Inspection Reports for Canterbury Nursing and Rehabilitation Center
IN, 46835
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 5, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed record with some deficiencies primarily related to Life Safety Code compliance, medication storage and administration, resident care monitoring, and environmental cleanliness. Several complaint investigations were substantiated, notably involving inadequate catheter care leading to infection and issues with dental services, but most complaints were unsubstantiated or found to have no related deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement in Life Safety Code compliance and complaint resolution compared to earlier findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a March 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454198.
Complaint Details
Complaint IN00454198 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 112
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 85
Census Payor Type - Other: 24
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
This visit was conducted for the investigation of three complaints: IN00449961, IN00451579, and IN00452220.
Complaint Details
Complaints IN00449961, IN00451579, and IN00452220 were investigated and no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 115
Total Capacity: 115
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 87
Census Payor Type Other: 23
Inspection Report
Re-Inspection
Census: 111
Capacity: 142
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 11/26/24 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Canterbury Nursing and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 142
Census: 111
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446237.
Complaint Details
Complaint IN00446237 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF beds: 113
Census total residents: 113
Census Medicare residents: 4
Census Medicaid residents: 88
Census other payor residents: 21
Inspection Report
Life Safety
Census: 103
Capacity: 142
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with Life Safety Code requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements due to the improper use of flexible cords and adapters as substitutes for fixed wiring in 4 of 9 smoke compartments. Specific issues included power strips powering high-amperage refrigerators and use of non-UL 1363A adapters in resident rooms and offices.
Deficiencies (1)
Facility failed to ensure flexible cords and adapters were not used in 4 of 9 smoke compartments as a substitute for fixed wiring, violating NFPA 70, 2011 Edition, Article 400.8.
Report Facts
Smoke compartments affected: 4
Total smoke compartments: 9
Facility capacity: 142
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meeta Anand | Executive Director | Named in relation to review of findings at exit conference |
| Maintenance Supervisor | Interviewed regarding findings about power strips and adapters |
Inspection Report
Annual Inspection
Census: 104
Capacity: 104
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
This visit was for an Annual Recertification and State Licensure Survey conducted over October 24, 25, 28, and 29, 2024.
Findings
Canterbury Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 80
Census Payor Type - Other: 21
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as an annual survey of Canterbury Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Date: Oct 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442721 and IN00444188.
Complaint Details
Complaint IN00442721 and Complaint IN00444188 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00442721 and IN00444188 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 103
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 86
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431801.
Complaint Details
Complaint IN00431801 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00431801 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 95
Total Capacity: 95
Payor Type Census: 1
Payor Type Census: 74
Payor Type Census: 20
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00428831 and IN00430926.
Complaint Details
Complaint IN00428831 and Complaint IN00430926 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaints IN00428831 and IN00430926 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 97
Total Capacity: 97
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 22
Inspection Report
Follow-Up
Census: 88
Capacity: 142
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/11/24 was performed by the Indiana Department of Health to verify compliance with regulatory requirements.
Findings
At this PSR survey, Canterbury Nursing and Rehabilitation Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered and had appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 142
Census: 88
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00424947 completed on January 22, 2024.
Complaint Details
Investigation of Complaint IN00424947; paper compliance review found facility in compliance.
Findings
Canterbury Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
This visit was for the investigation of Complaints IN00424947 and IN00426678. Complaint IN00424947 resulted in federal/state deficiencies related to the allegations, while Complaint IN00426678 had no deficiencies cited.
Complaint Details
Complaint IN00424947 was substantiated with federal/state deficiencies cited at F690. Complaint IN00426678 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure that an indwelling urinary catheter was medically necessary and monitored for symptoms of urinary tract infection (UTI) for 1 of 3 residents reviewed (Resident J). The resident experienced repeated episodes of blood in urine, was hospitalized with pyelonephritis, UTI, and sepsis, and there was no documentation of medical necessity or timely notification and follow-up by medical staff.
