Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Pavilion At Canal Fulton For Nursing And Rehab during CMS and state inspections, most recent first.
The QAPI committee failed to meet at least quarterly, as only one sign-in sheet was available for review and the Administrator confirmed no additional documentation of meetings. This had the potential to affect all 44 residents in the facility.
Staff failed to follow infection prevention protocols during wound care and medication administration. The DON did not perform hand hygiene before providing wound care to a resident with pressure ulcers, and an LPN administered medications to two residents consecutively without hand hygiene, contrary to facility policy and CMS guidance.
Surveyors found that several residents receiving hospice care were not accurately identified as such in their MDS assessments, and a resident with a long history of smoking was incorrectly documented as a non-smoker. These inaccuracies were confirmed by the MDS nurse, who was unaware of the correct information at the time of assessment.
Two residents with severe cognitive impairment and extensive self-care needs were found without accessible call lights, despite care plans and facility policy requiring call systems to be within reach. One resident was observed calling for help with the call light ten feet away, while another was in a wheelchair with the call light five feet from his position. Staff confirmed the call lights were not accessible to the residents.
A resident's DNRCC-A form was signed by an ADON and an LPN instead of a physician, APRN, or PA, as required. The nurses signed the form with verbal consent from the physician, but the necessary provider signature was missing. The resident had multiple diagnoses, including dementia and prostate cancer.
A resident was not given the required Quality Improvement Organization (QIO) contact information on their Notice of Medicare Non-Coverage, preventing access to the appeal process for ending skilled services. Staff interviews confirmed the omission of the QIO name and phone number on the notice.
Three residents with multiple chronic conditions began hospice care but did not have the required Significant Change MDS assessments completed within 14 days of hospice admission, as confirmed by the MDS nurse.
A resident with chronic heart failure, COPD, and nicotine dependence was not provided with a care plan addressing smoking, despite documented assessments and a long-term smoking history. Staff interviews confirmed the omission, and facility policy required such care planning for smoking-related issues.
A resident with cognitive impairment and multiple diagnoses continued to receive a higher dose of fluticasone nasal spray despite a pharmacy recommendation, approved by the physician, to reduce the dose or make it as needed. The recommended change was not implemented, and the original order remained active.
A resident's Percocet medication was misappropriated by an LPN who failed to document the removal of narcotic blister packs properly. The LPN destroyed the sign-out sheet, preventing verification of the medication count. An RN co-signed without observing the required procedures, leading to the misappropriation going initially undetected. The LPN later admitted to stealing the medication.
QAPI Committee Failed to Meet Quarterly
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee did not meet at least quarterly as required. Facility documentation review showed only one QAPI committee sign-in sheet for May 2025, with no evidence of additional meetings. During an interview, the Administrator confirmed that the May 2025 sign-in sheet was the only documentation available to support QAPI meetings. No further information was provided to indicate that other meetings had occurred. This deficiency had the potential to affect all 44 residents residing in the facility.
Failure to Follow Infection Control Practices During Wound Care and Medication Administration
Penalty
Summary
The facility failed to implement effective infection prevention and control practices for three residents, as evidenced by direct observations and staff interviews. For one resident with multiple diagnoses including multiple sclerosis and Alzheimer's disease, who was severely cognitively impaired and had pressure ulcers, the Director of Nursing (DON) did not perform hand hygiene before donning gloves and providing wound care. The resident had physician orders for wound treatment but no order for enhanced barrier precautions (EBP), despite facility policy and CMS guidance indicating EBP should be used for residents with wounds. The DON confirmed the lack of hand hygiene and acknowledged the need for EBP for this resident. Additionally, during medication administration, an LPN was observed preparing and administering medications to two residents consecutively without performing hand hygiene between residents. Both residents were at risk for infection according to their care plans. The LPN confirmed she did not wash her hands or use hand sanitizer between medication passes. Facility policy required hand hygiene immediately before touching a resident, but this was not followed during the observed medication administration.
Inaccurate MDS Assessments for Hospice Services and Tobacco Use
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, specifically regarding the documentation of hospice services and tobacco use. Medical record reviews for six residents who were receiving hospice care showed that their Minimum Data Set (MDS) assessments did not indicate the provision of hospice services, despite clear documentation in their medical records that hospice care had been initiated. This was confirmed in an interview with the MDS nurse, who acknowledged that the MDS assessments for these residents did not reflect their hospice status. Additionally, a review of another resident's records revealed a discrepancy regarding tobacco use. The resident's medical record and smoking assessment indicated a long history of smoking and current use requiring supervision, but the admission MDS assessment incorrectly documented that the resident did not use tobacco. The MDS nurse confirmed she was unaware of the resident's smoking status at the time of completing the assessment and verified the error in the MDS documentation.
