Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canterbury Woods during CMS and state inspections, most recent first.
Kitchen sanitation and food labeling deficiencies were identified when a Dishwasher was observed in the kitchen without a hair restraint and several bread products in the pantry were found without delivery or expiration dates. The EC verified both issues, and facility policy required hair restraints for food service staff and dating of foods before storage.
A facility failed to ensure that three residents understood BAA documents before signing them. One resident said she did not know about the agreement and had just had surgery, another said it felt like a condition of admission and he wanted more time to read it, and a third could not explain what an arbitration agreement meant and wanted to read the document. Staff gave conflicting accounts about who handled the admissions packet and BAA, while the DON stated residents must understand documents before signing.
A resident with COPD and acute respiratory failure with hypoxia received continuous oxygen therapy via nasal cannula at 2 LPM without a physician’s order and without an oxygen care plan in place. Documentation of oxygen use appeared in the resident’s vital sign records, and a CNA reported the resident had been on oxygen since the first day of stay. During review, the DON confirmed there were no active physician orders or care plan addressing oxygen therapy, despite facility policies requiring physician-ordered oxygen administration and inclusion of all services and treatments in baseline care planning.
A resident with acute pulmonary edema and other conditions was incorrectly administered Lasix three times daily instead of the prescribed three times weekly. This significant medication error was confirmed by staff interviews and a review of the medication administration record.
The facility failed to ensure safe and sanitary storage of foods brought by family or visitors, with items in the dining area refrigerator accessible to all residents, including those on special diets. Additionally, expired food was found in a cabinet, contrary to the facility's policy on discarding outdated items.
A facility failed to notify the Long-Term Care Ombudsman when a resident was transferred to an acute care hospital. The social service designee confirmed the omission, which was against the facility's policy requiring notification to the Ombudsman for resident transfers or discharges.
A resident with hearing loss and moderate cognitive impairment relied on a cellphone for communication, but the facility's care plan did not include this tool. The MDS assessment confirmed the resident's communication needs were not person-centered, violating the facility's care planning policy.
A facility failed to provide a resident-centered activity program for a resident with Alzheimer's and dementia. Despite the resident's preference for music and travel channels, these were not offered, and no reading or drawing materials were available. The activities coordinator noted the resident's participation in social dining but lacked documentation of activity refusals or updates to the care plan.
A resident experienced significant weight loss, but the facility failed to conduct an IDT meeting to assess and address the issue. Despite the resident's reluctance to eat and the provision of supplement shakes by family, there were no physician's orders for high-calorie food or supplements, and the care plan was not updated. The RD and DON confirmed the lack of documentation and IDT meetings, contrary to facility policies.
A facility failed to obtain informed consent before installing bed rails for a resident, as required by their policy. The bed rail was initially installed, removed, and then reinstalled without securing the necessary consent. The absence of an informed consent verification form was confirmed during interviews and record reviews, highlighting a lapse in following the facility's procedures.
A facility failed to document the administration of a controlled medication for a resident, leading to an inaccurate medication count. During a shift change, a discrepancy was found in the count of lacosamide, an anticonvulsant, as the accountability sheet showed 7 doses remaining, but only 6 were present. The evening shift nurse did not document the administration of one dose, and the DON acknowledged the need for proper documentation and counting during shift changes.
The facility failed to follow the recipe for chicken teriyaki puree, as the executive chef added extra milk not specified in the recipe. This deviation was confirmed by the registered dietitian and had the potential to affect the palatability and food intake of two residents on a puree diet.
A resident signed a binding arbitration agreement without fully understanding it, as the facility failed to ensure the agreement was explained in a comprehensible manner. Despite having intact cognition, the resident was unaware of their right to refuse or withdraw from the agreement, highlighting a deficiency in the facility's admission process.
A facility failed to follow infection control practices when an LVN assisted a resident without performing hand hygiene, as required by the facility's policy. The LVN handled a glucometer and stored it without washing hands, which was confirmed during an interview.
