Canterbury Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Canterbury Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF800Jul 23, 2021

  Based on interview and record review, the facility failed to ensure 4 of 4 residents reviewed (Resident B, Resident C, Resident D, and Resident E) were offered food choices at mealtimes. Findings include During an interview on 7/22/21 at 2:38 P.M., Resident C indicated the facility used to deliver a menu, but she had not seen one since about May of 2020. She indicated a lot of times she had to ask what the meal was and the aides didn't know, so she was not sure what she'd get until it arrived. She indicated the alternatives were hot dogs, hamburger or grilled cheese but would have to wait until the staff were done serving to get an alternate. During an interview on 7/23/21 at 9:37 A.M., Resident C indicated she was starving from last night's dinner. […]

• No harm, potential for more than minimal, isolatedF583Sep 29, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF684Sep 29, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF697Sep 29, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF690Jan 22, 2024

  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. […]