Health inspection·July 21, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (person who routinely visits the facility and advocates for the residents in the nursing homes) when one of two residents (Resident 18 ) was transferred to the hospital. This failure had the potential to result in the resident not being informed of her rights. Findings: Review of Resident 18's clinical record indicated she was admitted to the facility on [DATE] and was transferred to a hospital on 5/3/23 for further evaluation and treatment. There was no documentation in the record indicating the facility notified the Ombudsman of Resident 18's transfer to the hospital. During an interview, on 7/20/23, at 11:10 A.M., with Director of Nursing (DON), she stated the Social Services Director (SSD) responsibility to notify the Ombudsman regarding Resident 18. During an interview, on 7/20/23, at 11:20 A.M., with SSD, she stated that she notified the Ombudsman for planned discharges. She also stated the nurses are responsible in notifying the Ombudsman when a resident is transferred to a hospital. During an interview, on 7/20/23, at 11:30 A.M., with Nurse Supervisor (NS), she stated that she did not inform the Ombudsman of any resident being transferred to a hospital. She also stated she did not know that the Ombudsman must be notified. During an interview, on 7/20/23, at 11:30 A.M., with RN B, she stated she did not know she must inform the Ombudsman when a resident was transferred to a hospital. Review of the facility's Transfer, Evacuation, Relocation or Discharge policy, dated 8/2022, indicated The community will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 2 of 19 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 07/21/2023 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) assessment for one of 13 sampled residents (Resident 7) when Resident 7's completed and transmitted quarterly MDS did not reflect Resident 7's hospice care. Residents Affected - Few These omissions in coding resulted in an inaccurate MDS and not addressing the resident needs. Findings: Review of Resident 7's admission Record indicated, Resident 7 was admitted to the facility with diagnoses including encounter for palliative care (hospice care) dated 11/25/2022, congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), dementia (decline in mental capacity affecting daily function), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dysphagia (difficulty swallowing). During a concurrent interview and record review with the MDS nurse (MDSN) on 7/21/2023, at 8:34 a.m., the MDSN confirmed Resident 7 was on hospice and she did a significant change in status assessment in December 2022. The MDSN stated, MDS assessment was important because it would reflect the resident's status. The MDSN reviewed Resident 7's MDS Quarterly assessment dated [DATE]. The MDSN confirmed Resident 7's MDS section O0100 K. Hospice care should have been marked with an x, indicated Resident 7 was on hospice care. Review of the MDS Resident Matrix dated on 7/17/2023, it was indicated Resident 7 was not on hospice care related to inaccurate MDS coding. Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, indicated, O100K, Hospice care. Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions . Further review indicated, The importance of accurately completing and submitting the MDS cannot be over-emphasized. The MDS is the basis for: the development of an individualized care plan; the Medicare Prospective Payment System; Medicaid reimbursement programs; quality monitoring activities, such as the quality measure reports . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 3 of 19 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 07/21/2023 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)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing activity program that meet the resident's needs, interests, and preferences for one of 13 sampled residents (Resident 11) when Resident 11's activity care plan was not updated and implemented. Residents Affected - Few This failure had the potential to affect the resident's physical, mental, psychosocial well-being, and self-worth. Findings: During multiple observations on 7/17, 7/18, 7/19, 7/20/2023, between 8:20 a.m. to 11:11 a.m., Resident 11 was lying in bed, and did not have any activities. Review of Resident 11's admission Record, indicated, Resident 11 was readmitted to the facility on [DATE] with diagnoses including left hip fracture, diabetes mellitus (a condition which affects the way the body processes blood sugar), Alzheimer's disease (a type of dementia which is a progressive disease that destroys memory and mental functions) and repeated falls. Review of Resident 11's Significant Change in Status Assessment Minimum Data Set (SCSA MDS assessment tool), dated 6/23/2023, Section F indicated, it is Very important for Resident 11: to have books, newspapers, and magazines to read; to listen to music she likes; to keep up with the news; to do her favorite activities; and to go outside to get fresh air when