Kitchen Sanitation and Food Labeling Deficiencies
Penalty
Summary
Food was not stored and/or prepared under sanitary conditions when a kitchen staff member was observed in the kitchen without a hair restraint and unlabeled bread products were found in the dry food pantry. During an initial kitchen tour, the Executive Chef verified that a Dishwasher was walking around the kitchen without a hair net, and stated the staff member should have been wearing one. Other staff present in the kitchen were wearing hairnets. During a later tour of the dry food pantry, the Executive Chef verified that one pack of wheat bread and two packs of potato rolls were not labeled with a delivery and/or expiration date. Facility policy required food service workers to wear approved hair restraints when on duty and required foods to be dated before being placed in storage areas.
Residents Did Not Understand Binding Arbitration Agreements Before Signing
Penalty
Summary
The facility failed to ensure that three sampled residents who signed binding arbitration agreements understood the agreements before signing. Resident 9 verified her signature on a BAA signed after admission and stated she did not know about the agreement, was not aware she had signed it, and had just had surgery before signing; her MDS dated shortly after admission showed a BIMS score of 15. Resident 39 verified his signature on a BAA signed shortly after admission and stated it felt like a condition of admission and that he wished he had been given more time to read it, noting he had been brought in by gurney at the time. Resident 23 was lying in bed awake during interview and stated she was not sure whose signature was on the BAA signed after admission, could not explain what an arbitration agreement meant, and wanted to read the signed document. The Social Services Director stated it was not in their job description to do the admission packet and BAA, while the Life Enrichment Specialist stated social services did the admissions packet and BAA and that the BAA is usually presented right after admission; the LES also verified signing by Resident 23's niece and stated it would probably be better to have a witness sign to make sure the BAA was clearly understood. The DON stated the facility must make sure a resident understood prior to signing any document such as a BAA, and the facility policy required the agreement to be explained in a form and manner the resident and representative understood.
Oxygen Therapy Provided Without Physician Order or Care Plan
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice when a resident received oxygen therapy without a physician’s order and without an oxygen care plan. The resident was admitted with diagnoses including COPD with acute exacerbation and acute respiratory failure with hypoxia. Review of the resident’s Weights and Vital Summary for oxygen saturation from 1/12/26 to 1/14/26 indicated the resident was on oxygen via nasal cannula during that period. A CNA reported that the resident had been using oxygen via nasal cannula since the first day of stay. During an interview and concurrent record review, the DON stated the resident was on continuous oxygen therapy at 2 LPM during the stay. When reviewing the resident’s care plan and physician order summary with active orders as of 1/14/26, the DON confirmed there was no care plan for oxygen use and no physician order in place. The facility’s policy on Oxygen Therapy required that oxygen be administered by a licensed nurse as ordered by the physician, and the facility’s MDS Baseline Care Planning policy required inclusion of any services and treatments to be administered by the SNF and its personnel. These policies were not followed in the provision of oxygen therapy to this resident.
Significant Medication Error with Lasix Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the physician's order for Lasix, a diuretic medication, was not followed. The resident, who was readmitted to the skilled nursing facility with acute pulmonary edema, chronic diastolic congestive heart failure, and type 2 diabetes mellitus, was supposed to receive Lasix 20 mg orally once a day every Monday, Wednesday, and Friday. However, the medication administration record indicated that the resident received the medication three times a day over four consecutive days. The error was confirmed through interviews with the resident, a registered nurse, the minimum data set coordinator, and the director of nursing. The resident reported the error, and the staff verified that the medication was administered incorrectly, contrary to the physician's order. The facility's policy on medication administration requires adherence to prescriber's written orders, and the error was acknowledged by the staff involved.
