Canterbury Rehabilitation And Healthcare Center

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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 (Resident R1). The findings include: The facility failed to develop a baseline care plan to include diabetes and monitoring of blood sugars for Resident R1. Resident R1 was admitted to the facility on [DATE REDACTED] 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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Canterbury Rehabilitation and Healthcare Center

1776 Cambridge Drive Richmond, VA 23238

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 - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

(administrative staff member) #2, the interim director of nursing and ASM #3 the regional director of operations was made aware of the findings.A review of the facility's Falls and Fall Risk, Managing policy revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.A review of the facility's Nursing Services Policy and Procedure Manual policy revealed, Services provided to our residents are performed in accordance with current acceptable standards of clinical practice. No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet