Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on interviews, record review and
employee file review the facility failed to ensure all wound dressing were completed as ordered. This
affected one of three residents (Resident #66) reviewed for wound care. The facility census was
66.Findings Include: Review of the closed medical record for Resident #66 revealed an admission date
10/11/25 and was admitted on hospice. Diagnosis included malignant neoplasm of prostate, chronic
obstructive pulmonary disease and history of stroke.Review of the plan of care dated 10/11/25 for impaired
skin integrity to left great toe and left lower shin revealed complete skin assessments per facility policy,
encourage out of bed activities, inspect skin during routine skin care, pressure reducing mattress and
complete treatments as ordered.Review of the admission Minimum Data Set (MDS) 11/20/25 revealed
intact cognition and a maximum to total assist for activity of daily living (ADLs).Review of the physician
order dated 11/24/25 revealed cleanse lower outer leg with normal saline, pat dry and apply calcium
alginate and non-bordered super absorbent dressing and secure. Treatment order for left great toe revealed
cleanse area to left great toe with normal saline apply calcium alginate and non-bordered super absorbent
dressing and secure with kerlix every night shift ordered on 11/24/25.Review of wound note dated 11/24/25
revealed upon admission Resident #66 had multiply abrasions (left great toe, measuring 2.0 centimeters
(cm) by (x) 2.0 cm x 0.2 cm and left lower lateral leg, venous ulcer measuring 1.8 x 7.5 x 0.1 cm) due to
multiple falls and was being followed by the wound nurse practitioner.Review of the Treatment
Administration Record (TAR) for November 2025 revealed the treatment to the left lower outer leg and left
great toe had been initialed by the assigned nurse as completed (signed off) on 11/28/25 and 11/30/25 by
Licensed Practical Nurse (LPN) #456 and on 11/29/25 by Register Nurse (RN) #468. Interview on 01/29/26
at 9:00 A.M. with the Director of Nursing (DON) confirmed Registered Nurse (RN) #468 documented care
that had not been provided to the resident, by placing her initials on the TAR for 11/29/25 and LPN #456 on
11/28/25 and 11/30/25. However, on 12/01/25 during wound rounds completed by the Wound Nurse
Practitioner #464 and Wound Nurse/LPN #453 it was confirmed the dressing to Resident #66's left great
toe and her left outer, lower leg had not been changed daily and was dated 11/27/25. This observation
verified the dressing had not been changed per orders by LPN # 456 and RN #468. The DON stated LPN
#453 verified all treatments/dressings, in the facility, had been completed per orders.Interview on 02/25/26
at 2:00 P.M. with LPN #417 stated she had taken care of Resident #66 the day the treatments not being
completed was identified. She stated you are to sign off treatments when you complete them as well as
write the date and your initials on the new dressing when you apply it. LPN #417 stated on 12/01/25 she
went to complete her dressing change for Resident #66 and noticed he still had the same dressing on that
she had applied, on 11/27/25, for Resident #66's leg and great toe.Interview on 02/25/26 at 3:57 P.M. with
LPN #453 verified she was the wound nurse. On 12/01/25 she was notified by LPN #417 that the dressings
for Resident #66 had not been changed since
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
366214
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366214
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Canterbury Villa of Alliance
1785 Freshley Avenue
Alliance, OH 44601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
11/27/25.Attempts to reach LPN #456 during the onsite survey were unsuccessful Review of the personnel
file for RN #468 revealed a hire date of 10/24/25 and termination date of 12/02/25 for poor performance
issues. On 12/02/25 a Discipline form was completed and revealed the nurse was signing off treatments for
Resident #66 that had not been completed. The DON completed the form. Review of LPN #456's personnel
file revealed date of hire 11/02/22. A Disciplinary Action form dated 12/01/25 was noted for failure to meet
reasonable standards/expectations of performance or unsatisfactory work. This was the first written
disciplinary action. Treatments are to be completed as ordered. She signed on the Treatment Administration
Record (TAR) on 11/28/25 and 11/30/25 that treatments had been completed. Dressing was changed on
12/01/25 and the old dressing was dated 11/27/25. This document was completed by the DON.The
deficient practice was corrected on 12/20/25 when the facility implemented the following corrective actions:
Review of the whole house audit for all residents with dressing changes revealed all wound dressing were
completed as ordered. The audit was completed on 12/01/ 25 by the DON.House wide wound audits were
completed two times weekly by LPN #453/wound nurse beginning on 12/02/25 for one month to ensure
nurses were completing dressing changes per orders. No concerns were identified.Review of the Nursing
Deptartment Meeting, presented in person by the DON on 12/16/25 revealed all nurses (11 LPN's and 5
RN's) were in attendance. The in-service provided the following education: Dressings were to be changed
timely and per physician orders. If a dressing was found to have not been changed per order, report it to the
DON or wound nurse immediately. Nurses were directed to date and sign their initials on the dressing. LPN
#456 was in attendance.Review of the in-person nurses meeting notes on 02/20/26 held by the DON
revealed dressing changes/ dating/initialing/reporting was addressed during the meeting. There were 11
LPN's and 5 RN's that attended the meeting and signed in on the sign in sheet. Results of audits and
ongoing concerns will be address through QAPI. This deficiency demonstrated non-compliance
investigated under Complaint Number 2692772.