Deficiencies (1)
Failed to ensure an indwelling urinary catheter was medically necessary and monitored for symptoms of UTI for 1 of 3 residents reviewed (Resident J).
Report Facts
Census: 89
Total Capacity: 89
Residents with indwelling catheters reviewed: 3
Medicare residents: 3
Medicaid residents: 68
Other payor residents: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Solomon | AIT | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing | Interviewed regarding lack of documentation and follow-up on resident's catheter issues | |
| Nurse Consultant | Interviewed regarding lack of documentation and follow-up on resident's catheter issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00424947) regarding the care and monitoring of an indwelling urinary catheter for Resident J.
Complaint Details
This tag relates to Complaint IN00424947.
Findings
The facility failed to ensure the indwelling urinary catheter was medically necessary and properly monitored for symptoms of urinary tract infection for Resident J. Documentation was lacking regarding physician or nurse practitioner notification and follow-up on the resident's episodes of bloody urine and possible UTI symptoms.
Deficiencies (1)
Failure to ensure an indwelling urinary catheter was medically necessary and monitored for symptoms of urinary tract infection for 1 of 3 residents reviewed (Resident J).
Report Facts
Urine volume drained: 450
Urine volume emptied: 1000
Dates of nurse and NP notes: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed on 1/22/24 regarding lack of documentation for physician or NP notification and follow-up |
| Nurse Consultant | Nurse Consultant | Interviewed on 1/22/24 regarding lack of documentation for physician or NP notification and follow-up |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was conducted.
Findings
Canterbury Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Report Facts
Facility Number: 275
Provider Number: 155656
AIM Number: 100290930
Inspection Report
Annual Inspection
Census: 88
Capacity: 142
Deficiencies: 5
Date: Jan 11, 2024
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with several Life Safety Code requirements including corridor walking surfaces, egress door locking mechanisms, cooking equipment safety, electrical outlet safety, and trash receptacle capacity. Corrective actions were planned and requested for paper compliance.
Deficiencies (5)
Failed to ensure 1 of 8 corridor exits had an unobstructed level walking surface, creating a tripping hazard near the smoke doors on the 200 hall.
Failed to ensure means of egress through 1 of 2 exits on the 400-hall with special locking arrangements were readily accessible by staff at all times.
Failed to ensure 1 of 3 cook tops were disconnected from power whenever the kitchen (Bistro) is not under staff supervision.
Failed to ensure electrical outlets in the Bistro, 500-hall nurses' station, and breakroom contained cover plates and had no exposed electrical terminals.
Failed to ensure trash receptacles in 1 of 8 corridors were maintained in accordance with capacity and location requirements.
Report Facts
Facility capacity: 142
Census: 88
Residents affected by corridor exit deficiency: 25
Residents affected by egress door locking deficiency: 20
Residents affected by cooking equipment deficiency: 10
Residents affected by electrical outlet deficiency: 40
Trash receptacle capacity: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Solomon | AIT | Facility representative signing the report |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions for corridor walking surface, egress door locking, cooking equipment, electrical outlets, and trash receptacles |
Inspection Report
Annual Inspection
Census: 93
Capacity: 93
Deficiencies: 5
Date: Dec 19, 2023
Visit Reason
This visit was for an Annual Recertification and State Licensure Survey, which included the Investigation of Complaint IN00422529.
Complaint Details
Complaint IN00422529 was investigated with no Federal/State deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including failure to ensure meal trays were distributed in a manner that promoted dignity for residents, failure to provide education on safe sexual practices for a resident, failure to recognize and identify triggers for potential re-traumatization for a resident with a history of trauma, failure to monitor resident behaviors appropriately, and failure to ensure social services needs were identified and provided for residents.
Deficiencies (5)
Failed to ensure meal trays were distributed in a manner that promoted dignity for 3 of 19 residents reviewed.
Failed to ensure education was provided for a resident pertaining to safe sexual practices for 1 of 3 residents reviewed.
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.
Failed to ensure resident behaviors were monitored for 1 of 7 residents reviewed.
