Canterbury Retirement Inn

Facility failed to provide weekly generator inspection reports.

Multiple fire doors (404, 405, 302, 312, 218, 178, 120, 153, 150, 606) found to have items on them.

Facility failed to provide annual resistance rated construction inspection; hole in dry kitchen storage ceiling; hole in maintenance director office door and fails to self-close.

Uncorrected deficiencies from 6/5/2025 and 9/3/2025 sprinkler reports; ice buildup on freezer sprinkler head; dust on laundry sprinkler heads; mixed quick/standard response heads in room 106; missing documentation for 3-year dry system test, annual forward flow, and 2025 Q1 report.

Exit door at back of employee entrance is screwed shut; cross corridor door by room 197 fails to open all the way.

Open electrical in 3rd floor storage room with light hanging from wires; electrical cover missing in laundry room.

Facility failed to provide fire drill records for: Q1 swing and night shift, Q2 swing shift, Q4 night shift.

Combustible material storage found in mechanical room outside by compactor.

Bed mattresses stored in electrical room and excessive storage found.

Facility failed to document specific resident-identified care and service needs (transfer poles, diet types, home health services) in the NSA for 4 of 12 residents.

Failed to provide documentation of regular examinations, immunizations, and disease-free certification for 1 of 4 pets living in the facility.

Facility failed to ensure a written family medication assistance plan was submitted for 1 of 4 residents receiving family medication help.

Failed to ensure 14 of 14 fire extinguishers received required monthly inspections throughout the year.

Facility failed to complete safety assessments for smoking, medical devices, and self-administration of medications for 4 of 6 sampled residents.

Failed to ensure Medicaid policy was on a separate page and signed on or before admission for 3 of 9 sampled residents (R3, R4, R8).

Failed to maintain an accurate resident characteristic roster for 5 residents (R2, R4, R7, R8, R9), specifically regarding medical devices, nurse delegation, smoking status, diet/hearing, and dementia diagnosis.

Facility failed to develop and implement systems to promote safe medication service; 2 of 9 residents had medication administration errors.

Facility failed to complete Negotiated Service Agreements (NSA) upon admission or within 30 days for 6 of 12 sampled residents.

Failed to ensure 2 of 5 sampled staff (G and H) completed the required 12 hours of annual continuing education.

Failed to have documentation of the signing date for the Negotiated Service Agreement (NSA) for 2 of 9 sampled residents.

Fire damper fusible link painted in storage room by 508/608.

Suitable noncombustible ash trays or match receivers missing in smoking area.

Kitchen appliance not restrained from movement.

Electrical covers missing in boiler room, laundry room, maintenance office, and room 313; culinary manager has broken electrical flex conduit.

Missing annual fire door inspection report; attic access door not self-closing; gaps in cross corridor door (601) and door 605.

Fire drill records missing for 2023 and 2024.

Oxygen tank in room 124 not secured.

Extension cord used as permanent wiring in laundry room.

Cigarette found in garbage can; no ashtray present.

Missing annual and 3-year sprinkler trip tests; facility in process of replacing dry pendant heads.

Carbon monoxide detector in room 148 is in trouble state.

Multiple doors (105, 103, 106, 104, 118, 101, 124) found wedged open.

Electrical panel blocked by items near room 122.

Missing annual emergency light testing report; exit sign by dining room failed to illuminate.

Holes in walls in boiler room, stairwell by room 608, and trash area by room 508.

Facility failed to maintain fire resistance rated construction in boiler room around fire sprinkler piping.

Facility failed to provide 5 year hydro testing of FDC.

Facility failed to provide the third quarter swing shift and night shift fire drills.

Facility failed to provide heat survey results and proper fusible link selection for kitchen hood suppression system.

Facility failed to provide quarterly fire sprinkler inspection reports, annual forward flow testing, and was missing a sprinkler trim ring in room 151.

Facility failed to maintain/provide fire rated door/hatch in mechanical room by 608 and 142.

Facility failed to provide sensitivity testing of the fire alarm smoke detectors.