Event ID:
Facility ID:
366214
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366214
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Canterbury Villa of Alliance
1785 Freshley Avenue
Alliance, OH 44601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE
FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, observation, staff
interview and policy review the facility failed to ensure residents were transferred properly while using a
mechanical lift This affected one resident (Resident #12) of one residents reviewed for mechanical lift
transfer. There were seven residents identified as needing a mechanical lift transfer.Findings include: A
review of the medical record for Resident #12 revealed an admission date of 07/26/24. Diagnosis for
Resident #12 included left side hemiplegia, atrial fibrillation, seizures, and peripheral vascular disease.
A review of the quarterly minimum data set assessment dated [DATE] for Resident #12 revealed that she
had no evidence of cognitive impairment and required moderate assistance to total dependence upon staff
for activities of daily living.
A review of the plan of care for Resident #12 revealed that she required a total mechanical lift (Hoyer lift) for
transfers.
Review of the General Investigation of the incident dated 12/04/25 at 7:15 A.M. revealed Resident #12 hit
her head during transfer with CNA #406 and CNA #466, when the lift tipped, revealed the following
investigation:
Review of the original copy of the neurological assessment flowsheet for Resident #12 dated 12/04/25
revealed neuro checks were completed, resident complained of a headache at first, then had no
complaints.
Review of the 72-hour Post incident monitoring dated 12/04/25 for Resident #12 revealed Resident #12 hit
her head on the lift.
Review of the incident assessment marked other dated 12/04/25 at 7:15 A.M. revealed the nurse was
notified by CNA #406 that Resident #12 bumped her head on the metal bar. Resident #12 stated I hit my
head Vital signs were taken. No bruising, redness or edema noted to forehead. Review of the statement
from LPN #418 dated 12/04/25 revealed she was in the hall preparing, another residents medications. She
heard CNAs yelling her name. She went into Resident #12's room. Resident #12 was in the lift sling above
wheelchair. The lift was tipped and she yelled for more help. Staff were able to get Resident #12 in her
wheelchair safely and the lift detached. The resident stated she hit her head during this. There was no
redness, bruising or edema noted. Lift education for staff and staff monitor head placement during
transfers.
Review of the incident statement dated 12/04/25 from CNA #406 stated they were getting the resident in
her wheelchair with the lift, CNA #466 and herself. We pushed her (Resident #12) back to get her in the
wheelchair and the lift tipped over. Resident #12 stated the lift hit her in the head. We yelled for help and
LPN #418 came with other staff to assist with getting the resident unhooked from the lift. LPN #418 then
stated they were telling aides not to put residents in their chairs sideways, but CNA #466 and herself, did
not remember that.
Review of the statement from CNA #466 dated 12/04/25 revealed two aides were using the lift to transfer
Resident #12 into her wheelchair from her bed at about 7:30 A.M. on 12/04/25. As they were over
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366214
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366214
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Canterbury Villa of Alliance
1785 Freshley Avenue
Alliance, OH 44601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
the chair the lift tipped and the other aide and I hollered for help and help came. We safely got the chair and
lift tipped back up and got the lift pad unhooked from the Hoyer.
Review of the provider note dated 12/08/25 revealed Resident #12 was seen due to bumping her head
without negative findings.