the weather is good. During a concurrent interview and record review on 7/20/2023, at 9:32 a.m., the activity director/social service designee (AD/SSD) reviewed Resident 11's care plans. The AD/SSD confirmed there was no activity care plan and no preferences care plan found in Resident 11's list of care plans. The AD/SSD stated there should be a care plan for activities to know what to do with her. At 9:48 a.m., AD/SSD reviewed the SCSA MDS Section F and their documentations on Resident 11's activities. The AD/SSD confirmed the activity care plan was not updated when Resident 11 had a significant change. During a concurrent interview and record review on 7/21/2023, at 8:25 a.m., the MDS nurse (MDSN) reviewed Resident 11's clinical records including the SCSA MDS and care plans. The MDSN stated Resident 11 had an old activity plan. The MDSN stated the activity care plan should have been revised when Resident 11 was readmitted with some changes. The MDSN confirmed Resident 11's revision of activity care plan was missed. During a review of the facility's policy and procedure titled, Activity Assessment, date revised 04/2020, indicated, .4. The activity assessment was used to develop an individual activities care plan as part of the comprehensive care plan that will allow the resident to participate in activities of their choice and interest. 5. Each resident's activities care plan should have relate to their comprehensive assessment and should reflect their individual needs. 6. The activity assessment and activities care plan will identify if a resident is capable of pursuing activities independently or if dependent on staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 4 of 19 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 07/21/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure that the wheels on the bed of residents were locked for two of five sampled residents (Resident 4 and Resident 220). This failure had the potential to result in accident and injury. Findings: 1. Review of Resident 4's Care Plan, revised on 7/30/22, indicated the resident was at risk for falls related to gait/balance problems, episode of fall. During an observation on 7/18/23, at 8:46 A.M., three out of four wheels of Resident 4's bed were unlocked. During an interview on 7/18/23, at 8:51 A.M., with Certified Nursing Assistant (CNA K), she confirmed the above observation. She also stated that all wheels of the bed should have been locked and at the lowest position. 2. Review of Resident 220's Care Plan, revised on 6/30/23, indicated the resident is at risk for falls related to antihypertensive medication, gait/balance problems, left hip pain, status post fractures of the other parts of pelvis/sacrum. During an observation on 7/18/23, at 12:32 P.M., two out of four wheels on Resident 220's bed were found unlocked. During an interview on 7/19/23, at 3:19 P.M., with Nurse Supervisor (NS), she stated that the staff should ensure wheels on the residents' beds are always locked for safety reasons. During an interview on 7/20/23, at 1:39 P.M., with Director of Nursing (DON), she stated that all wheels on the residents' beds should have been locked to prevent the bed from moving for the safety of all residents. Review of facility's MDS Baseline Care Planning policy, dated 8/2022, indicated Staff must implement the interventions to assist the resident to achieve care plan goals and objectives. Review of facility's Falls Prevention and Management Program policy, dated 12/2022, indicated Avoid furnishings that might slip when leaned on for support or ensure that wheels are locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 5 of 19 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 07/21/2023 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care for one of one sampled resident (Resident 4) in accordance with professional standards of practice and facility's policy and procedure when a Certified Nursing Assistant A (CNA A) administered oxygen (a colorless and odorless gas that people need to breath) to a resident. This failure had the potential for unsafe oxygen administration and negatively affect the resident's health and safety. Residents Affected - Few Findings: Review of Resident 4's clinical record indicated she was admitted on [DATE] and had a diagnosis of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), hypoxemia (a low level of oxygen in the blood). Review of Resident's 4's physician order indicated To administer 2 liters continuously to keep oxygen saturation (the amount of oxygen circulating in the blood) above 92 percent and for shortness of breath. During an observation on 7/17/23, at 12:22 P.M., the nasal cannula (a flexible tube that contains two open prongs intended to sit just inside the nostrils to deliver supplemental oxygen) was found on the floor beside the resident's bed and the oxygen concentrator (a medical device that concentrates oxygen from environmental air) was on. The CNA A entered the resident's room to assist the resident. After the CNA A exited the room, the nasal