Other·August 15, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey regarding a complaint and entity report incident conducted on 7/21/17, 7/24/17, 7/25/17, 8/3/17, 8/4/17, 8/9/17, and 8/11/17. For Complaint CA00544575 and Entity Report Incident CA00543879 regarding Quality of Care/Treatment, a federal deficiency was identified ("G" level deficiency for F323, 483.25(d)(1)(2)(n)(1)-(3)). In addition, a Class "A" Citation was issued. Inspection was limited to the specific complaint and entity report incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 27007, Health Facilities Evaluator Nurse.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 08/15/2017 (d) Accidents. The facility must ensure that - LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure Resident 1 was seated securely while riding in the facility's bus. On 7/11/17 at approximately 12:30 p.m., Resident 1 did not have a seatbelt and shoulder harness in place and fell out of her wheelchair onto the floor when the driver was making a left hand turn. She sustained a laceration to her right knee requiring sutures, and abrasions to the right side of her head and her right shoulder. On 7/19/17, Resident 1 was placed under Hospice care (end of life) to control her pain. During a telephone interview on 7/25/17 at 8 a.m., Resident 1's family member stated Resident 1 expired in the evening on 7/21/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: https://www.transit.dot.gov/regulations-andguidance (Web based Internet site) Section 38.23(d) of the Department of Transportation (DOT) American Disabilities Act (ADA) regulations requires all ADA-compliant buses and vans to have a two-part securement system, one to secure the wheelchair, and a seatbelt and shoulder harness for the wheelchair user. (On 7/21/17 at 11 a.m., an observation of the facility's bus was conducted, accompanied by the driver. A shoulder/lap extension was visible attached to the wall on the left side of the bus.) Review of the facility's job description titled "Driver II" dated 9/20/15, indicated the driver is responsible for the scheduling and safe transportation of residents. One of the primary responsibilities listed was to "inform residents that they must wear seatbelts during transportation." http://sure-lok.com/products/occupantrestraints (Web based Internet site) indicated a warning: occupant restraints are not wheelchair securements. Always secure the occupant in the vehicle with a complete occupant restraint system, consisting of lap and shoulder belts. Review of the facility's Policy and Procedure dated 7/14/17 indicated the bus driver will attach the shoulder and lap seatbelt harness extension (Sure-Lok) to the seatbelt harness anchored to the passenger bus and the attendant will apply the safety belt harness so that the lap portion of the safety belt rests over the hips prior to the bus is in motion. Clinical record review for Resident 1 was initiated on 7/21/17. Resident 1 was admitted to the facility on 7/21/14 with diagnoses including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE muscle weakness, osteoporosis (brittle bones) and Parkinson's disease (a disease that includes symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking, and impaired balance and posture). Review of Resident 1's Clinical Psychologist note dated 1/18/17 indicated Resident 1 was oriented to name, place and time and was looking forward to celebrating her 100th birthday. Resident 1 was very involved in the current news reports. Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 4/22/17 indicated she was alert and oriented (able to make herself understood) and required assistance from one to two staff members for all her activities of daily living (ADL). Review of Resident 1's care plan problems indicated a "current" problem (not dated) to address her self care deficit in ADL care related to decreased mobility, involuntary movement, functional impairment, joint stiffness, and generalized weakness. Review of Resident 1's Weekly Summary reports dated 6/28/17 and 7/5/17, indicated she was in no pain; however on 7/12/17 her pain level was a score of three (on a scale of 0-10 with 0 having no pain to a 10 being the worse) and on 7/19/17 she had frequent pain at a moderate level in her shoulder. Review of Resident 1's July 2017 Physician Order Sheet indicated the following medication orders: a. on 6/17/15: administer Tylenol (pain medication) 325 milligrams (mg) two tablets by mouth every six hours as needed for general discomfort; b. on 2/10/17: administer Tylenol 325 mg two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tablets by mouth twice a day for pain; c. on 7/13/17: administer Tramadol (a narcotic pain medication) 25 mg by mouth every four hours as needed for moderate pain and 50 mg by mouth for severe pain; and d. on 7/19/17: administer Morphine (a narcotic pain medication) five mg every hour by mouth or sublingual (under the tongue) as needed for mild pain, 10 mg every hour by mouth or sublingual for moderate pain and 20 mg every hour by mouth or sublingual for severe pain. Review of Resident 1's July 2017 Medication Administration Record (MAR) indicated after her fall