Residents Affected - Few
An interview on 01/21/26 at 10:58 A.M. with Resident #12 revealed that she was transferred by staff with
the Hoyer lift. There was one time that the Hoyer lift tipped and she hit her head.
An interview on 01/22/26 at 11:30 A.M. with the DON revealed that there was an incident where the
mechanical lift tipped but the resident did not fall. There were two staff members present during the transfer,
and additional staff were needed to get the lift back to a standing position. The lift was immediately taken
out of service. The DON verified the two CNAs had not followed protocol when they were using the
mechanical lift to transfer the Resident #12 to her wheelchair. Staff had been educated on not approaching
on the side of the wheelchair when transferring a resident with the lift. All transfers into a wheelchair were to
be completed from the front.
An interview on 01/27/26 at 1:56 P.M. with the Administrator revealed the lift that tipped had maintenance
work completed after 12/04/26. It was taken out of service immediately after tipping with Resident #12
being transferred by Certified Nurse Assist (CNA) #406 and CNA #466. After maintenance deemed the
facility lift was safe for use it was put back into service.
Interview on 02/25/26 at 12:47 P.M. with DON stated she did not do a fall investigation at the time of the
incident because she did not feel the transfer resulted in a fall but she initiated a general investigation. As a
result of the investigation, it was determined the CNAs did not follow facility procedure regarding the
appropriate techniques when using the mechanical lift.
Interview on 02/25/26 at 1:36 P.M. with Licensed Practical Nurse (LPN) #418 stated she heard yelling and
went into Resident #12's room and Resident #12 was right above the chair, in the mechanical lift and she
believed the legs of the lift were separated.
Interview on 02/25/26 at 2:03 P.M. with Certified Nurse Assistant (CNA) #406 stated her and another aide
were trying to get Resident #12 to her chair, using a mechanical lift. Due to the resident's size we had to go
into the wheelchair from the side, so we could put her back in her chair all the way, and we opened the legs
of the lift. When we pulled her back, the lift tipped and Resident #12 hit the back of the wheelchair, making
the back of the wheelchair lay back, hitting the dresser that was behind the wheelchair. The lift tipped
sideways when we pulled her back against the back of the wheelchair and Resident #12 landed in her
wheelchair. The CNA stated they had to lean the wheelchair back, back so they could finish putting the
resident in the chair. CNA #406 stated they had to stand on the lift (feet) to keep it from falling on Resident
#12 until more staff showed up to assist with getting Resident #12 unhooked from the lift.
Review of the facility procedure How to use a Hoyer lift, not dated revealed the boom of the lift does not
swivel. The resident ' s weight must be centered over the base legs at all times. Do not attempt to lift
resident with the mast/boom assembly swiveled to either side. Always keep Resident facing the attendant
operating the lift.
The deficient practice was corrected on 12/11/25 when the facility implemented the following corrective
actions:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366214
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366214
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Canterbury Villa of Alliance
1785 Freshley Avenue
Alliance, OH 44601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the in person, in-service record dated 12/04/25 revealed 36 staff members were present for
training on Hoyer lift for all nursing staff. CNA #406 and CNA #466 signed the training log. This was
provided by the DON.
Both CNAs had evidence of a mechanical lift competency, CNA #406 on 12/10/25 and CNA #466 on
12/11/25.
Review of the In person lift training/competency completed by DON/or Designee on 12/09/25 revealed all
CNAs had completed the training/competency and provided return demonstration on lift transfers.
Review of the lift audits completed by the DON/Designee from 12/07/25 through 02/15/26 revealed audits
were completed twice a week for four weeks and then once a week to be continued for four weeks and then
continue to monitor as needed.
Review of lift inspection logs dated 12/01/25 completed by Maintenance Director #410 revealed that
mechanical lift transfers were documented as inspected at least monthly during the past twelve months.
Any required maintenance or repairs completed at the time of inspection was also documented on the log.
On-going compliance will be monitored in Quality Assurance Performance Improvement.
This deficiency demonstrates noncompliance investigated under Complaint Number 2692772.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366214
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the February 26, 2026 survey of CANTERBURY VILLA OF ALLIANCE?
This was a inspection survey of CANTERBURY VILLA OF ALLIANCE on February 26, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CANTERBURY VILLA OF ALLIANCE on February 26, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.