cannula was placed on the resident's nose. During an interview on 7/17/23, at 12:35 P.M., with CNA A, she stated that she assisted the resident to the bathroom and placed the nasal cannula on the resident's nose. She confirmed that she administered the oxygen and did not call the licensed nurse to administer the oxygen. She also stated that certified nursing assistants were not allowed to apply or remove nasal cannula and she should have been called a licensed nurse. During an interview on 7/18/23, at 8:59 A.M., with Nurse Supervisor (NS), she stated the licensed nurses were allowed to administer oxygen. She also stated that certified nursing assistants were not allowed and should have inform the nurse if the resident requires oxygen. During an interview on 7/18/23, at 12:44 P.M., with Certified Nursing Assistant (CNA K), she stated that certified nursing assistants are not allowed to administer oxygen to residents. She also stated the licensed nurses was allowed to administer oxygen. During an interview on 7/20/23, at 1:39 P.M., with Director of Nursing (DON), she stated the licensed nurses were allowed to administer oxygen to residents. During a review of the facility's Oxygen Therapy policy, dated July 2022, indicated Oxygen therapy was administered by a licensed nurse as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 6 of 19 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 07/21/2023 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)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and facility's document review, the facility failed to provide a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure had the potential to affect resident's care, health, and well-being. Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report from the Centers for Medicare and Medicaid Services (CMS) dated January 1 - March 1, 2023, it indicated, under Metric, No RN Hours was Triggered on 1/1, 1/15, 2/18 and 3/18/2023. During an interview with the director of nursing (DON) on 7/21/2023, at 8:14 a.m., the DON confirmed the days without an RN. DON stated the only RNs in their facility were her and RN B. DON stated they were hiring an RN, but nobody applied yet. During an interview with the executive director (ED) on 7/21/2023, at 8:45 a.m., the ED stated they were hiring for the RN position since March 2023, but unfortunately, nobody applied. Review of the licensed nurses schedule for the months of January to March 2023, it indicated a confirmation, there were no RN that worked on 1/1, 1/15, 2/18 and 3/18/23023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 7 of 19 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 07/21/2023 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 7) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 7 received Lorazepam (a medication for anxiety) without documentation of its specific duration in the resident's clinical record. This failure had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical, mental, and psychosocial well-being. Findings: Review of Resident 7's admission Record indicated, Resident 7 was admitted to the facility with diagnoses including encounter for palliative care (hospice care) dated 11/25/2022, congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), dementia (decline in mental capacity affecting daily function), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), delirium ( and dysphagia (difficulty swallowing). Review of Resident 7's Order Summary Report, it indicated, Lorazepam Tablet 0.5 milligram (mg,]\unit of measurement). Give 1 tablet by mouth every 1 hours as needed for anxious, date ordered 12/22/2022 and no end date. Review of Resident 7's medication regimen review (MRR-a thorough evaluation of the medication regimen of a resident, with a goal of promoting positive outcomes and minimizing adverse effects associated with medication) with a note to the attending physician, dated 6/8/2023, it was indicated, .CMS (Centers of Medicare and Medicaid services) guidelines released on 11/2017 indicate PRN (pro re nata, which means as needed) psychotropic medications are now limited to 14 days. If the PRN psychotropic order needs to be extended beyond 14 days duration, it need to be justified by MD (medical doctor). Please evaluate the following for a stop date: Lorazepam 0.5 mg q (every) 1 h (hour) prn anxious. The physician's response as indicated in the MRR, Very justified. His aggressive behavior is well controlled and he already failed a trial off this medication, signed on 7/18/2023. Review of Resident 7's May and June 2023 medication administration record (MAR, a record of medications given) indicated, Resident 7 did not receive Lorazepam due to no behavior related to being anxious recorded. During multiple observations on 7/17/2023, at 8:55 a.m. and 12:18 p.m., 7/18/2023 at 8:19 a.m., and 7/19/2023 at 8:21 a.m. and 9:33 a.m., Resident 7 was in bed, calm and most of the time asleep. During an interview with the director of nursing (DON) on 7/20/2023, at 1:25 p.m., DON stated it was necessary for hospice residents