the error was documented in both the medical record and the facility's transfer form. The LPN acknowledged the mistake during an interview, and it was noted that the resident's blood sugar level at the time was 75 mg/dL, although this was not documented in the medical record. The facility's medication administration policy requires medications to be administered by authorized and trained personnel in accordance with laws and accepted standards of practice.
Failure to Address Fall Risks and Implement Interventions
Penalty
Summary
The facility failed to adequately investigate and address fall risks for two residents, leading to significant harm for one of them. Resident #77, who was at risk for falls due to cognitive impairment and mobility issues, fell and sustained a right femoral neck fracture. Despite family and hospice concerns about the resident's attempts to ambulate independently, the facility did not implement additional fall prevention measures, such as a bed alarm, citing policy restrictions and lack of recent falls. The facility's decision not to use an alarm was based on the absence of documented self-transfer attempts, despite verbal reports from family and staff. Resident #77's medical history included dementia, muscle weakness, and impaired mobility, necessitating assistance with transfers and ambulation. After a hospital admission for renal failure and a UTI, the resident returned to the facility on hospice care. Despite being identified as a fall risk, the care plan was not updated following the resident's readmission, and no new interventions were implemented. The resident's family and hospice staff expressed concerns about the resident's increased anxiety and attempts to get up unassisted, but these were not addressed by the facility. Resident #42 also experienced a deficiency in care related to fall prevention. The resident, who had a history of falls and required a pressure sensor alarm in the chair, was observed without the alarm in place. This oversight indicates a failure to adhere to physician orders and care plan interventions designed to mitigate fall risks. The facility's lack of compliance with its fall management policy, which requires regular assessment and updating of care plans, contributed to these deficiencies.
Failure to Timely Notify Physician of Stat Lab Delays
Penalty
Summary
The facility failed to notify the physician in a timely manner when they were unable to obtain stat laboratory tests for a resident with dehydration. The resident, who had diagnoses including acute kidney failure, dementia, and malignant neoplasm of the bladder and prostate, was reported by family members to have not been eating or drinking well, and had experienced emesis and lethargy. The physician was notified and ordered a basic metabolic panel, which was later changed to a stat complete metabolic panel (CMP) and a stat chest x-ray due to the resident's declining condition. Despite the urgency, the stat CMP was not drawn on the day it was ordered due to the lab's unavailability of a phlebotomist. The physician was not informed of this delay until the following morning, over 19 hours later. Further complications arose when the phlebotomist experienced technical issues, causing additional delays in obtaining the necessary lab work. The physician was eventually notified of the ongoing issues, but the stat labs were not collected until late in the evening of the following day. The delay in obtaining the stat labs resulted in the resident being sent to the hospital with diagnoses of acute kidney injury and hydronephrosis. Interviews with the attending physician and the Director of Nursing (DON) confirmed the expectation that stat orders should be completed the same day or that the physician should be notified if they cannot be obtained. The facility's lab policy did not specify a time frame for obtaining stat laboratory tests, contributing to the deficiency.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement their abuse policy regarding thoroughly investigating allegations of resident-to-resident abuse for four residents. Resident #50, who had severe cognitive impairments and behavioral disturbances, was involved in multiple incidents where she hit Resident #129. Despite witness statements and progress notes documenting these incidents, the facility's investigation was inconsistent and incomplete. The Director of Nursing (DON) and Administrator acknowledged discrepancies in the investigation and admitted to needing more training on conducting self-reported incident (SRI) investigations. Another incident involved Resident #65, who had impaired cognition and behavioral issues, hitting Resident #128. The facility's response was inadequate as skin checks were not performed on the involved residents or other residents in the dementia unit. The DON and Administrator provided conflicting information about the incident and the investigation process. The DON admitted that skin checks were not done immediately and were only performed during the regularly scheduled weekly checks. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property requires immediate reporting and thorough investigation of all incidents and allegations. However, the facility failed to adhere to this policy, resulting in incomplete investigations and inadequate documentation. The Administrator and DON both acknowledged the deficiencies in their investigation processes and the need for additional training.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving four residents. Resident #50, who had severe cognitive impairments and behavioral disturbances, was reported to have hit Resident #129 multiple times. Despite witness statements and progress notes documenting the incidents, the facility's investigation was inconsistent and incomplete. The Director of Nursing (DON) and Administrator acknowledged discrepancies in the investigation and admitted to needing more training on conducting self-reported incident (SRI) investigations. Another incident involved Resident #65 hitting Resident #128's hand twice when she tried to take his drink. The facility's investigation was again found lacking, with incomplete documentation and failure to conduct timely skin checks on the involved residents. The DON and Administrator confirmed that proper procedures were not followed, including immediate skin assessments and thorough documentation of the incident. Interviews with staff revealed further inconsistencies and gaps in the investigation process. The DON admitted to providing incorrect information and failing to document witness statements properly. The Administrator acknowledged the deficiencies in the investigations and expressed a need for additional training. The facility's policy on abuse, neglect, and exploitation requires thorough investigation of all allegations, which was not adhered to in these cases.
Failure to Provide Drinking Water to Residents
Penalty
Summary
The facility failed to ensure that four residents had drinking water available in their rooms. Resident #132, who had multiple diagnoses including chronic kidney disease and dementia, was observed without fresh water or a cup in her room during medication administration. This was verified by an LPN. Resident #132 had recently been to the emergency room for acute abdominal pain and was diagnosed with a urinary tract infection, for which she was prescribed Levaquin. Similarly, Resident #26, who had severe cognitive impairment and multiple health issues including congestive heart failure and diabetes, was also found without fresh water in his room during medication administration. This was confirmed by a Registered Nurse, and the resident himself mentioned that fresh water was not always provided consistently. Resident #62, who had severe cognitive impairment and multiple diagnoses including dementia and diabetes, was also observed without fresh water or a cup in his room during medication administration. This was verified by the same LPN. Lastly, Resident #17, who had moderately impaired cognition and multiple diagnoses including diabetes and osteoarthritis, was found without fresh water or a cup in his room during medication administration. This was again confirmed by the LPN. These observations indicate a systemic issue in the facility's provision of fresh water to residents, affecting their hydration and overall health.
Failure to Include Mechanical Lift in Care Plan
Penalty
Summary
The facility did not ensure the care plan for a resident included the use of a mechanical lift for transfers, despite recommendations from therapy. The resident, who had multiple diagnoses including mechanical loosening of an internal right knee prosthetic joint and muscle weakness, was admitted with orders for weight bearing as tolerated and required assistance with activities of daily living (ADLs). The physical therapist recommended the use of a mechanical lift due to the resident's self-limiting behavior and fearfulness during transfers. However, this recommendation was not included in the care plan or physician orders, leading to inconsistent documentation and practice regarding the use of the mechanical lift. Interviews with staff confirmed that the resident was being transferred using a mechanical lift on several occasions, even though it was not documented in the care plan. The Director of Nursing and MDS Nurse verified the use of the mechanical lift but acknowledged that it should have been written as an order and added to the care plan. This oversight affected the resident's care and highlighted a gap in the facility's documentation and care planning processes.
Failure to Provide Adequate Supervision During Resident Care
Penalty
Summary
The facility failed to provide the appropriate level of staff assistance and supervision during resident care for Resident #127, resulting in the resident hitting his head on the wall. Resident #127, who had multiple diagnoses including multiple sclerosis, cerebral infarction, and vascular dementia, required extensive assistance of two staff members for bed mobility. However, the care plan did not specify the number of staff needed for bed mobility assistance. During an incident, a nursing assistant was providing care alone and accidentally hit the resident's head on the wall while turning him, causing the resident to experience pain in his forehead area. The incident was reported by the resident, who stated that an older aide had hit his head on the wall while providing care. The nursing assistant confirmed that she was providing care alone and that the resident's bed was up against the wall, which led to the accidental injury. The resident continued to complain of pain in the forehead area, although no swelling or discoloration was noted. The facility's investigation included witness statements and confirmed the details of the incident, highlighting the failure to provide the required level of assistance and supervision during resident care.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory care equipment was stored in a protective barrier when not in use for two residents. Resident #44, who has multiple diagnoses including chronic obstructive pulmonary disease (COPD) and dementia, was observed with her aerosol mask lying directly inside the top drawer of her bedside table without a protective barrier. This was confirmed by an LPN and later verified by the Director of Nursing (DON). Resident #44 had an order for ipratropium-albuterol solution inhalation every four hours while awake for COPD. Similarly, Resident #39, who has diagnoses including COPD, end-stage renal disease, and congestive heart failure, was observed with her oxygen nasal cannula and tubing lying across the top of the oxygen concentrator without a protective barrier. This was also confirmed by the same LPN and verified by the DON. Resident #39 had an order for oxygen at two liters as needed per nasal cannula to maintain saturation above 90 percent. The facility identified 17 residents requiring oxygen and eight residents requiring aerosol treatments, but failed to ensure proper storage of respiratory equipment for these two residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 495 citations issued within 25 miles in the last 12 months — including the 4 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 Alliance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mccrea Manor Nsng And Rehab Ctr Llc | 1 mi | ★★★★★ | 15 | 0 |
| Altercare Of Alliance Ctr For Rehab & Nc Inc | 2.9 mi | ★★★★★ | 0 | 0 |
| Roselawn Gardens Nursing & Rehabilitation | 3.1 mi | ★★★★★ | 0 | 0 |
| Green Meadows Skilled Nursing And Rehab | 3.5 mi | ★★★★★ | 0 | 0 |
| Bel Air Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Canterbury Villa Of Alliance.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.