Failed to ensure social services needs were identified and appropriate social services provided for 2 of 7 residents reviewed.
Report Facts
Census: 93
Total Capacity: 93
Residents reviewed for meal tray distribution: 19
Residents reviewed for safe sexual practices education: 3
Residents reviewed for trauma informed care: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meeta Anand | Executive Director | Signed the report |
| RN 7 | Registered Nurse | Provided interview regarding behavior monitoring and policies |
| Social Services Director (SSD) 6 | Social Services Director | Provided interview regarding trauma informed care assessment |
| Social Services Director (SSD) 3 | Social Services Director | Provided interview regarding meal service practices |
| Administrator | Provided interview and policy information | |
| Director of Nursing (DON) | Director of Nursing | Provided interview regarding behavior monitoring and policies |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 19, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Canterbury Nursing and Rehabilitation Center.
Findings
The facility was found deficient in several areas including failure to ensure meal trays were distributed in a manner that promoted dignity, failure to provide education on safe sexual practices, failure to recognize and identify triggers for potential re-traumatization, failure to monitor resident behaviors adequately, and failure to provide appropriate social services to meet resident needs.
Deficiencies (5)
Failed to ensure meal trays were distributed in a manner that promoted dignity for 3 of 19 residents reviewed.
Failed to ensure education was provided for a resident pertaining to safe sexual practices for 1 of 3 residents reviewed.
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.
Failed to ensure resident behaviors were monitored for 1 of 7 residents reviewed.
Failed to ensure social services needs were identified and appropriate social services provided for 2 of 7 residents reviewed.
Report Facts
Residents reviewed: 19
Residents reviewed: 3
Residents reviewed: 7
Residents reviewed: 7
BIMS score: 6
BIMS score: 6
BIMS score: 12
BIMS score: 12
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD 3) | Interviewed regarding meal tray distribution process |
| Administrator | Administrator | Interviewed regarding meal service policy and safe sexual practices |
| Medical Doctor | Medical Doctor (MD 5) | Evaluated Resident 12 for ability to consent to sexual activity |
| Social Services | Social Services (SS6) | Interviewed regarding safe sexual practices education and trauma informed care |
| Registered Nurse | Registered Nurse (RN 7) | Interviewed regarding suicide precautions and behavior monitoring |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding behavior management and staff communication |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 19, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, care, social services, and behavioral health management at Canterbury Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure meal trays were distributed in a manner that promoted dignity, failure to provide education on safe sexual practices for a resident, failure to recognize and identify triggers for potential re-traumatization, failure to monitor resident behaviors adequately, and failure to provide appropriate social services for residents with behavioral and psychosocial needs.
Deficiencies (5)
Failed to ensure meal trays were distributed in a manner that promoted dignity for 3 of 19 residents reviewed.
Failed to ensure education was provided for a resident pertaining to safe sexual practices for 1 of 3 residents reviewed.
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.
Failed to ensure resident behaviors were monitored for 1 of 7 residents reviewed.
Failed to ensure social services needs were identified and appropriate social services provided for 2 of 7 residents reviewed.
Report Facts
Residents reviewed: 19
Residents reviewed: 3
Residents reviewed: 7
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director (SSD) 3 | Social Services Director | Interviewed regarding meal tray distribution and serving order |
| Administrator | Administrator | Interviewed regarding meal service policy and safe sexual practices policy |
| Medical Doctor (MD) 5 | Medical Doctor | Evaluated Resident 12 for ability to consent to sexual activity |
| Social Services (SS6) | Social Services | Interviewed regarding safe sexual practices education and trauma informed care |
| Registered Nurse (RN) 7 | Registered Nurse | Interviewed regarding suicide precautions and behavior monitoring |
| Social Service Director (SSD) 6 | Social Service Director | Interviewed regarding trauma informed care assessment for Resident 36 |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding behavior monitoring and new/worsening behaviors forms |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Date: Nov 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421642.
