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 Canton Oaks during CMS and state inspections, most recent first.
Two residents suffered serious injuries due to improper transfers by CNAs who failed to follow care plans. One resident, requiring a two-person assist, was transferred alone and fell, breaking both hips. Another resident, needing a Hoyer lift, was transferred using a stand and pivot method, resulting in a hip fracture. The CNAs involved were either unaware of or ignored the care plans, leading to these incidents.
A resident with a history of HIV, gastrostomy malfunction, and quadriplegia experienced severe complications after their tube feeding was not stopped as ordered, leading to aspiration pneumonia and acute respiratory failure. The responsible nurse forgot to turn off the feeding due to being busy with other tasks and did not seek help from available staff. The oversight was discovered when the resident began vomiting, resulting in emergency hospitalization.
A resident with multiple diagnoses, including quadriplegia and dysphagia, was dependent on tube feeding for nutrition. LVN A documented that the tube feeding was discontinued at a specific time, but later admitted she forgot to perform the task due to being busy. The resident was found vomiting and sent to the hospital. The ADON and DON confirmed the documentation error, which violated the facility's policy requiring accurate record-keeping.
The facility failed to conduct accurate PASRR screenings for two residents with mental health disorders. One resident with major depression and bipolar disorder and another with anxiety and psychotic disorders were not properly screened, despite receiving relevant medications. The oversight led to a deficiency in providing necessary assessments and services.
Improper Transfers Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for two residents, leading to serious injuries. One resident, who was identified as requiring a two-person assist for bed mobility, was improperly transferred by a CNA who attempted to change the resident alone. During the process, the resident fell from the bed and sustained fractures in both hips. The CNA was aware of the resident's care plan but chose to ignore it, resulting in the resident's fall and subsequent injuries. Another resident, who was identified as needing a Hoyer lift for transfers, was improperly transferred using a stand and pivot method by a different CNA. This resident, who could not bear weight, later showed signs of a hip fracture. The CNA responsible for the transfer was not aware of the resident's care plan and relied on incorrect information from another CNA, leading to the improper transfer and potential cause of the injury. Both incidents highlight a failure in the facility's adherence to care plans and proper transfer techniques, resulting in significant harm to the residents. The lack of compliance with established care protocols and inadequate supervision contributed to the residents' injuries, underscoring the need for strict adherence to care plans and proper training for staff.
Failure to Stop Tube Feeding Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received appropriate care and services, leading to severe complications. The resident, who had a history of HIV, gastrostomy malfunction, dysphagia, quadriplegia, and malnutrition, was supposed to have their tube feeding stopped at 7:00 a.m. as per physician orders. However, the feeding continued for an additional 6.5 hours, resulting in an excess volume delivery of 1072 ml. This oversight led to the resident experiencing vomiting, cyanosis, and a dangerously low oxygen saturation level of 52%, necessitating emergency transfer to the hospital where they were diagnosed with aspiration pneumonia and acute respiratory failure. The incident occurred because the nurse responsible for the resident's care, LVN A, forgot to turn off the tube feeding due to being busy with other tasks such as administering insulin and performing blood sugar checks. Despite the facility being adequately staffed, LVN A did not seek assistance from other available nurses. The oversight was discovered when a CNA noticed the resident vomiting and reported it to LVN A, who then realized the tube feeding had not been stopped. The resident's condition deteriorated rapidly, requiring immediate medical intervention. Interviews with staff revealed that the facility had policies in place for managing tube feedings, but these were not followed in this instance. The ADON confirmed that LVN A had prematurely signed off on the task of stopping the tube feeding, which contributed to the oversight. The facility's failure to adhere to physician orders and properly monitor the resident's condition led to a serious health crisis, highlighting the critical importance of following established protocols for enteral feeding management.
Removal Plan
- The Director of Nursing/Designee will validate that physician orders for tube feeding are being followed as written.
- LVN A was suspended pending investigation and terminated post investigation.
- The Director of Nursing/Designee will re-educate Licensed Nurses on following physician orders including start and stop times of tube feedings.