to have an indefinite order of prn Lorazepam. During an interview with the pharmacy consultant (PC) on 7/21/2023, at 9:38 a.m., PC confirmed she did the MRR once a month. PC stated she evaluated the use of the prn psychotropic medications and would send a note to the attending physician about the CMS guidelines. PC further stated, if the physician did not address the duration of the psychotropic medication, the PC would remind the nurses and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 8 of 19 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 07/21/2023 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the DON to address this with the physician. PC confirmed she was not the one who did the MRR in June 2023. During a review of the facility's policy and procedure titled, Psychotropic Drugs, date revised 06/2023, indicated, Based on a comprehensive assessment of a resident, the Skilled Nursing Facility (SNF) must ensure that .c. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days . Event ID: Facility ID: 055303 If continuation sheet Page 9 of 19 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 07/21/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling for one of one medication cart. This failure had the potential to result in the administration of outdated or expired medication. Findings: During a concurrent observation and interview, medication storage cart inspection on [DATE], at 1:05 P.M., with Registered Nurse (RN B) and Nurse Supervisor (NS), an opened box of Omeprazole (a medication for upset stomach) was found. RN B and NS were not able to locate the expiration date label. During a concurrent interview on [DATE], at 3:30 P.M., with NS, she stated she removed the medication from the cart because she was not sure of the expiration date and replaced it with an unopened box with expiration date of 12/2023. During an interview on [DATE], at 9:30 A.M., with Pharmacy Consultant (PC), she stated she highly recommend throwing a medication that have no expiration date. Review of facility's Storage of Medication policy, dated 11/2017, indicated Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 10 of 19 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 07/21/2023 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observations, interview and facility document review, the facility failed to ensure the director of dining services (DDS) comprehensively carried out the functions of the food and nutrition services when the DDS did not perform kitchen audits monthly as scheduled. This failure resulted lapses in the delivery of services associated with food safety and sanitation (cross-reference F812) which had the potential transmission of foodborne illness to 16 residents. Findings: During multiple observations at the facility's kitchen on 7/17 through 7/19/2023, there were multiple issues identified with respect to the functions of food and nutrition services (cross-reference F812). 1. Issues with condiments: opened but not labeled or dated; stored beyond used date, and label about storage after opening was not followed. One condiment did not have the right cap to cover the bottle tightly. 2. Issues with improper use of hair restraints: two dietary staff inside the kitchen, were not wearing hair restraints and three other dietary staff were not wearing the hair restraints properly. 3. Issues with use of gloves and hand hygiene by the facility's cook and chef. 4. Issues with grayish buildup substances behind the ice/water machine especially the piping, behind the steamers, and the wheels of oven. 5. Issues with whitish, and brownish buildup in the water dispenser chute. 6. Issues with use of expired quat test strips (used to determine that the concentrations of quaternary ammonium [quat-a chemical that kills bacteria, molds, and virus] in sanitizer solutions are at the correct level). 7. Issues with the ice buildup in the walk-in freezer. 8. Issues with water pooling on the kitchen floor behind the steamer. During an interview with the DDS on 7/18/2023, at 12:57 p.m., DDS stated the kitchen audit should be done once a month. During an interview with the registered dietitian (RD) on 7/18/2023, at 1:08 p.m., RD stated the last kitchen audit that was done for 2023 was in May. RD further stated the kitchen audit should have been done once a month. During a concurrent interview and record review on 7/20/2023, at 4:35 p.m., DDS reviewed the kitchen audits they did for 2023. DDS confirmed she missed the February, March, April, and June 2023 kitchen audits. DDS stated, we included this (kitchen audit) in our QAPI (Quality Assurance and Performance Improvement-data driven and proactive approach to quality improvement) because we need (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 11 of 19 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 07/21/2023 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many improvement. DDS agreed the above issues would have been addressed if only the kitchen audits were done monthly. DDS confirmed it was the DDS responsibility to