Complaint Details
Complaint IN00421642 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00421642 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Date: Oct 23, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418407 and IN00419084.
Complaint Details
Investigation of Complaints IN00418407 and IN00419084 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00418407 and IN00419084 were cited. The facility was found to be compliant with relevant federal regulations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 82
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00417450 completed on September 28, 2023.
Complaint Details
Investigation of Complaint IN00417450; facility found in compliance.
Findings
Canterbury Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication storage and administration regulations, specifically ensuring drugs and biologicals are properly labeled and securely stored.
Findings
The facility failed to properly secure residents' medications for 3 of 5 residents reviewed (Residents B, C, and D). Medications were frequently left within reach of residents without proper assessment or orders for self-administration, and some medications lacked pharmacy labels. The Director of Nursing confirmed no assessments for self-administration were completed for these residents, and policies were reinforced to prevent medications being left unattended.
Deficiencies (1)
Failure to properly secure resident's medication for 3 of 5 residents reviewed (Resident B, Resident C, and Resident D).
Report Facts
Residents reviewed: 5
Residents affected: 3
Inservice signatures: 18
BIMS score: 15
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Observed medication storage and provided statements regarding medication orders and assessments |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 100
Deficiencies: 1
Date: Sep 26, 2023
Visit Reason
This visit was conducted as an investigation of complaints IN00417193, IN00417450, and IN00418269 regarding medication storage and administration practices at Canterbury Nursing and Rehabilitation Center.
Complaint Details
Complaint IN00417193 had no deficiencies related to the allegations. Complaint IN00417450 had deficiencies related to medication storage and administration cited at F761. Complaint IN00418269 had no deficiencies related to the allegations.
Findings
The facility failed to properly secure residents' medications for 3 of 5 residents reviewed (Residents B, C, and D), leaving medications at bedside without proper assessment, orders, or care plans. Deficiencies were cited related to medication labeling, storage, and administration practices.
Deficiencies (1)
Facility failed to properly secure resident's medication for 3 of 5 residents reviewed, leaving medications at bedside without assessment, order, or care plan.
Report Facts
Residents reviewed for medication security: 5
Census: 100
Total licensed capacity: 100
Medicare residents: 1
Medicaid residents: 81
Other payor residents: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meeta Anand | Executive Director | Signed the report |
| Director of Nursing | Observed medication storage issues and provided interview statements |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 0
Date: Aug 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416133.
Complaint Details
Complaint IN00416133 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00416133 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 101
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 79
Census Payor Type - Private: 21
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413386 and IN00414692.
Complaint Details
Investigation of Complaints IN00413386 and IN00414692 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00413386 and IN00414692 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 98
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 78
Census Payor Type - Other: 19
Inspection Report
Complaint Investigation
Census: 100
Capacity: 100
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00410303 and IN00411287.
Complaint Details
Complaint IN00410303 and IN00411287 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 81
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Census: 100
Capacity: 100
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402299.
Complaint Details
Complaint IN00402299 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type: 100
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 84
Census Payor Type - Other: 15
Total Census: 100
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00400150 completed on February 14, 2023.
Complaint Details
Investigation of Complaint IN00400150 completed with the facility found in compliance.
Findings
Canterbury Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00400150) regarding the facility's failure to provide showers or complete bed baths as preferred to Resident H.
Complaint Details
This Federal finding relates to Complaint IN00400150.
Findings
The facility failed to ensure that Resident H was offered showers or complete bed baths as preferred, providing only one complete shower or bed bath during multiple weekly periods reviewed. Interviews with staff and family confirmed the deficiency, and the facility policy required offering two showers per week or bed baths if refused.
Deficiencies (1)
Failed to provide care and assistance to perform activities of daily living for Resident H, specifically not offering showers or complete bed baths as preferred.