- The Director of Nursing/Designee will reeducate Licensed Nurses on assessing residents for complications related to tube feedings which includes monitoring for nausea, vomiting, diarrhea and constipation, gastric distention and bowel sounds, monitoring for aspiration which may include adventitious breath sounds.
- Licensed Nurses and Certified Nursing Assistants will be reeducated by the Director of Nursing/Designee on tube feeding management and prevention of tube feeding complications which includes: Licensed Nurses may hold/pause feeding while ADL care is performed that requires the head of bed to be lowered, Certified Nursing Assistants will notify the licensed Nurse prior to performing ADL care that requires the head of the bed to be lowered to allow for the Licensed Nurse to pause/hold the feeding and resume the feeding once ADL care completed, Certified Nursing Assistants will not adjust the tube feeding, only licensed nurses.
- Nursing Staff not receiving this education will receive prior to their next scheduled shift.
- The Director of Nursing/Designee will randomly interview a minimum of 3 nursing staff members to validate understanding and compliance with tube feeding management and prevention of tube feeding complications.
- Medical Director was notified of the incident and plan for improvement.
- An Ad Hoc QAPI will be held to discuss the contents of this plan.
- The daily monitoring tool for physician orders adherence as written for peg tubes will be utilized. The DON will validate that physician orders for tube feeding are being followed as written.
- The DON will randomly interview nurses and aides to ensure understanding and compliance with tube feeding management and potential complications of tube feeding.
- No staff will be allowed to work until they have received all in-services.
Failure to Accurately Document Tube Feeding Discontinuation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records in accordance with professional standards for a resident receiving tube feeding. The resident, who was readmitted with diagnoses including HIV, gastrostomy malfunction, dysphagia, quadriplegia, and unspecified protein-calorie malnutrition, was dependent on staff for various activities and received a significant portion of nutrition and fluids through tube feeding. The care plan required specific interventions for tube feeding, including elevating the head of the bed and monitoring for intolerance. However, LVN A documented that the resident's tube feeding was discontinued at 7:00 a.m., although she had not actually completed this task. LVN A admitted during an interview that she forgot to turn off the tube feeding due to being busy with other tasks and only turned it off around 12:30 p.m. The resident was later found vomiting and was sent to the hospital. The ADON and DON confirmed that LVN A should not have documented the task as completed if it was not done, as the documentation system was designed to remind nurses of pending tasks. The facility's policy required accurate documentation of medication and treatment administration, which was not adhered to in this case.
Failure to Conduct Accurate PASRR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that two residents with mental health disorders received appropriate Preadmission Screening and Resident Review (PASRR) screenings. Resident #6, a female with a history of cerebrovascular accident, diabetes mellitus, MELAS syndrome, major depression, and bipolar disorder, was admitted to the facility without an accurate PASRR Level 1 Screening. Despite being prescribed antidepressant and antipsychotic medications, her screening indicated no evidence of mental illness, and no further actions were taken to refer her for additional evaluation. Similarly, Resident #48, a female with generalized anxiety disorder, visual hallucinations, and psychotic disorder, was admitted and readmitted to the facility without a proper PASRR Level 1 Screening. Her medical records showed she was receiving medications for anxiety and psychotic disorders, yet her screening also failed to identify her mental illness. The facility did not take necessary steps to correct the screening or refer her for further evaluation. Interviews with facility staff revealed a lack of awareness and oversight regarding the PASRR process. The MDS/LVN responsible for PASRR tasks was unaware that corrections to the original screenings had not been completed. The Director of Nursing expected these tasks to be performed correctly and timely, but the failure to notify the local authority of residents with mental illnesses resulted in a deficiency in providing necessary assessments and services.
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What surveyors actually found near you
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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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Van Healthcare | 12.8 mi | ★★★★★ | 9 | 0 |
| Avir At Grand Saline | 13.2 mi | ★★★★★ | 16 | 1 |
| Azalea Trail Nursing And Rehabilitation Center | 13.3 mi | ★★★★★ | 1 | 0 |
| Avir At Bradburn | 13.5 mi | ★★★★★ | 7 | 2 |
| Crestwood Health And Rehabilitation Center | 13.6 mi | ★★★★★ | 5 | 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.