Canterbury Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 2, 2026

  Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to prevent abuse for 1 of 8 residents (Resident #2), in the survey sample which resulted in the identification of Immediate Jeopardy.The findings included: Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to prevent abuse for 1 of 8 residents (Resident #2), in the survey sample which resulted in the identification of Immediate Jeopardy.The findings included: The facility staff failed to prevent Resident #1 from abusing Resident #2 by pushing him out of a chair and onto the floor as well as attempting to hit Resident #2 with a chair while Resident #3 stood in close proximity to the incident. 1. […]

• Immediate jeopardy, isolatedF600Apr 9, 2026

  Based on observation, staff interviews, clinical record review and facility document review, the facility staff failed to protect residents' right to be free from abuse by other residents for 4 of 18 residents in the survey sample, Residents #17, #16, #15, and #2, resulting in the identification of immediate jeopardy and substandard quality of care for Resident #2. The findings include:1.For Resident #17 (R17), the facility staff failed to protect the resident's right to be free from physical abuse by Resident #14 (R14) on 3/20/24.R17 was admitted to the facility 10/16/23 with diagnoses to include but not limited to Lewy body dementia with agitation, hereditary idiopathic neuropathy, frontotemporal neurocognitive disorder, type 2 diabetes mellitus, major depressive disorder, bipolar… […]

• Immediate jeopardy, isolatedF689Apr 9, 2026

  Based on observation, staff interviews, clinical record review and facility document review, the facility staff failed to provide adequate supervision in an accident and hazard free environment to protect residents' safety and failed to provide adequate supervision of a resident with known aggressive behaviors (Resident #14) which resulted in altercations with four other residents in a survey sample of 18 residents. Residents #17, #16, #15, and #2, resulting in the identification of immediate jeopardy, substandard quality of care and harm for Resident #2. The findings include:1.For Resident #17 (R17), the facility staff failed to provide adequate supervision from Resident #14 (R14) on 3/20/24 from entering her room and resulting in physical altercation between the two residents. […]

• Immediate jeopardy, isolatedF689Aug 6, 2024

  The facility staff failed to provide a safe environment by monitoring trach residents for two of eight residents, Residents #3 and #1. The findings include: During the abbreviated complaint survey [DATE], night shift staff were identified for interview for Resident #1. On [DATE] at 6:30 AM, surveyor arrived to interview night shift RTs (respiratory therapist) and RNs (registered nurse). During the first interview, surveyor was informed of Resident #3's death with similar conditions as to those in Resident #1's which necessitated a transfer to the hospital. 1. […]

• Actual harm, isolatedF686Apr 9, 2026

  Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the necessary care and services, consistent with professional standards of practice, to prevent a pressure injury for one of 18 residents in the survey sample, Resident #8. A tourniquet was left in place on Resident #8's left upper arm for an extended period causing an unstageable pressure injury, resulting in harm cited at past non-compliance. The findings include:Resident #8 (R8) was admitted to the facility with diagnoses that included but were not limited to quadriplegia (1), chronic respiratory failure (2) and pressure ulcer of sacral region. […]