do the kitchen audits once a month and it was only done twice this year. During a review of the facility's Audit Schedule, dated March 2022, it indicated Food Safety and Sanitation/Workplace Safety Audit should have been done monthly and the person responsible was the DDS. During a review of the Position Analysis of the Director of Dining Service, dated January 2021, indicated, Responsible for maintaining high standards in service, food preparation .,safety, sanitation, training and special functions .Performs any other duties, as assigned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 12 of 19 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 07/21/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. The condiments were opened but not labeled or dated, stored beyond used date, label about storage after opening was not followed and one condiment did not have the right cap to cover the bottle tightly; 2. The walk-in freezer's ceiling had ice buildup; 3. Dietary staff did not follow the proper use of hair restraints; 4. A water dispenser was not kept in a sanitary condition; 5. Dishwasher D (DW D) used the expired quat test strips (used to determine that the concentrations of quaternary ammonium [quat-a chemical that kills bacteria, molds, and virus] in sanitizer solutions are at the correct level); 6. There was water pooling in the kitchen floor behind the steamer; 7. There were grayish build up substance behind the steamers, the wheels of oven and some brownish, blackish substance buildup between the hot preparation table and the oven; and 8. The facility's chef and [NAME] I did not follow the proper use of gloves and did not perform hand hygiene. These failures had the potential to cause cross-contamination of food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 16 health center residents eating at the facility. Findings: 1a. During an interview with cook C on 7/17/2023 at 8:07 a.m., cook C stated the permanent marker date written on each condiments indicated the date the product was received. During a concurrent observation and interview with the chef on 7/17/2023 at 8:11 a.m., inside the kitchen, a gallon of rice vinegar stored under the hot preparation table had an orange sticker, indicated, Today's date (date opened) 2-3-23, Good Thru 7-3-23. The rice vinegar's container indicated, BEST IF USED BY [DATE]. The chef confirmed the rice vinegar was expired and they always follow the expiration date. 1b. On 7/17/2023 at 8:15 a.m., a gallon of red wine vinegar was not labeled with date opened and good thru date. The bottom part of the red wine vinegar, indicated, Best If Used by Date on Cap. The cap used to cover the red wine vinegar was a soy sauce cap and it was loose and not sealed tightly. The chef confirmed it was not the right cap and it should be labeled with opened date once opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 13 of 19 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 07/21/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm 1c. On 7/17/2023 at 10:51 a.m., a half-gallon container of red hot sweet chili sauce was also found stored at the bottom of the hot preparation table, almost half of the red hot sweet chili sauce was consumed. The container indicated a permanent marker writing, 12-16-22. The label at the back of the container, indicated, Refrigerate After Opening. Chef confirmed the red hot sweet chili sauce should not be stored at the bottom of the preparation table once opened. Residents Affected - Many During a review of the facility's policy and procedure titled, FOOD AND SUPPLY STORAGE, date revised 5/2021, indicated, All food, non-food items and supplies use in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. The sell-by date is the date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date of the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate or other approved labeling system. Products are good through the close of business on the date noted on the label. 2. During a concurrent observation and interview with the chef on 7/17/2023 at 8:30 a.m., inside the kitchen's walk-in freezer, the internal freezer temperature was 2 degrees Fahrenheit (F-scale of temperature) as indicated in the thermometer. There were some ice build up at the ceiling of the walk in freezer. Chef confirmed the observation above. Chef stated it was hard to maintain the freezer temperature. Chef further stated there was something wrong with the freezer and a service contractor came to fix the problem. During a concurrent observation and interview with the director of dining services (DDS) on 7/17/2023 at 10:02 a.m., DDS confirmed there were some ice buildups at the ceiling of the walk-in freezer. DDS stated a service contractor performed a quarterly check for routine maintenance of their freezer and refrigerators. DDS also confirmed the walk-in freezer was unable to maintain a zero degrees F temperature. DDS stated, they (service contractor) fix it last Friday. During a follow up observation and interview with DDS on 7/18/2023 at 12:50 p.m., inside