Canterbury Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure privacy of personal health information for 3 of 25 residents reviewed (Resident 7, Resident 56, and Resident 78). Findings include:In an observation, on 9/26/2025 at 8:43 AM, the 100 hall nurses cart was unattended in the hallway with residents in the area. A worksheet containing vital signs and other resident information for Resident 56 and Resident 78 was lying face up on top of the cart. A stickered medication card with Resident 7's name on a medication label was lying on top of the cart in full view. The label indicated the medication ordered was Vitamin D 50 mcg tablets, take 2 tablets once daily.During an interview, on 09/26/2025 at 8:48 AM, Registered Nurse 2 indicated he was instructed to go to the dining room immediately and had left his cart unattended because he was in a hurry.In an interview on 09/26/2025 at 8:48 AM, the Director of Nursing indicated worksheets with resident information should not be left on top of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure timely resident assessment and care for 1 of 23 residents reviewed (Resident 117).Findings include:Resident 117's record was reviewed on 09/25/2025 10:58 AM. Diagnoses included Type 2 diabetes mellitus, depression, hypertension, chronic pain syndrome, and polysubstance disorder.Resident 117's current admission Minimum Data Set assessment dated [DATE] had not been completed at the time of facility exit. Nurse Practitioner 11's progress notes, dated 9/22/25 2:15 PM, indicated Resident 117 had been admitted to the hospital from [DATE] to 9/21/25 for a 2-week history of watery stools, increased weakness, confusion, nausea, syncope, and poor oral intake. The progress note indicated Resident 117 was alert and a poor historian with inconsistent responses.Resident 117's census records indicated he was readmitted to the facility on [DATE] 12:37 PM.Observations including the admission assessment, Braden scale skin risk assessment, fall risk assessment and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure pain management was provided and documented for 1 of 3 residents reviewed. (Resident 2)Findings include:A record review for Resident 2 began on 9/23/2025 at 2:13 PM. Diagnoses included chronic pain syndrome, displaced intertrochanteric fracture of right femur, sleep apnea, delirium due to known physiological condition, and recurrent major depressive disorder.A review of Resident 2's current quarterly MDS, 8/7/25, indicated their BIMS (Basic Interview for Mental Status) score was 8 (cognitively impaired).A review of Resident 2's current Care plan, titled Resident will be free from adverse effects of Pain, indicated the resident had a problem of pain, with a goal date of 12/03/2025. Interventions included observation of adverse side effects of pain medication including, but not limited to over sedation, constipation, skin rash, nausea/vomiting, loss of appetite, change in mental status, stomach upset. Document abnormal findings and notify MD. Notify MD if pain is unrelieved and/or worsening. Administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an indwelling urinary catheter was medically necessary and monitored for symptoms of UTI for 1 of 3 residents reviewed (Resident J). Findings include: On 1/22/24 at 11:35 A.M., Resident J's family member was interviewed. They indicated when the resident admitted to the facility, an indwelling urinary catheter was placed. Following placement of the catheter, the resident had repeated episodes of blood in his urine. After several weeks of these episodes, the resident was sent to the hospital where he was diagnosed with pyelonephritis (kidney infection), urinary tract infection (UTI) and sepsis. The family member indicated they hadn't understood continued use of an indwelling catheter, why it had taken so long to address the blood in the urine, or provide treatment for the UTI. On 1/22/24 at 11:14 A.M., Resident J's record was reviewed. Diagnoses included fracture of right femur and right wrist following a fall at home. He had been hospitalized for surgical repair of the fractures and admitted to the facility for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure meal trays were distributed in a manner that promoted dignity for 3 of 19 residents reviewed (Resident 52, Resident 66, and Resident 77). Findings include: 1) During an observation on 12/13/23 at 11:46 AM meal service was observed in the women's dementia care unit. Certified Nurse Aide (CNA 2) served trays to individuals throughout the room without serving all residents at a table before proceeding to the next table. Resident 77's tablemate was the first resident served in the dining room. At 11:58 AM, another resident arrived at the table where Resident 77 was sitting, and her meal tray was delivered right after she was seated. Resident 77 was observed staring at her tablemates' food and fidgeting in her chair. Residents at other tables were continuing to receive their trays as Resident 77 still had not been