Canterbury Rehabilitation And Healthcare Center

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews facility document review and clinical record review, it was determined the facility staff failed to develop a baseline care plan for one of six residents in the survey sample, Resident #1 (R1).

The findings include:

The facility failed to develop a baseline care plan to include diabetes and monitoring of blood sugars for R1. R1 was admitted to the facility on [DATE] with diagnosis that included diabetes, acute/chronic respiratory failure and trach (tracheostomy).The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/18/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and set up for eating. A review of the baseline care plan dated 11/13/25 revealed, FOCUS: Resident is a new admission with discharge potential.

Stay projected to be short in duration. INTERVENTIONS: Discuss with rehab (rehabilitation) any special equipment needs and facilitate obtaining prior to discharge.

Encourage patient and family to be involved in planning of care and discharge planning.

Make referrals to other community agencies as deemed appropriate.

Social work and Care Navigator to visit with patient and/or family to discuss any concerns regarding potential discharge.A review of the physician order dates 11/17/25 revealed Blood sugar checks AC and HS before meals and at bedtime for blood sugar check.There is no evidence of the baseline care plan including any focus or interventions related to diabetes or blood sugar monitoring until 11/20/25.On 12/30/25 at 8:00 an interview was conducted with LPN (licensed practical nurse) #2.

Asked what the baseline care plan should include, LPN #2 stated, it should include the initial plan of care for the resident.

When asked if a resident with diabetes should have it on the baseline care plan, LPN #2 stated, yes, that should go on the baseline care plan.

The blood sugars will pop on the MAR (medication administration record), and you document it there.On 12/30/25 at 2:30 PM, ASM (administrative staff member) #2, the interim director of nursing and ASM #3 the regional director of operations was made aware of the findings. No further information was provided prior to exit.

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Canterbury Rehabilitation and Healthcare Center

1776 Cambridge Drive Richmond, VA 23238

SUMMARY STATEMENT OF DEFICIENCIES