the walk-in freezer, DDS confirmed there were still ice buildup at the ceiling of the walk-in freezer. Another follow up observation and interview with DDS on 7/19/2023 at 11:09 a.m., inside the walk-in freezer, DDS confirmed there were still ice build up at the ceiling of the walk-in freezer. DDS stated the service contractor came on 7/18/20203 to check the freezer. DDS further stated, I will call them again. Review of the service contractor's service report, dated 04/19/23, indicated the freezer's routine maintenance was performed. The report also indicated, Freezer door hinged need to be replaced. Review of the service contractor's service reports dated 6/20, 6/26, 7/01, 7/05, 7/13, 7/18, and 7/20/2023, it all indicated, temperature problem and the service contractors replaced some broken parts. On 7/20/2023 report, it indicated, a problem at the bottom door gasket. 3a. During a concurrent observation and interview with DDS on 7/18/2023 at 12:30 p.m., inside the kitchen, dietary staff E (DS E) was observed not wearing a hair restraint. DS E stepped out of the kitchen when this surveyor went inside the kitchen. Dishwasher J (DW J) was also observed not wearing a hair restraint inside the kitchen. Both DS E and DW J did not have hair on top of their head but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 14 of 19 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 07/21/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many with some hair at the side and back of their head. DDS confirmed above observations and stated, both DS E and DW J should have worn a hairnet inside the kitchen. During a concurrent observation and interview with DS E on 7/18/2023 at 12:37 p.m., DS E was already wearing a hairnet and sliced some lemons. DS E confirmed above observation and stated he should always wear a hairnet inside the kitchen. 3b. During a concurrent observation and interview on 7/18/2023 at 12:44 p.m., DS F was wearing a hairnet but some hair at the back of her head were not tucked inside the hairnet. DS F confirmed the above observation and stated her hair should be tucked inside the hairnet. 3c. During a concurrent observation and interview on 7/18/2023 at 12:45 p.m., DS G was wearing a hairnet but some hair at the back of her head were out and not properly tucked inside the hairnet. DS G confirmed this surveyor's observation. 3d. During another concurrent observation and interview on 7/18/2023 at 12:46 p.m., DS H was observed with her hair not properly restraint, especially the hair at the back of her head. DDS agreed DS H needed to fix her hair and properly wear the hairnet. During a review of the facility's policy and procedure titled, UNIFORM DRESS CODE, date revised 1/2021, indicated, .Hair must be neat and clean .Wear the approved hair restraint when on duty. The only exception is to remove hair restraints when delivering trays to patients/residents. 4. During an initial kitchen observation on 7/17/2023 at 7:50 a.m., the ice/water machine was located inside the kitchen and observed with a sign posted both in English and Spanish, indicated, Out of Order - Fuera de servicio. A picture was taken to get a better view of the water chute area. The picture revealed a whitish build up at the water chute and some orange-brown colored build up at the side. During an interview with the DDS on 7/17/2023 at 9:54 a.m., DDS confirmed the ice machine had been broken for three months. DDS stated she ordered a new one but it was not delivered yet. During a concurrent observation, and interview with DDS on 7/19/2023 at 11:05 a.m., a dietary staff was observed filling up some pitchers of water from the ice/water machine. DDS stated the ice dispenser was broken but they could still get water to serve to the assisted living and health center residents. Surveyor showed the picture of the water chute taken on 7/17/2023 and showed the back of the ice/water machine to DDS. DDS confirmed the back of the ice/water machine had some grayish substance buildup around the tubing, and some rust like colored substance buildup. DDS agreed the water dispenser and the machine itself should be cleaned. DDS stated the service contractor should have done maintenance or deep cleaning of the water dispenser quarterly. Review of the ice/water machine maintenance log indicated, the last time it was serviced was on 11/1/2022. Maintenance or deep cleaning was not performed for 2023. 5. During a concurrent observation and interview with dishwasher D (DW D) on 7/17/2023 at 12:54 p.m., DW D demonstrated how to test the sanitizing solution using the quat test strip. DW D logged the test strip result. Surveyor checked the expiration date of the quat test strip from the test kit, it indicated an expiration date on July 15, 2023. DW D confirmed the quat test strip was expired. DW D stated the quat test strip expiration date should be checked first prior to using it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 15 of 19 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 07/21/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with the DDS on 7/17/2023 at 1:14 p.m., DDS confirmed the quat test strip the dishwashers have been using was expired. During a review of the poster located above the dishwashing sink, titled, Quaternary Sanitizer Testing Procedures .IMPORTANT. Verify expiration date on QT-10 Test Kit before use. Out of date kits should be discarded. 