Improper Food Storage and Expired Items in Dining Area
Penalty
Summary
The facility failed to ensure that foods brought by family or visitors and stored in the refrigerator at the facility dining area were kept in a safe and sanitary manner. During an observation, it was noted that the refrigerator contained various food items, including juices, snack packs, yogurts, and an opened bottle of wine, which were readily accessible to all residents. This was particularly concerning for residents on special diets. Interviews with the Director of Nursing (DON), Director of Dining Services (DDS), and the Registered Dietitian (RD) confirmed that the refrigerator should not have been accessible to residents, especially those with dietary restrictions. The facility's policy indicated that access to storage areas should be restricted to authorized personnel only. Additionally, the facility failed to remove expired food items from the dining area. An observation revealed that a packet of expired eclipse gum with discolored gums was stored in a cabinet above the refrigerator. Both the DON and RD acknowledged that the expired gum should not have been kept in the cabinet and confirmed its removal. The facility's policy on food storage required the discarding of outdated items, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide written notification to the Long-Term Care Ombudsman for a resident who was transferred to an acute care hospital. This deficiency was identified during an interview and record review, which revealed that the facility did not document the notification of the Ombudsman regarding the transfer of the resident. The social service designee confirmed that the notification was not sent, acknowledging that it should have been done. The facility's policy and procedure on transfers and discharges require that a notice be sent to a representative of the Office of the State Long-Term Care Ombudsman when a resident is transferred or discharged.
Failure to Implement Person-Centered Care Plan for Resident's Communication Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with communication needs. The resident, who was admitted with diagnoses including myringotomy tube status and bilateral presbycusis, reported during an interview that he could not hear and relied on his cellphone's translator function as a communication tool. However, a review of his care plans revealed that his communication problem related to hearing deficit did not include the use of his cellphone as a communication tool. The minimum data set (MDS) assessment for the resident indicated a moderate cognitive impairment and highly impaired hearing, with no hearing aid or appliance used. During a review with the MDS coordinator, it was confirmed that the care plan did not reflect the resident's use of his cellphone for communication, which was acknowledged as a failure to provide person-centered care planning. The facility's policy on care planning emphasized the need for interventions that provide effective, safe, and person-centered care, which was not adhered to in this case.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an activity program that met the needs, interests, and preferences of a resident diagnosed with Alzheimer's disease and dementia. The resident's minimum data set indicated a strong preference for listening to music, yet during observations, there were no music or travel channels offered, nor were there any books, magazines, or drawing materials available in the resident's room. The activities care plan noted the resident's limited activity involvement due to immobility or physical limitations and included interventions to invite the resident to activities of interest or provide room activities if unable to attend group activities. The activities coordinator acknowledged that the resident was only participating in social dining and had refused all other activities, but there was no documentation to support this claim. Additionally, the care plan was not updated to reflect the resident's participation in social dining. The facility's policy and procedure on activities emphasized the need for an ongoing program based on comprehensive assessments and care plans to support residents' choices and well-being, but the facility failed to document or offer the activities outlined in the resident's care plan.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) assessed and discussed the cause of unplanned weight loss for a resident, updated the care plan with measurable goals and interventions, and provided necessary and timely interventions to maintain the resident's acceptable weight. The resident, who was admitted with diagnoses including epilepsy, hemiplegia, and type 2 diabetes, experienced significant weight loss over a period of weeks. Despite this, there was no follow-up by the IDT after the significant weight loss was identified. The resident's medical records indicated a weight loss of 7.7% over 12 days, and further significant weight loss was noted in subsequent weeks. The registered dietitian (RD) observed the resident's reluctance to eat due to shakiness and instability and noted that the resident's family provided nutrition supplement shakes. However, there was no documentation of an IDT meeting to address the weight loss, nor were there physician's orders for high-calorie food or supplements. The care plan did not reflect additional feeding support or the use of nutrition supplement shakes. Interviews with the RD and the director of nursing (DON) confirmed the lack of documentation and IDT meetings regarding the resident's weight loss. The facility's policies and procedures required IDT review and intervention for significant weight changes, but these were not followed. The RD acknowledged that interventions such as a fortified diet and high-calorie supplements could have been recommended but were not implemented.
