Driftwood Healthcare Center - Santa Cruz

Inspectors wroteBased on interview and record review, the facility failed to provide care, services, and assistance for showering for two of three sampled residents (resident 1 and 2). This failure had the potential to affect the personal hygiene, comfort, skin concerns, health condition, and well-being for Residents 1 and 2.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (plan of care addressing individual care, treatments, which should be sensitive to a resident's cultural, personal values, and lifestyle) for activities of daily living (ADL, basic and routine tasks required for a resident) care for one of three sampled resident (Resident 1), when Resident 1's care plan lacked interventions for refusal of showers. This failure had the potential for the lack of participation in developing and implementing a person-centered plan of care for ADLs for Resident 1, especially regarding showering.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper use of bed rail (or side rail, adjustable rigid bars attached to the side of a bed) for 12 of 15 residents (64,11, 80, 51, 71, 8, 9, 14, 17, 26, 35, and 36) when there were no documented evidence that the side rail entrapment risk assessments for the 12 residents were completed. This failure had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of five Residents (8,18,40,44) eye drops medications were appropriately stored and labeled. This failure placed residents at potential risk for receiving the wrong medication and expired medications, which could lead to medication ineffectiveness and medication adverse reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure puree food recipes were followed during cooking for 14 of 84 residents. This failure had the potential to compromise the health and safety of 14 residents who receive pureed diets. During an observation in the kitchen on December 9, 2025, at 11:39 a.m., [NAME] A was observed adding hot water from the kitchen faucet to the blender to prepare pureed bread without measuring the amount added. During an observation in the kitchen on December 9, 2025, at approximately 11:50 a.m., [NAME] A was observed adding 1 scoop (4 ounce) of food thickener to the pureed Brussels sprouts and adding approximately 21/2 scoops (10 ounce) of food thickener to the pureed bread. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served under sanitary conditions and failed to follow infection control protocols when:1. Five food items were not labeled with an open date, and three food items were expired in the walk-in refrigerator; 2. One food item in the dry storage room was not labeled with an open date; 3. Two trash cans in the kitchen were observed without lids when not in use; 4. Kitchen staff used contaminated gloved hands to touch the blender blade assembly; 5. Kitchen staff did not wash or replace the blender lid after it fell into the sink and continued to use it to prepare pureed Brussels sprouts; 6. Kitchen staff did not use tongs to distribute bread and instead used gloved hands that had touched multiple surfaces; and7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention techniques were followed when:1. For one of three residents (Resident 36) the licensed nurse failed to wear gloves when giving an injection2. The Certified Nursing Assistant (CNA) B failed to wear the proper Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illness)) when providing care to one of seven residents (Resident 71) on Enhanced Barrier Precautions (EBP, infection control guidelines, primarily for nursing homes, that require staff to wear gowns and gloves during high-contact resident care activities to prevent the spread of multidrug-resistant organisms [MDROs, microorganisms that are resistant to many common antibiotics]).3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the administration of controlled medications (narcotics, including potential opioids for pain management) for two of eight sampled residents (Resident 7, 37), by failing to document the administration and refusal of Resident 7's and 37's medications on the Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility). This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement their abuse policy and procedures for one of three sampled residents (Resident 1) when the facility did not report Resident 1's allegation of abuse. This failure resulted in Resident 1's allegation of abuse not reported to required agencies California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility. During an interview on 5/15/25 at 1:11 p.m., with Resident 1. Resident 1 stated she has a concern about a gentleman that comes in her door, she stated she is afraid for other residents what the gentleman can do to them. Resident 1 stated the gentleman's room was two doors next to hers. Resident 1 stated she filed a grievance for that, and social services knows. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) when Resident 1 got out of the facility without supervision. This failure put Resident 1 at risk for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The registered dietician (RD) walked in the hallway to the big dining room with gloves on; 2. The rehab director (RHD) checked the residents' lunch tickets on the lunch trays, passed lunch trays to certified nursing assistant N (CNA N) and certified nursing assistant O (CNA O) to bring to the residents in their rooms without sanitizing her hands; CNA N and CNA O carried lunch trays to the residents without sanitizing their hands; licensed vocational nurse A (LVN A) checked the residents' lunch tickets on the lunch trays and opened the lids of the lunch trays to check on the food without sanitizing her hands; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four residents (39, 48, and 64) had informed consents (written permission before implementing a healthcare intervention) prior to initiating psychotropic medication (medication capable of affecting the mind, emotions, and behavior). These failures resulted in the residents receiving psychotropic medications without