served. Resident 77's tray was delivered at 12:09 PM and the resident was observed handling her silverware properly and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure education was provided for a resident pertaining to safe sexual practices for 1 of 3 residents reviewed (Resident 12). Findings include: Resident 12's record was reviewed on 12/14/23 at 11:06 AM. Diagnoses included cerebral infarction, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and unspecified viral hepatitis C without hepatic coma. A review of Resident 12's current annual, Minimum Data Set (MDS) indicated his Basic Interview for Mental Status (BIMS) score was 12 (moderately impaired cognition). The MDS indicated Resident 12 was independent with transfers and ambulation. A review of progress notes dated 11/6/23 at 12:09 PM indicated the facility had requested a physician's evaluation to determine if Resident 12 was able to consent to sexual activity. The progress note indicated Medical Doctor (MD) 5 had evaluated Resident 12 and determined he was appropriate to pursue a sexual relationship.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure recognition and identification of triggers for potential re-traumatization of a resident with a history of trauma for 1 of 7 residents reviewed. (Resident 36) Findings include: In an interview on 12/14/23 at 9:52 AM Resident 36 was observed avoiding eye contact and looking at the floor when spoken to. Resident 36's record was reviewed on 12/15/23 at 11:09 AM. Diagnoses included anxiety, major depressive disorder, panic disorder, dementia, visual hallucinations, unspecified psychosis and a history of alcohol dependence. Resident 36's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 12 (mild cognitive impairment). A Social Service assessment dated [DATE] indicated Resident 36 had a history of trauma and had triggers that made them feel unsafe or stressed. The Social Service Assessment indicated the resident had a history of substance abuse. A Social Service assessment dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident behaviors were monitored for 1 of 7 residents reviewed. (Resident 82) Findings include: In an interview on 12/13/23 at 11:05 AM Resident 82 responded to conversation with an inappropriate comment. Resident 82's record was reviewed on 12/13/23 at 11:45 AM. Diagnoses included stroke, malnutrition and cognitive communication deficit. Resident 82's current quarterly Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) was 10 (moderate cognitive impairment). Resident 82's care plan for psychosocial wellbeing dated 10/20/23 indicated the resident had been masturbating in the privacy of his own room with curtains pulled and lights out. The target goal was for Resident 82 to remain private with their personal sexual stimulation through 1/23/24. An intervention dated 10/20/23 was to educate Resident 82 on the need to remain protected with the curtains pulled and/or door closed during their self-stimulation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure social services needs were identified and appropriate social services provided for 2 of 7 residents reviewed. (Residents 36 and 82) Findings include: 1. In an interview on 12/14/23 at 9:52 AM Resident 36 was observed avoiding eye contact and looking at the floor when spoken to. Resident 36's record was reviewed on 12/15/23 at 11:09 AM. Diagnoses included anxiety, major depressive disorder, panic disorder, dementia, visual hallucinations, unspecified psychosis and a history of alcohol dependence. Resident 36's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 12 (mild cognitive impairment). A Social Service assessment dated [DATE] indicated Resident 36 had depression, anxiety, panic disorder and hallucinations. The Social Service Assessment indicated Resident 36 had a history of trauma and had triggers that made them feel unsafe or stressed. The Social Service Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to properly secure resident's medication for 3 of 5 residents reviewed. (Resident B, Resident C, and Resident D). Findings include: 1) During an observation and interview, on 9/26/23 at 9:22AM, Resident B indicated the nursing staff frequently leave her medications within reach for her to take on her own. Resident B indicated they brought her medications and left the room multiple times every week without ensuring she took them. Resident B indicated she was not assessed for knowing her medications or when she took them. On her over bed table, a partial bottle of Coricidin HBP liquid (without a pharmacy label), an open box with some tablets removed of Coricidin maximum strength (without pharmacy label), and a bottle of multi vitamins without a pharmacy label were observed. Across the room on a shelf was a partially used bottle of bio freeze in a pharmacy bag with a label. Resident B was able to explain what the medications were for and indicated her son brought the medications in to her. Resident B acknowledged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.