Failure to Ensure Call Lights Within Resident Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with severe cognitive impairment and significant self-care deficits. For one resident with multiple sclerosis, atrial fibrillation, and Alzheimer's disease, observation revealed she was lying in bed calling for help, with her call light button hanging on the wall by the curtain approximately ten feet away. A CNA confirmed that the call button was not within her reach. The resident's care plan required staff to encourage her to use the call light when assistance was needed, and facility policy stated that each resident should have a means to call staff directly from their bed. Another resident with chronic obstructive pulmonary disease, Parkinson's disease, and vascular dementia was observed sitting in a wheelchair in his room, approximately five feet from his bed where the call light was positioned. The DON confirmed that the call light button was out of the resident's reach. Both residents' care plans included interventions to encourage use of the call light for assistance, and the facility's policy required accessible call systems for residents. These observations and interviews demonstrated that the facility did not follow its own policy or the residents' care plans regarding call light accessibility.
Advance Directive Lacked Required Provider Signature
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically a Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) form, contained the required signature of a physician, APRN, or PA. Instead, the form was signed by the Assistant Director of Nursing and a Licensed Practical Nurse, with a note referencing the supervising physician's information but lacking the actual provider's signature. The deficiency was identified during a review of the resident's medical record, which showed an active DNRCC-A order, and was confirmed in an interview with the Administrator, who acknowledged that the nurses signed the form based on the physician's verbal consent rather than obtaining the required provider signature. The resident involved had diagnoses including urinary tract infection, dementia, and prostate cancer.
Failure to Provide QIO Information on Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide required information regarding the Quality Improvement Organization (QIO) on the Notice of Medicare Non-Coverage letter given to a resident whose skilled services and therapies were ending. Review of the resident's medical record showed that the notice, signed by the resident or their representative, did not include the QIO's name or phone number, which is necessary for the resident to request a timely appeal of the termination of services. This omission was confirmed during interviews with both the Social Service Coordinator and the Director of Nursing, who acknowledged that the notice lacked the required appeal information.
Failure to Complete Timely Significant Change MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete Significant Change in Minimum Data Set (MDS) status assessments within 14 days following the initiation of hospice services for three residents. Specifically, medical record reviews showed that each of the three residents, who had complex medical histories including conditions such as COPD, Alzheimer's disease, chronic respiratory failure, major depressive disorder, dementia, diabetes, and neurocognitive disorder, began hospice care but did not have the required Significant Change assessments completed within the mandated timeframe. This deficiency was confirmed during an interview with the MDS nurse, who acknowledged that the assessments were not performed as required for these residents.
Failure to Develop Smoking Care Plan for Resident with Smoking History
Penalty
Summary
The facility failed to develop a care plan addressing smoking for a resident with a history of chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and nicotine dependence. The resident was admitted on 03/13/25 and had documented smoking assessments indicating both the need for supervision and, at another time, no need for supervision or adaptive equipment. Despite these assessments and the resident's long-term smoking history, the care plan did not include any interventions or considerations related to smoking. Interviews confirmed that the resident smoked at the facility and that the MDS nurse was unaware of the resident's smoking status when completing the assessment, resulting in the omission of a smoking care plan. Facility policy required that smoking privileges, restrictions, and concerns be documented in the care plan and communicated to all staff, which was not done in this case.
Failure to Implement Physician-Approved Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely manner for a resident with diagnoses including dementia, depression, Alzheimer's disease, and hallucinations. The resident had an active order for fluticasone nasal spray, and the pharmacy recommended either discontinuing the medication or reducing the dose to one spray as needed for rhinitis. Although the physician approved the recommendation to change the order, the physician's order was not implemented, and the original medication regimen remained active. This deficiency was confirmed through record review and interview, affecting one of five residents reviewed for unnecessary medications.
Misappropriation of Resident's Narcotic Medication by Staff
Penalty
Summary
The facility failed to protect a resident's belongings, specifically narcotic medication, from misappropriation by staff. The incident involved Resident #44, who had a prescription for Percocet to manage pain associated with Alzheimer's disease with dementia and lumbar radiculopathy. The issue came to light when the pharmacy reported that there should have been a two-week supply of Percocet remaining, but the medication was missing. The facility's investigation could not initially verify the misappropriation due to destroyed documentation. The investigation revealed that an LPN had removed and signed out two narcotic medication blister packs without properly documenting the removal on the controlled medication shift change log. The LPN destroyed the sign-out sheet, which made it impossible to verify the medication count. A co-signing RN did not observe the LPN discarding or returning the medications to the pharmacy, as required by facility policy. This lack of proper documentation and oversight allowed the misappropriation to occur undetected initially. Further investigation, including police involvement, confirmed that the LPN had an outstanding warrant for stealing narcotics and admitted to taking 48 tablets of Percocet from the resident. The facility's policy on medication disposal and returns was not followed, as it required two individuals to witness and document the destruction of medications, which did not happen in this case.
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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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Nursing homes near Canal Fulton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Lane Nursing And Rehabilitation | 1.5 mi | ★★★★★ | 15 | 0 |
| Chapel Hill Community | 2.5 mi | ★★★★★ | 0 | 0 |
| Altercare Of Nobles Pond, Inc | 3.3 mi | ★★★★★ | 7 | 0 |
| Laurels Of Massillon, The | 4.7 mi | ★★★★★ | 1 | 0 |
| Amherst Meadows Skilled Nursing And Rehab | 4.7 mi | ★★★★★ | 2 | 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.