being informed about their risks and side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans related to alleged abuse were reviewed and updated by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) for three of six residents (Residents 61, 63, and 75). This deficient practice had the potential to place the residents at risk of psychosocial and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for five (Residents 81, 285, 22, 26, and 28) of 14 residents (residents who used bed or side rails) when: 1. Residents 81 and 285 had side or bed rails even when their siderail evaluation revealed both residents did not require the use of siderails; 2. Residents 22 and 28 had side or bed rails even when their siderail evaluation revealed both residents did not require the use of siderails; and Residents 22 and 26 did not have a documented physician's order for the use of siderails. These failures had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, evaluate and managed residents' behavior for one of two sampled residents (Resident 285) when Resident 285 had episodes of screaming which sounded like a baby crying. The failure had the potential for Resident 285, not attaining her highest practicable physical, mental, and psychosocial well-being and caused discomforts to other residents in the same hallway (Residents19 and 61).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriate social services (SS) support for four of six residents (Residents 61, 63, 75 and 285) when: 1. There was no documentation of timely SS support following Resident 61's complaint of missing money; 2. There was no SS support following an alleged abuse to Resident 63 and no documentation on SS follow up to address Resident 63's psychosocial needs; 3. There was no SS support following an alleged abuse to Resident 75 and no documentation on SS follow up to address Resident 75's psychosocial needs; and 4. There was no SS follow up to address Resident 285's behavior. These failures resulted in a lack of timely social services interventions and had the potential not to address Residents 61, 63, 75, and 285's psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate pharmacy pharmaceutical services when: 1. A medication, Lamictal (a medication used to treat conditions such as bipolar disorder and seizure disorders) 200 milligrams (mg, unit of measure), was not available for one out of six residents (Resident 8), 2. There were discrepancies between the controlled drug (those with high potential for abuse and addiction) record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for four out of four residents (Residents 3, 22, 40, and 51), 3. A controlled substance medication was wasted without a witness for Resident 41, 4. The controlled substances medication destruction records did not have a registered nurse (RN) signature for three out of three residents (Residents 82, 335, and 336), and, 5. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure 3 of 18 sampled residents (Residents 2, 41, and 59) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 2 received five psychotropic medications without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) and without documented clinical rationale why the GDR was contraindicated (advised against in specified cases or under specified conditions); 2. Resident 41 received Seroquel (generic name: [...]

Inspectors wroteBased on observation and interview the facility failed to ensure food served was palatable and attractive. This failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition and health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Pans and a bowls used for food preparation and food service were stacked and stored wet; 2. A cup was left inside the sugar container; 3. Unpasteurized eggs were used during a breakfast meal service. These failures had the potential to cause food contamination and food-borne illness to 79 of 79 residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the dumpster lid was kept closed. This failure had the potential to attract pests in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call buttons (a red button used by residents to request assistance) were easily accessible for use for seven of 18 sampled residents (Residents 285, 286, 6, 80, 40, 13, and 49). This failure had the potential to cause delays in attending to Residents 285, 286, 6, 80, 40, 13, and 49's needs which could affect their physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents when: 1. Resident 59's room had bent window screens, a big hole on the wall, and the pipe at the toilet in his restroom was leaking every time the toilet was flushed; and 2. The walls at the heads of the beds of Resident 29 and Resident 72 were peeled off and the dry wall was exposed. These failures had the potential to adversely affect the health and safety and to create a poor quality of life for the residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure two of eight residents (Residents 6 and 284) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatment patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) when the licensed nurse left the computer screen open and unattended on top of the treatment cart for two of eight residents (Residents 31 and 64). This deficient practice had the potential to compromise the resident's privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for one out of 18 residents (Resident 59) when they did not include a care plan to include goals, approaches, interventions, and the monitoring for the signs of symptoms of bleeding related to an anti-coagulant medication:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for two of 18 residents (10 and 184) when: 1. Resident 10 had five open skin areas on her face, but there was no treatment order for them; and 2. Resident 184 did not have floor mat at his bed side as ordered by the physician, recommended by the interdisciplinary team (IDT, a team comprises professionals from various disciplines who work in collaboration to address residents' needs), and indicated as one of the interventions in Resident 184's fall care plan. These failures had the potential to affect the residents' care and could jeopardize their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for indwelling catheter for one of three residents (Resident 31) when Resident 31's indwelling catheter (a catheter which is inserted into the bladder [a sac-shaped muscular organ that stores the urine secreted by the kidneys],via the urethra [the tube through which urine leaves the body] and remains in place to drain urine) was not properly secured and the urinary tube connected to a urine drainage bag was filled with thick yellow sediments(caused by the precipitation of calcium, phosphorus, and magnesium minerals in the urine). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported drug irregularities during the monthly medication regimen review (MRR); and that there was documented clinical rationale when the physician disagreed with the CP's recommendation, for two of 18 sampled residents (Resident 2 and 29). The failure resulted in Resident 29 receiving concomitant use of two medications in the same therapeutic class, the loop diuretics (a type of medication that exerts its action on certain part of the kidneys; used in the management and treatment of fluid overload conditions such as heart failure and high blood pressure), for over a year; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one out of 18 sampled residents (Resident 29) was not receiving two medications of the same therapeutic class for over one year. This deficient practice had the potential for Resident 29 to receive unnecessary medication from duplicate therapy and increased risk of adverse effects from the medications.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 7.41% when two medication errors occurred out of 27 opportunities during medication administration for one out of six residents (Resident 8). This failure resulted in medication not given in accordance with the prescriber's order and facility policy and procedure (P&P), which resulted in resident not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals were stored appropriately when: 1. An emergency medication kit (e-kit, a kit/box containing medications for immediate use during a medical emergency) contained an expired medication in it. This had the potential for residents to be given expired medications in an emergency, which would be ineffective for their treatment. 2. A treatment cart with wound care supplies was left unlocked, and the cart's drawer was left opened. This had the potential for access to medications and supplies by unauthorized persons such as residents and visitors

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food preferences were honored when Resident 46 disliked the planned lunch entrée. This failure had the potential to result in decreased food intake and potential weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure snacks was in accordance with resident's needs, preferences, and requests for one (Resident 288) of seven sampled residents (residents who attended the resident council's meeting). This failure resulted in Resident 288's needs and preferences not being met. This failure had the potential for other residents not to have snacks in their requested times.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a safe, and comfortable environment for one of six residents (Resident 81) when Resident 81's headboard and footboard of bed were loose and wobbly. This failure had a potential to compromise residents' safety, well-being, and health.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent unauthorized drug use for one of two sampled residents (Resident 1) when: 1. The interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) did not conduct an IDT meeting to discuss Resident 1's concerns regarding unauthorized drug use of fentanyl (an opioid drug to treat pain); 2. The care plan for unauthorized drug use was not updated; 3. The care plan for alcohol abuse (overuse of alcohol), opioid abuse (overuse of a broad range of drugs used to reduce pain, including illegal drugs), and/or non-compliance behavior of unauthorized drug use was not developed; 4. The elopement risk assessment was not accurate about medical history and did not develop a care plan for elopement risk; and 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to assign the recommended one-on-one staff to one of 2 sampled residents (Resident 1) for adequate monitoring, as was indicated in the plan of action of the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients), following an incident on 6/9/23 where Resident 1 was found to have consumed an un-prescribed (not prescribed by a medical practitioner) Diazepam [Valium; a controlled medication to treat anxiety, alcohol withdrawal, and seizures (convulsions)]. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) and manufacturer's instructions for medication administration to ensure safe medication dosage administration for one of two residents (Resident 1) when it was discovered Resident 1 had an excess of buprenorphine patches (adhesive patch with opioid [opium-like; opium is a natural substance found in the poppy plant that works in the brain to relieve pain sensation, among a variety of other effects] medication on it for pain relief when applied to the skin) simultaneously applied to his skin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (1)'s plan of care for fall prevention was implemented during her readmission on [DATE]. This failure had resulted in Resident 1 falling out of bed with injury as bleeding from her nose and a lump on her forehead.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent accidents for one of two sampled residents (Resident 1) when: 1. Staff did not provide supervision or the required assistance, 2. Staff did not develop a care plan for Activities of Daily Living (ADL), and 3. Staff did not implement resident-centered interventions for falls. These failures resulted in Resident 1's fall in the facility with a fracture (broken) of the second cervical vertebra (vertebra of the neck).