6. During a concurrent observation and interview with DDS on 7/19/2023 at 11:17 a.m., DDS confirmed there was a water pooling on the kitchen floor, behind the steam kettle. DDS couldn't find where the water was coming from. During a follow up interview with the DDS on 7/20/2023 at 2:14 p.m., DDS confirmed the water pooling in the kitchen floor, behind the steam kettle was coming from a leak in the steamer's tubing. 7. During an interview with DDS on 7/19/2023 at 11:05 a.m., DDS confirmed no one did deep cleaning in the kitchen. During a concurrent observation and interview with the director of nutrition and wellness (DNW) on 7/19/2023 at 11:24 a.m., there were grayish/blackish substance buildup at the back of the steamer, at the wheels of the oven and in the space between the oven and the hot preparation table. DNW confirmed no deep cleaning was done at the kitchen. During a concurrent interview and record review on 7/19/2023 at 4:40 p.m., DDS reviewed the Basic Sanitation Checklist. DDS confirmed the last kitchen audit was done on 5/2/2023 by the director of nutrition and wellness (DNW). DDS stated, we included this (kitchen audit) in our QAPI (Quality Assurance and Performance Improvement-data driven and proactive approach to quality improvement) because we need improvement. DDS repeated her statement, kitchen audit should be done monthly. Another concurrent interview and record review on 7/20/2023 at 4:35 p.m., DDS reviewed another Basic Sanitation Checklist. DDS stated she was the one who did the kitchen audit on 1/31/2023. DDS confirmed it was the DDS responsibility to do the kitchen audits once a month and it was only done twice this year. 8. During a tray line observation on 7/19/2023 at 11:36 a.m., [NAME] I touched the garbage lid and threw his used gloves. [NAME] I did not wash his hands and continued to don (put on) a new pair of gloves. [NAME] I opened refrigerator door near the dry storage room, touched his head and took out a container of broccoli. [NAME] I touched the garbage lid again to throw something and went to open another refrigerator door. He then touched the chopping board and knife used for the tray line with his dirty gloves, while talking to the dietary staff. DDS asked [NAME] I to stepped out of the kitchen with her. During an interview with DNW on 7/19/2023 at 11:45 a.m., DNW confirmed above observation. DNW stated DDS and herself have given repeated instruction to [NAME] I regarding hand hygiene and use of gloves. DNW further stated dietary staff should always change their gloves and should wash their hands after touching dirty areas. During a continuation of tray line observation on 7/19/2023 at 12:00 p.m., the chef was observed touching his face mask to adjust twice, did not change his gloves, did not wash his hands, and continued with tray line. Another observation at 12:11 p.m., chef adjusted his face mask again and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 16 of 19 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 07/21/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many continued touching the scooper. DNW had same observation and instructed the chef to change his gloves and wash his hands. During an interview with the facility's infection preventionist (IP) on 7/20/2023 at 10:42 a.m., IP was informed about the surveyor's tray line observation. IP stated kitchen staff should change gloves and wash their hands prior to donning a new pair of gloves: upon touching the facemask, upon touching their cap, upon touching the garbage, and before handling kitchen utensils or food. During a review of the facility's document, titled, ATTENDANCE VERIFICATION SHEET, dated 12/10/2022, it indicated a training about Infection Control which included handwashing. The attendance sheet indicated [NAME] I attended the training. During a review of the facility's policy and procedure, titled, HAND HYGIENE, date revised 1/2023, indicated, In the Food & Nutrition Services Department: All associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: . Before handling food or clean utensils/dishes/equipment; Before putting on gloves; .After touching hair, skin, beard, or clothing; . After handling garbage; . After removing gloves; After any other activity that may contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 17 of 19 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 07/21/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. During an observation, on 7/17/23, at 8:02 A.M., the EST was seen wearing disposable gloves on both hands while cleaning a resident's room. After cleaning, she removed one glove only. She proceeded to hold a plastic bag with soiled rags with the ungloved hand and pushed the cart using the gloved