on 7/11/17, she required stronger and frequent pain medication. The following pain medication was administered: a. Routine Tylenol 325 mg two tablets by mouth twice a day from 7/1-7/21/17; b. As needed Tylenol 325 mg two tablets by mouth on 7/13/17, 7/17/17 and 7/19/17; c. Tramadol 25 mg by mouth: 10 doses from 7/13-7/17/17 d. Tramadol 50 mg by mouth: 10 doses from 7/13-7/19/17; e. Tramadol 100 mg by mouth: 3 doses from 7/17-7/19/17; f. Morphine 5 mg by mouth: 2 doses from 7/197/20/17; g. Morphine 10 mg by mouth: 5 doses from 7/19-7/21/17; and h. Morphine 20 mg by mouth: 12 doses from 7/20-7/21/17. Review of the attendant's written interview statement dated 7/11/17 indicated she was watching Resident 1 several times (in the bus) to make sure she was comfortable. During one of her visual checks, she saw the resident on the floor. She stated the bus was moving when the incident occurred and "there was no seatbelt on the way to there but we put the seatbelt on the way back home (back to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility)." The attendant seating diagram indicated Resident 1 was seated on the left side in the back of the bus and she was seated a few seats in front of Resident 1 on the right side of the bus, away from the resident. Review of the facility's Investigation Report dated 7/11/17 indicated the driver "reported that when she had first tried to use the shoulder and lap seatbelt harness extension, the shoulder and lap seatbelt harness extension did not buckle in as it was supposed to. From that point on, the driver said that she would not use this extension to secure the resident into the wheelchair." When the director of administrative services tested the shoulder and lap seatbelt extensions on 7/11/17, he was able to buckle the two pieces together (shoulder and lap seatbelt extensions) and the buckle locked securely. Review of Resident 1's Emergency Physician Record dated 7/11/17 indicated Resident 1 sustained a five centimeter laceration to her right knee that required nine sutures, and abrasions and pain to her right shoulder and right forehead. Her X-ray report of her right knee dated 7/11/17 indicated her bones were osteoporotic (brittle bones) and the X-ray was limited due to the resident's inability to straighten her leg out (contracted: bent). Resident 1's X-ray results on 7/11/7 of her right shoulder indicated a possible fracture of the shoulder bone socket and to consider a computerized tommography (CT: a more detailed X-ray) scan. (Review of Resident 1's Care Plan Conference Summary dated 7/18/17, indicated Resident 1's family member did not want to put her mother through any further tests and declined to have the follow-up CT scan completed.) Review of the Resident 1's Physician notes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 7/14/17 showed after the resident slid out of her wheelchair on 7/11/17, she had marked decreased range of motion to her right shoulder and required the use of Tramadol to control her pain. A note dated 7/21/17 indicated the resident was "now comfortable with Roxanol (a form of Morphine), does not respond today and was on hospice care at the family's request for pain control. He documented the family was notified Resident 1's condition was unlikely to improve. Review of Resident 1's Nurse's Notes indicated: a. On 7/13/17 at 12 p.m., Resident 1 was put back to bed due to complaining of pain. The director of nurses (DON) documented the pain medication (Tylenol) was not covering the pain and the physician was contacted and ordered Tramadol 25 mg every four hours for moderate pain and 50 mg every four hours for severe pain; b. On 7/17/17 at 12 p.m., Resident 1's pain level was a nine. The DON notified the physician and an order was obtained to increase the administration of Tramadol to 100 mg; and c. On 7/18/17 at 11:45 a.m., Resident 1 told the DON she wanted to be under hospice care because, "I do not want to be in any pain" (see July 2017 MAR). Review of the administrator's summary note dated 7/14/17 indicated "Resident 1's wheelchair had been safely secured onto the passenger bus floor; however Resident 1 was not fastened onto the wheelchair using the shoulder and lap seatbelt harness extension. It appears Resident 1 slipped forward, out of her wheelchair and onto the bus floor while the driver was making a left turn. From interviewing the driver, the shoulder and lap seatbelt harness extension that was supposed to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE used to fasten Resident 1 onto her wheelchair was not fastened because the driver believed that the bus did not have the appropriate extension (a device used to secure the resident in her wheelchair during transportation)." Review of a letter regarding the fall incident in the facility's bus on 7/11/17 from the administrator to Resident 1's family members dated 7/20/17, indicated, "I apologize for this oversight in our operations. I am sorry it took this accident for us to become aware of this shortcoming in our transportation practices. While we went to great efforts to safely lock and secure wheelchairs into place, we did not provide a shoulder and lap belt (extension)." During