Failure to Obtain Informed Consent for Bed Rail Installation
Penalty
Summary
The facility failed to adhere to its policy regarding the use of bed rails for a resident, identified as Resident 2. The deficiency was identified when it was observed that there was no informed consent verification form obtained prior to the installation of bed rails. The bed rail was initially installed on July 6, 2022, removed on April 25, 2024, and reinstalled on May 6, 2024. Despite the physician's order dated May 6, 2024, indicating the use of side rails to assist with mobility and provide comfort, the facility did not secure informed consent from the resident or their representative before the initial installation. During interviews and record reviews, it was confirmed by the Minimum Data Set Coordinator (MDSC) that the informed consent verification form was missing from Resident 2's clinical records. The facility's policy, dated April 2017, mandates that informed consent must be obtained and documented before the installation of bed rails. The absence of this documentation suggests that the resident and their responsible parties were not fully informed about the use of bed rails, which is a critical step in ensuring resident safety and compliance with regulatory standards.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to document the administration of controlled medications on the controlled medication accountability sheet for a resident, which compromised the facility's ability to ensure accurate administration of medications. During a controlled medications accountability check, it was found that the count of lacosamide, an anticonvulsant medication, was incorrect. The accountability sheet indicated there should be 7 doses remaining, but only 6 were found in the bottle. This discrepancy was noted during a shift change when the registered nurse did not open the bottle to verify the count. Further investigation revealed that the evening shift nurse did not document the administration of one dose of lacosamide on the previous day. The Director of Nursing acknowledged that the licensed nurses should have documented the administration of controlled medications and conducted a proper count during shift changes. The facility's policy and procedure for controlled substance medication orders require documentation in the resident's medical record with the date, time, and signature of the person receiving the prescription.
Failure to Follow Puree Recipe for Chicken Teriyaki
Penalty
Summary
The facility failed to ensure that the recipe for making puree was followed, specifically when the executive chef did not adhere to the recipe for chicken teriyaki puree. During an observation, the executive chef was seen adding 12 ounces of chicken teriyaki and 3 ounces of milk into a blender, then pureeing them. After checking the consistency, the chef added an additional 2 ounces of milk, which was not specified in the facility's undated pureed recipe. The recipe indicated that 4 ounces of protein should be combined with 1 ounce of milk until smooth and pudding-like in consistency, without any mention of adding extra milk. The registered dietitian confirmed that the executive chef should have followed the recipe as written. The facility's policy on modified texture foods, revised in January 2024, emphasized the importance of following standardized processes to ensure palatability, flavor, texture, and nutritional value. This deviation from the recipe had the potential to affect the palatability and food intake of two residents on a puree diet, out of a total census of 15 residents in the skilled nursing facility.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident, who signed a binding arbitration agreement (BAA), understood the agreement prior to signing. This deficiency was identified during an interview and record review involving one of the five sampled residents. The resident, who had a BIMS score indicating intact cognition, stated that he was not aware he had a choice not to sign the BAA during admission and did not recall if the agreement was explained in a way he understood. The resident also mentioned feeling overwhelmed by the amount of paperwork during admission and was unaware of his right to terminate or withdraw from the agreement within 30 days of signing. Interviews with facility staff, including the Activities Coordinator and Director of Nursing, revealed that the BAA was a new and recent addition to the admission process. The staff indicated that they would not allow a resident to sign the BAA if they appeared sleepy or did not understand the agreement. However, the facility's policies and procedures require that the agreement be explained in a manner that the resident and their representative understand, which was not adhered to in this case. This oversight posed a risk for the resident to make uninformed decisions regarding their rights in the event of disputes or allegations of medical malpractice.
Infection Control Breach During Resident Assistance
Penalty
Summary
The facility failed to implement proper infection control practices for one of the residents, identified as Resident 165, during a medication administration observation. On the specified date and time, a Licensed Vocational Nurse (LVN) assisted Resident 165 with her bare hands without performing hand hygiene as per the facility's policy. After assisting the resident, the LVN handled a glucometer and stored it in the medication cart without performing hand hygiene. During an interview, the LVN confirmed the observations and acknowledged the failure to perform hand hygiene before and after assisting the resident, which is a requirement according to the facility's handwashing/hand hygiene policy revised in October 2021.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 183 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pacific Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Hill Manor Health Center | 0 mi | ★★★★★ | 2 | 0 |
| Oceanview Post Acute | 0.6 mi | ★★★★★ | 15 | 0 |
| Cypress Ridge Care Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Monterey Post Acute | 1.6 mi | ★★★★★ | 4 | 0 |
| Westland House | 2.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Canterbury Woods.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.