Inspection Reports for
Canterbury Woods

The visit was complaint-related due to reports of missing personal belongings from resident rooms. Sixteen residents reported missing items, and eleven residents refused to file personal property inventory lists.

During the visit, sixteen residents reported missing items, and it was noted that eleven of these residents had refused to file personal property inventory lists and signed declination forms. The facility was also undergoing construction, which was not interfering with residents' daily living functions.

During the visit, the Licensing Program Analyst met with the senior executive assistant and followed up on the facility's investigation. The facility had recently implemented visitor badges and additional video cameras for security. The analyst was also notified of a planned water shut off due to construction and the facility's efforts to provide alternative water access for residents and staff.

The facility was found to be clean, in good repair, and compliant with safety and health regulations. No deficiencies were issued during this inspection. Residents and staff files were reviewed and found to be up to date.

The facility was found deficient in multiple areas including failure to notify the Long-Term Care Ombudsman of resident transfers, incomplete person-centered care plans, inadequate activity programs, insufficient nutritional interventions for weight loss, lack of informed consent for bed rails, medication administration documentation errors, medication errors, failure to follow food preparation recipes, improper storage of resident and visitor foods, failure to ensure resident understanding of binding arbitration agreements, and lapses in infection control hand hygiene practices.

The facility was found to be clean, in good repair, and compliant with safety and health standards. No deficiencies were issued during this inspection.

During the inspection, the Licensing Program Analyst toured the facility and found no deficiencies. A copy of the report was provided and an exit interview was conducted.

The complaint was substantiated. Resident 1 was admitted on 2/20/2023 and assessed as independent in nutrition and meals on 3/1/2023. On 7/17/2023, the resident collapsed due to hypotension and was treated for dehydration and acute kidney injury.

The investigation found that one resident did not receive adequate personal assistance, resulting in dehydration and acute kidney injury. The allegations were substantiated based on interviews, record reviews, and observations.

The facility was found to be in compliance with no deficiencies cited. The inspection included tours of the facility, review of emergency preparedness, medication storage and administration, and resident and staff files.

The facility had multiple deficiencies including failure to maintain sanitary environments, inadequate notification procedures, inaccurate resident assessments, insufficient activity programming, unsafe bed safety practices, improper respiratory care, lack of registered nurse coverage, improper psychotropic medication use, medication storage issues, food safety and sanitation lapses, and infection control failures.

The Licensing Program Analyst (LPA) interviewed the Administrator, obtained copies of staff and resident files, and will request additional police and medical records related to the incident. A follow-up visit may occur if necessary.

The visit was triggered by a complaint or incident report dated 2023-06-15. No substantiation status is provided.

The Licensing Program Analyst interviewed the Administrator, reviewed staff and resident files, and planned to request additional police and medical records related to the incident. A follow-up visit may occur if necessary.

The complaint involved allegations that Staff 1 was rough when providing care to Resident 1, causing pain in his legs when assisting with dressing. Resident 1 reported the issue had been ongoing for about a month and a half.

The inspection found that the facility elevator was out of service for several weeks, limiting resident mobility, and that a staff member was rough when providing care to a resident, causing pain and discomfort. Deficiencies were cited related to maintenance and operation as well as personal rights of residents.

No citations were issued during the visit per the California Code of Regulations Title 22. The Licensing Program Analyst conducted a tour, interviewed a resident and the administrator, and reviewed relevant documentation.

The facility was toured inside and out, including assisted living areas, with no obstructions found in fire exit routes. Medications and hazardous items were secured. Infection control measures including COVID-19 symptom screening, PPE usage, and vaccination clinics were reviewed. No citations were issued per California Code of Regulations Title 22.

The Licensing Program Analyst and Program Clinical Consultant reviewed facility policies and procedures related to screening, isolation, disinfecting, staffing, training, PPE usage, and visitation. Recommendations included posting hand washing signs, maintaining an isolation room PPE cart, and continuing staff training on infection prevention and control.

The Licensing Program Analyst and Program Clinical Consultant reviewed the facility's policies and procedures related to screening, isolation, disinfecting, staffing, training, PPE usage, and visitation. Recommendations included posting hand washing signs, maintaining an isolation room PPE cart, and continuing staff training on infection prevention and control.

The complaint investigation found substantiated failures in post-fall neurological assessments for three residents, improper medication storage with expired medication present, and use of expired sanitizing test strips in the kitchen.

The facility failed to perform neurological checks as required after unwitnessed falls for three residents, failed to ensure safe storage of medications by having expired medication in the medication cart, and used expired sanitizing test strips in the kitchen. These failures posed potential risks to resident health and safety.