Health inspection·February 11, 2020

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), abnormalities with gait and mobility, and muscle weakness. Review of Resident 1's clinical record indicated Resident 1 had two unwitnessed falls on 11/1/19 and 1/24/2020. Review of Resident 1's fall care plans, on 5/13/19, indicated an intervention of follow facility fall protocol. Her fall care plan initiated on 1/25/2020, the interventions included monitor/document/report as needed for 72 hours to the doctor for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, and perform neurological checks. During an interview and record review with the DON on 2/10/2020 at 2:04 p.m., she stated neurological checks were included in the facility's fall protocol. She further stated neurological checks were computer generated. During an interview and record review with registered nurse C (RN C) on 2/11/2020 at 9:14 a.m., she stated when a resident had an unwitnessed fall, the nurses should perform neurological checks. She further stated some nurses follow the hard copy neurological assessment for frequency of assessments and others use the triggers of the computer system. RN C stated the computer system did not triggered assessments as frequently and timely as the hard copy's neurological assessment required. During an interview with the regional nurse consultant on 2/11/19 on 1:29 p.m., she stated the computer system was not triggering neurological assessments the way it's supposed to. Neurological checks should have triggered more frequently with the correct timing. During a review of the facility's policy and procedure dated 10/19/17, Comprehensive Care Planning Policy, indicated the community must develop and implement an individual, written, comprehensive person centered care plan for each resident Based on interview and record review the facility failed to follow post fall assessments for three out of eight residents (1, 3, 12) when neurological checks (are used to assess an individuals neurological functions and level of consciousness in order to determine whether or not individual is functioning properly and reacting appropriately) were not followed per facility protocol. This failure put residents' health and safety at risk. (continued on next page) 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 Page 1 of 5 Event ID: 055303 Printed: 05/15/2026 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 055303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Woods 651 Sinex Avenue Pacific Grove, CA 93950 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)