Inspectors wroteBased of observation, interview, and facility document review, the facility failed to ensure there was effective oversight for the Food and Nutrition Department as evidenced by: 1. Lapses in the delivery of services associated with staff competency (Cross-reference F802), accommodating resident food preferences (Cross-reference F806), food safety and sanitation (Cross-reference F812), and equipment maintenance (cross-reference F908); and 2. A lack of an effective system to determine portion sizes for therapeutic diets ordered in the facility. This failure to ensure dietetic services systems are accurately and effectively delivered may result in food borne illness for a highly susceptible population and/or not meeting the nutritional needs of the 50 residents who received food from the kitchen out of a facility census of 50.

Inspectors wroteBased on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when: 1. Staff did not follow the pureed (foods that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid for people with chewing or swallowing difficulties) recipe. 2. Staff did not demonstrate the proper procedures for testing the strength of chlorine and did not know the standard temperature of the chemical low temperature dishmachine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Temperatures for Time/Temperature Control for Safety Foods (TCS=food requires time/temperature control for safety) to limit the growth of pathogens (i.e., bacterial, or viral organisms capable of causing a disease or toxin formation) were above 41°F (°F, degrees Fahrenheit a temperature scale) in the kitchen walk-in refrigerator; 2. The metal part of the can opener blade was chipped off; 3. Staff did not perform hand hygiene when changing gloves; 4. Juice gun was placed nearby handwashing sink without splash guards and, 5. Garbage cans were not covered when not in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the walk-in refrigerator and ice machines in safe operating and sanitary conditions when: 1. The walk-in refrigerator did not maintain food at safe temperatures, and 2. Staff did not follow manufacturer's guidelines for cleaning and sanitizing the ice machines. These failures may lead to food-borne illness (illness resulting from contaminated food) and infectious disease (disorders caused by organisms such as bacteria, viruses, fungi or parasites) for 50 out of 50 residents who were receiving food from the kitchen and using ice from ice machines at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Staff did not wear N95 masks properly; 2. Maintenance assistant (MA) did not wear his N95 (a high filtering face mask) while talking to another staff; 3. Housekeeper C (HKS C) did not remove gloves and did not perform hand hygiene in between task; 4. Laboratory staff (LS) was wearing gloves in the hallway. These failures had the potential to result in transmission of infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the choices of one of 13 residents (Resident 16) when her preference for taking her medication was not followed. This failure had the potential of negatively affecting her psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe and home like environment for two of three sampled rooms (Rooms AA and BB) when the sliding screen door and sliding cabinet door were off track. This failure had the potential to cause injury to residents and at risk for insects, rodents to enter the resident's room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and service in accordance with professional standards of practice for one of 13 residents (Resident 21) when Resident 21's physician order for ketoconazole 2% shampoo was not administered as ordered. This failure had the potential to compromise the residents' health and could affect his well-being.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure the availability of medications to two of six residents (Resident 46 and Resident 54) when: an inhaler (a portable device for administering a drug used to be breathed in) and vitamin D2 (a nutritional supplement) were not readily available for residents. This failure had the potential for residents to miss the doses for treatment of shortness of breath and receive a supplement.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the pharmacy consultant's (PC) medication regimen review (MRR, the process of reviewing medications) recommendations for three out of 13 residents (Resident 11, 21 and 6) was followed-up and acted upon. This failure had the potential for the residents to suffer unnecessary adverse side effects that could negatively impact his/her physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 13 sampled residents (Residents 49 and 21) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions and behavior) when: 1. For Resident 49, the facility failed to ensure there was a specific duration of use for a PRN (PRN as needed) psychotropic medication that exceeded 14 days for the use of Lorazepam (a medication for anxiety [persistent feelings of worry and fears]) and, 2. For Resident 21, failed to identify the specific target behavior for the use of Seroquel. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 18.18% when six medication errors occurred out of 33 opportunities during medication administration for three out of six residents (Residents 46, 54, 5). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an alternative entrée of equal nutritive value when Resident 33 disliked the planned entrée. This failure had a potential to lead to unmet nutritional needs and weight loss for one of three sampled residents receiving foods from the kitchen at the facility.