Report Facts
Residents affected: 1
Residents reviewed: 11
Showers/bed baths provided: 1
Showers per week policy: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided documentation and interviews regarding bathing schedules and care plans for Resident H. | |
| Certified Nursing Assistant (CNA) 3 | Indicated residents were offered bathing at least 2 times a week. | |
| Licensed Practical Nurse (LPN) 2 | Indicated residents were offered 2-3 completed bed baths and/or showers a week. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 1
Date: Feb 10, 2023
Visit Reason
This visit was conducted for the investigation of four complaints (IN00399597, IN00400150, IN00400646, IN00401057) regarding care and services at Canterbury Nursing and Rehabilitation Center.
Complaint Details
Complaint IN00399597 was unsubstantiated due to lack of evidence. Complaint IN00400150 was substantiated with federal/state deficiencies cited at F677. Complaint IN00400646 was substantiated with no deficiencies cited. Complaint IN00401057 was unsubstantiated due to lack of evidence.
Findings
The facility was found to have substantiated deficiencies related to complaint IN00400150, specifically failing to ensure that 1 of 11 residents (Resident H) was offered showers or complete bed baths as preferred. Other complaints were unsubstantiated or had no deficiencies related to the allegations.
Deficiencies (1)
Failed to ensure 1 of 11 residents were offered showers or complete bed baths as preferred (Resident H).
Report Facts
Census: 96
Total Capacity: 96
Medicare Census: 4
Medicaid Census: 80
Other Payor Census: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00398267 completed on January 11, 2023.
Complaint Details
Investigation of Complaint IN00398267 completed on January 11, 2023; facility found in compliance.
Findings
Canterbury Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 100
Capacity: 100
Deficiencies: 1
Date: Jan 11, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00398267, which was substantiated with federal/state deficiencies cited.
Complaint Details
Complaint IN00398267 was substantiated with federal/state deficiencies cited at F921 related to environmental cleanliness.
Findings
The facility failed to maintain a clean environment for 3 of 9 residents reviewed, with observations of used briefs, clothing on bathroom floors, smeared brown matter on walls, food crumbs, and ants in resident rooms and bathrooms.
Deficiencies (1)
Facility failed to maintain a clean environment for 3 of 9 residents reviewed, including presence of used briefs and clothing on bathroom floors, smeared brown matter on walls, food crumbs, and ants.
Report Facts
Residents reviewed: 9
Residents affected: 3
Total census: 100
Total capacity: 100
Residents on 300 Hall: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meeta Anand | Executive Director | Signed the report |
| Certified Nursing Assistant (CNA) 2 | Interviewed regarding cleanliness issues | |
| Licensed Practical Nurse (LPN) 3 | Interviewed regarding cleanliness and trash removal | |
| Housekeeping Supervisor | Interviewed regarding cleaning tasks and schedule | |
| Housekeeper 4 | Interviewed regarding daily cleaning duties |
Inspection Report
Life Safety
Census: 97
Capacity: 142
Deficiencies: 4
Date: Jan 10, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Requirements for Participation related to Life Safety Code. Deficiencies included exit doors in the kitchen not opening properly, staff not knowing exit door codes on Memory Care halls, horizontal fire doors failing to close and latch, and unsealed penetrations in smoke barrier walls.
Deficiencies (4)
Failed to ensure 1 of 3 exit doors in the kitchen were able to open from the egress side due to a broken door handle.
Failed to ensure the means of egress through 2 of 2 Memory Care exits with special locking arrangements were readily accessible by staff; staff did not know the code to open the exit doors.
Failed to ensure 1 of 3 horizontal 1 hour fire door sets were arranged to automatically close and latch due to a broken latch.
Failed to ensure penetrations caused by the passage of wire and/or conduit through 2 of 10 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier.
Report Facts
Facility capacity: 142
Census: 97
Residents potentially affected: 35
Residents potentially affected: 40
Residents potentially affected: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meeta Anand | Executive Director | Signed the report |
| Maintenance Director | Interviewed and involved in observations related to deficiencies | |
| Administrator | Interviewed and involved in exit conference |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey for Canterbury Nursing and Rehabilitation Center.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 9, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure review.