an interview on 7/21/17 at 9:10 a.m., Resident 1's family member stated prior to the incident on 7/11/17, Resident 1 was wheelchair bound, had a good memory and was able to converse. A concurrent observation of Resident 1 was conducted during the interview. Resident 1 was in bed, lying on her left side. Her head was slightly elevated and she was receiving oxygen via a nasal cannula. Resident 1 did not response to verbal commands and showed no voluntary movements. On 7/21/17 at 9:20 a.m., an observation was conducted when Licensed Vocational Nurse (LVN) A and the DON removed Resident 1's right knee dressing. Sutures and steristrips (thin, adhesive strips used to hold wounds closed) were visible on the knee cap. A small amount of bright red blood was oozing from the center of the wound. Resident 1's legs were contracted (bent). Further observation showed slight bruising on Resident 1's right shoulder and outer forearm. During an interview on 7/21/17 at 10:05 a.m., Resident 1's primary care physician (PCP) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated prior to Resident 1's fall on 7/11/17, the resident was alert and oriented and "sharp as a tack." He stated Resident 1 had a change in her condition after the fall on 7/11/17, it was the family's decision to place her on hospice (end of life comfort measures) to ensure the resident was pain free after the fall. The PCP stated today (7/24/17) the resident was unresponsive, and "snowed" (heavily sedated) to keep her as comfortable as possible and pain free. During an interview 7/21/17 at 10:30 a.m., the bus driver stated the facility's bus had the capacity to transport 22 passengers without a wheelchair and 18 passengers if a resident is in a wheelchair. She stated on 7/11/17 while making a complete turn to the left, the attendant told her to stop the bus because Resident 1 fell out of her wheelchair. The driver stated Resident 1 was found in a fetal position (head facing down and the knees bent) on her right side. She stated the attendant and her lifted the resident back into the wheelchair, grabbed the first aid kit and placed a dressing onto the resident's right knee. On 7/21/17 at 11 a.m., an observation of the facility's bus was conducted, accompanied by the driver. The passenger seats had the capability to apply seatbelts. The rear of the bus had the back seats folded up to make an area available for two residents in wheelchairs. A shoulder/lap extension was visible attached to the wall on the left side of the bus. A concurrent interview was conducted with the driver. She stated the shoulder extension was to be pulled across the wheelchair and attached to the back seatbelt buckle. The driver stated she did not put the shoulder/seatbelt extension on during Resident 1's trip on 7/11/17 because she was unable to locate the shoulder and lap extensions. She stated (after Resident 1's incident) she "looked and looked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for the shoulder/seatbelt extension, she finally found it." She confirmed the bus equipment and safety of the residents are the responsibility of the driver. During an interview on 7/21/17 at 11:10 a.m. the attendant stated she had accompanied Resident 1 in the bus on 7/11/17. She stated she hooked Resident 1's wheelchair to the floor board in the bus per the driver's request. The attendant stated there was a shoulder/seatbelt strap in the bus but she was told by the driver the strap was not to be used. She stated on 7/11/17, she sat on the right side of the bus in front of Resident 1 and kept turning around to check on the resident. The attendant stated when the bus was making a turn, she turned around and she saw Resident 1 on the floor. She did not hear any noise prior to seeing the resident on the floor. The attendant stated she removed her own seatbelt and told the driver to stop the bus so they could help the resident. She said the driver and her lifted Resident 1 back into her wheelchair and then applied the shoulder strap extension. During an interview on 7/21/17 at 11:30 a.m., Resident 1's family member was interviewed. He stated Resident 1 was placed under hospice care after the accident on 7/11/17 because the resident was in excruciating pain and the family felt if the resident was under hospice care she could receive the appropriate amount of pain medication to keep the resident pain free. On 7/25/17 at 10:30 a.m., a telephone interview was conducted with the director of administrative services. He stated after Resident 1's fall out of her wheelchair in the bus on 7/11/17, he located the shoulder and lap seat harness extension inside a bag in the back of the bus. The director of administrative FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055303 (X3) DATE SURVEY COMPLETED 08/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANTERBURY WOODS 651 Sinex Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services stated he was able to buckle the harness extension safely. He stated the driver was aware of the location of the shoulder and lap seat harness extension. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F5T611 Facility ID: CA070000032 If continuation sheet 11 of 11