hand towards the end of the hallway. She then went to the dirty utility area carrying the plastic bag. She then came out and opened a closet located in the hallway still with one gloved hand and removed several rolls of toilet paper. After that she then removed the glove. No hand hygiene or hand washing performed. Residents Affected - Some During an interview, on 7/17/23, at 9:26 A.M., EST stated that when cleaning resident rooms, she would perform hand hygiene, wear gloves, use only one rag to mop the floor. She also stated that after cleaning the room, she would remove gloves, rags, garbage and do hand hygiene. During an interview on 7/20/23, at 1:39 PM, with Director of Nursing (DON), she stated that both used gloves should have been removed after any procedure, staff must perform hand hygiene, and hand washing. During an interview, on 7/20/23, at 2:12 P.M., with IP, he stated that no gloves are to be worn in the hallway for environmental services technician. He also stated that staff are educated about hand hygiene/handwashing before and after giving medication, cleaning resident rooms. Review of facility's Personal Protective Equipment policy, revised 7/2020, indicated Gloves shall be used only once and discarded into the appropriate receptacle, located in the room in which the procedure is being performed. Review of facility's Personal Protective Equipment policy, revised 7/2020, indicated Wash your hands after removing gloves. Review of facility's Hand Washing/Hand Hygiene policy, revised 10/2021, indicated Hand hygiene is the final step after removing and disposing of personal protective equipment. Based on observation, interview and record review, the facility failed to implement infection control and prevention practices when: 1. For Resident 171, the nurse did not perform hand hygiene before donning (putting on) and doffing (taking off) gloves. 2. Registered nurse B (RN B) did not follow manufacturer's instructions for a disinfectant wipe (product used to kill microorganisms). 3. Environmental Services Technician (EST) did not follow proper hand washing and gloving technique. These failures had the potential to result in transmission and spread of infection in the facility. Findings: 1. During a medication administration observation on 07/19/23, at 09:27 a.m., RN B administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 18 of 19 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 07/21/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm oral medication to Resident 171. After administering the oral medication, RN B touched Resident 171's communication board without performing hand hygiene,then donned a pair of gloves. RN B administered Brimonidine Tartrate ophthalmic solution (eye drop used to treat glaucoma [high fluid pressure in the eye]) into Resident 171's eyes, then removed her gloves. RN B did not perform hand hygiene after removing her gloves. Residents Affected - Some During an interview with RN B on 07/19/23, at 09:31 a.m., she confirmed she did not perform hand hygiene before donning and after removing her gloves. During an interview with the infection preventionist (IP) on 07/20/23, at 10:41 a.m., the IP stated nurses should have perform hand hygiene before wearing a new pair of gloves and after removing used gloves. The facility's policy and procedure titled, Hand Washing/Hand Hygiene, dated 07/2023, indicated to use an alcohol-based hand rub or soap and water before putting on gloves and immediately after glove removal. 2. During a medication pass observation on 07/19/23, at 12:05 p.m., RN B removed a glucometer from the medication cart and tested Resident 169's blood sugar. After testing Resident 169's blood sugar, RN B wiped the glucometer with a Clorox (bleach) wipe for less than one minute, then put the glucometer back in its bag. During an interview with RN B on 07/19/23, at 12:08 p.m., RN B confirmed she wiped the glucometer with a Clorox wipe and did not allow the glucometer to remain wet for three minutes before putting it back in its bag. The manufacturer's instructions on the container of Clorox Healthcare Bleach Germicidal Wipes were reviewed. The directions indicated, Blood and other body fluids must be thoroughly cleaned from surfaces and other objects before applying this product. Allow surface to remain wet for 3 minutes, let air dry. During a concurrent interview and record review with the IP on 07/20/23, at 10:27 a.m., the IP stated the glucometer should have been disinfected with Sani Cloth Wipes. The IP reviewed the Environmental Protection Agency (EPA) website and verified that Sani Cloth Wipes should have been used to disinfect the glucometer and the wet times should have been followed. The facility's undated document titled To Clean and Disinfect the Meter indicated, With ONLY PDI Super Sani Cloth Wipes (or any disinfectant with the EPA* reg. no. of 9480-4), rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. The document further indicated, Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055303 If continuation sheet Page 19 of 19