Findings
Canterbury Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Annual Recertification and State Licensure review.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 9, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00391502 completed on December 12, 2022.
Complaint Details
Investigation of Complaint IN00391502; paper compliance review completed with findings of compliance.
Findings
Canterbury Nursing and Rehabilitation Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Annual Inspection
Census: 90
Capacity: 90
Deficiencies: 5
Date: Dec 12, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted in conjunction with the Investigation of Complaint IN00396293.
Complaint Details
The survey was conducted in conjunction with the Investigation of Complaint IN00396293.
Findings
The facility was found deficient in multiple areas including failure to communicate resident code status accurately, inadequate discharge planning, failure to follow physician orders, failure to identify significant weight loss, and failure to provide dental services.
Deficiencies (5)
Failed to ensure the resident's code status was communicated accurately to staff in 1 of 1 resident reviewed (Resident 77).
Failed to ensure discharge planning was provided for 1 of 2 residents reviewed (Resident 93).
Failed to ensure physician orders were followed for 1 of 2 residents reviewed (Resident 41).
Failed to identify significant weight loss for 1 of 2 residents reviewed (Resident 41).
Failed to ensure dental services were provided for 1 of 3 residents reviewed (Resident B).
Report Facts
Census: 90
Total Capacity: 90
Survey Dates: 5
Residents with Medicare: 2
Residents with Medicaid: 76
Residents with Other Payor: 12
Weight loss: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meeta Anand | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 1
Date: Dec 12, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00396293 and was conducted in conjunction with a Recertification and State Licensure Survey.
Complaint Details
Complaint IN00396293 was substantiated. The complaint involved Resident B's missing partial denture plate for several months, lack of clear facility plan communicated to family, incomplete oral screening documentation, and delayed dental referrals.
Findings
The facility failed to ensure dental services were provided for 1 of 3 residents reviewed (Resident B), specifically related to the loss and replacement of dentures and lack of timely dental care and documentation.
Deficiencies (1)
Failure to provide or obtain routine and emergency dental services as required, including timely referral for lost dentures and documentation of care.
Report Facts
Census: 90
Total Capacity: 90
Survey Dates: 5
Medicare Census: 2
Medicaid Census: 76
Other Payor Census: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meeta Anand | Executive Director | Signed the report |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 12, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, discharge planning, treatment and care according to orders, nutrition and hydration, and dental services at Canterbury Nursing and Rehabilitation Center.
Findings
The facility was found deficient in several areas including failure to accurately communicate a resident's code status, inadequate discharge planning, failure to follow physician orders, failure to identify significant weight loss, and failure to provide or obtain dental services for residents.
Deficiencies (5)
Failed to ensure the resident's code status was communicated accurately to staff for Resident 77.
Failed to ensure discharge planning was provided for Resident 93, including lack of signed discharge instructions and communication with receiving facility.
Failed to ensure physician orders were followed for Resident 41, including missed urinalysis and lab opportunities.
Failed to identify significant weight loss for Resident 41 and to assess denture fit or provide appropriate interventions.
Failed to provide or obtain dental services for Resident B, including failure to replace missing dentures and complete oral status screenings.
Report Facts
Weight loss percentage: 14
BIMS score: 3
BIMS score: 9
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Interviewed regarding urine sample collection and resident weight protocols. |
| DON | Director of Nursing | Interviewed regarding code status communication, discharge planning, lab orders, and dental services. |
| NP 2 | Nurse Practitioner | Ordered labs and transfer to emergency department for Resident 41. |
| NP 3 | Nurse Practitioner | Ordered labs and evaluated Resident 41. |
| Registered Dietician | Registered Dietician | Provided assessments and progress notes on Resident 41's weight loss. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 0
Date: Sep 6, 2022
Visit Reason
The visit was conducted for the investigation of Complaint IN00387567.
Complaint Details
Complaint IN00387567 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 95
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 81
Census Payor Type - Other: 13
Total Census: 95
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