Inspection·January 18, 2024

F 0755 Level of Harm - Actual harm Residents Affected - Few found to have one 10 mcg patch on his back and he also had three 5 mcg patches on his chest for a total of 25 mcg. [ .] This in addition to the urine infection is likely what is causing the patient's fuzziness as he does not have signs of a stroke at this time. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) A on 9/29/23 at 9:44 a.m., Resident 1's Medication Administration Record (MAR), dated 9/2023, was reviewed with LVN A. LVN A stated when applying a transdermal patch, the nurse should make sure to remove the old patches, apply the new patches that the administering nurse labels with the date and her/his initials, and document the new patch's location in the clinical record. LVN A confirmed Resident 1's MAR lacked a designated area to document placement locations of transdermal patches. During an interview with LVN B on 9/29/23 at 10:25 a.m., she stated when discarding residents' used transdermal patches (after removing them from the resident), nurses usually cut them or fold them in half prior to disposing them in the medication disposal bin of the medication cart. She stated the disposal of transdermal patches required two nurses. She confirmed neither the Controlled Drug Record (CDR, an inventory and dispensing record for narcotics) or MAR had a place to document removal and disposal of residents' used transdermal patches. During a concurrent interview and record review with the Director of Nursing (DON) on 9/29/23 at 11:20 a.m., Resident 1's CDR and MAR, dated 9/2023, were reviewed with the DON. She confirmed both the CDR and MAR indicated he last received buprenorphine 15 mcg/hr patch on 9/15/23, but there was no documented evidence to indicate old patches were disposed of that day. She confirmed 9/15/23 was the last time Resident 1 received buprenorphine prior to his ED visit. She stated nurses would remove an old patch by cutting it up and disposing it in the medication disposal bin of the medication cart. She stated two nurses should sign off upon the removal and disposal of transdermal patches; however, there was no place for nurses to document the removal and disposal of the old patch. During an interview with Resident 1 and his wife on 9/29/23 at 1:00 p.m., Resident 1 stated he went to his appointment with his primary doctor in the community with his wife on 9/20/23. He stated, during the appointment, he felt weird; so, he was sent to the ED. The ED doctor at the hospital saw several patches on him of the same medication with different strengths. Resident 1 stated he could not remember whether the nurse removed any old patches on 9/15/23. Resident 1's wife confirmed her husband's statement was accurate. Review of the United States Drug Enforcement Administration (DEA) Drug Fact Sheet, dated 5/2022, indicated Buprenorphine . produces . sedation. However, acute, high doses of buprenorphine have been shown to have a blunting effect on both physiological (of the body) and psychological (of the mind) effects due to its partial opioid activity. Review of the facility's P&P, Transdermal Medication Disk (patch), dated 8/18/2021, indicated, Procedure 6. Remove any previously applied medication disk by gently lifting and peeling away from the skin [ .] Documentation 1. On the medication sheet, record: type of medication, date, time, and site of application, and dose. [ .] 3. Document in the electronic health records system. If the electronic health records system is not available, the documentation can be accomplished in paper form. Review of the facility's Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for buprenorphine transdermal patch, dated 6/2022, indicated, Each BTS patch is intended to be worn for 7 days . The old patch should be removed before applying the new one . the maximum BTS dose is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055109 If continuation sheet Page 2 of 3 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 055109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Driftwood Healthcare Center - Santa Cruz 675 24th Avenue Santa Cruz, CA 95062 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 0755 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 20 mcg/hour . Do not exceed a dose of on 20 mcg/hour . Dose adjustments may be made in 5 mcg/hour, 7.5 mcg/hour, or 10 mcg/hour increments by using no more than two patches of the 5 mcg/hour . or 10 mcg/hour system(s). The total dose from both patches should not exceed 20 mcg/hour. Because extended-release products deliver the opioid over an extended period of time, there is a greater risk for overdose and death, due to the larger amount of buprenorphine present. Event ID: Facility ID: 055109 If continuation sheet Page 3 of 3