Inspection·March 4, 2024

F 0689 doctor) was contacted, message was left awaiting further orders. Level of Harm - Actual harm Review of Resident 1's Observation Detail List Report: Risk Meeting Notes Initial Week One, dated 6/9/23, .Resident consumed medication that was not prescribed . On 6/9/23 at 0600 the Charge nurse went into residents' room to check vital signs and resident noted to have a bubble pack of diazepam 10 mg on side of his pillow. The nurse immediately confiscated the pills and secured them in a locked narcotics drawer (drawer to keep controlled drugs). The resident was assessed. All Vitals stable and WNL (within normal limits). The Doctor was notified .IDT Plan of action: 1) Monitor resident for the next 72 hours for any s/sx (signs and symptoms) of being under the influence of illicit drug use. 2) Staff do thorough sweeps (search) of the room q (every) shift for any non-prescribed drugs. 3)recover and confiscate any drugs if found. Monitor resident q (every) shift for any signs or symptoms of illicit drug use. 4) monitor resident for any attempts to receive non prescribed drugs from any source .7) One on one to monitor resident . Residents Affected - Few Review of Resident 1's Nurses Progress Notes, dated 6/12/2023 at 1:31 p.m., indicated, RESIDENT NOTED TO BE SEDATED AND SLURRING HIS WORDS. CHARGE NURSE WENT TO ASSESS RESIDENT FURTHER AND RESIDENT NOTED WITH A PACKET OF DIAZEPAM AT BEDSIDE PACK OF 20 WITH 3 LEFT IN PACKAGE. AS CHARGE NURSE WALKED IN RESIDENT 2 IN ROOM A WAS IN RESIDENT 1 ROOM AND RESIDENT 2 HANDED RESIDENT 1 A PILL AND RESIDENT 1 SWALLOWED IT AS NURSE ASKED FOR IT. MD (medical doctor) WAS CONTACTED AND ORDER TO SEND TO ER (emergency room) FOR FURTHER EVAL (evaluation) WAS GIVEN. Review of Resident 1's Nurses Progress Notes, dated 6/12/2023 at 3:16 PM, indicated, Staff contacted 911 for this resident due to overdose of medication labeled as Diazepam. This resident has a documented DX (diagnosis) of depression and a history of suicidal ideation (thoughts and preoccupation with death and dying). The resident's VS (vital signs, an objective measurement of the body's most basic functions) were low per his baseline; BP 95/57 (blood pressure, the measurement of the pressure or force of blood inside your arteries, between 90/60 and 120/80 mmHg (millimeters of mercury) is considered ideal), RR 16 (respiratory rate, rate of breathing, normal rate is 12-18 breaths per minute for adults at rest) and O2 Sat 90% (oxygen saturation,indicates the percentage of oxygen in the blood and provides information about the functioning of the lungs, normal rate is 95% or higher) on rm (room) air (air we breathe which has 21% of oxygen). Staff assessed and determined the resident to be altered, drowsy but rousable. Resident stated he felt awful and dizzy. Staff was unable to determine with absolute certainty exactly what and how much drugs this resident consumed. The EMT's (Emergency medical technicians, provide life-saving care to patients at the scene of an emergency and during transportation in an ambulance during transport to a hospital) assessed the resident and transferred him out as a 5150 (allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for further monitoring and evaluation . Review of Resident 1's ED (Emergency Department) Physician Notes, dated 6/12/23, indicated: Arrival mode: Ambulance History of Present Illness: The patient presents with benzodiazepine (medication that produce sedation and hypnosis, relieve anxiety, and muscle spasms, and reduce seizures) overdose. This is a [age]-year-old male BIBA (brought in by ambulance) from [SNF name] to the ED (emergency department) on a 5150 hold .after a suspected 17mg ingestion of Valium around 1400 today. Per EMS (Emergency Medical Services), patient was seen by staff with the Valium bottle that originally contained 20 tablets and only 3 were left when they looked. Staff is not sure if the 20 tablets was the original amount of Valium. Patient is not prescribed the Valium . Patient states he did not take the Valium. Per staff, patient is normally more alert and oriented, but is more lethargic (drowsy & lack of energy and mental alertness, a decrease in consciousness) Resp Rate (Monitor) rate 10 Breaths/Min (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055109 If continuation sheet Page 2 of 4 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 03/04/2024 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 0689 (minute) (respiration; breathing, how the air moves into and out of lungs. A normal respiration rate is 16 to 20 breaths per minute). Level of Harm - Actual harm Residents Affected - Few During an interview with licensed vocational nurse A (LVN A) on 8/31/23, at 2:55 p.m., the LVN A stated she was the charge nurse when Resident 1 had an episode of medication overdose on 6/12/23. The LVN A stated Resident 1 had a small box of Diazepam found on his bedside table. The LVN stated it's not the same bubble pack (type of medication package) from the facility, and Resident 1 looked sedated that time. During a phone interview and concurrent record review with the staffing coordinator (SC) 12/5/23, at 2:05 p.m., the SC stated she assigns the one-on-one staff as communicated by the director of nursing (DON). The SC reviewed the Nursing Staffing Assignment and Sign-in sheet dated 6/9/23, 6/10/23, 6/11/23, and 6/12/23. The SC confirmed there was no one-on-one staff assigned to Resident 1 on these days. The SC stated that she did not assign a one-on-one staff for Resident 1 because she was not instructed to assign a one-on-one staff for Resident 1. The SC stated it is the DON who communicates with the SC (her) which residents need a one-on-one. During an interview and concurrent record review with the Director of Nursing (DON) on 12/8/23, at 12:00 p.m., the DON reviewed the Risk Meeting IDT notes dated 6/9/23. The DON confirmed the IDT's plan of action after Resident 1's suspected medication overdose on 6/9/23, included one-on one monitoring for Resident 1 and that there was no one-on-one staff assigned to Resident 1 following the suspected overdose episode on 6/9/23 until 6/12/23 when Resident 1 was transferred to the hospital for evaluation. The DON stated Resident 1's first episode of medication overdose occurred on 6/9/23 on a Friday. The DON stated the one-on-one monitoring IDT recommendation was not assigned timely. The DON stated it should be implemented because another medication overdose incident happened so quickly. The DON instructed the nursing staff (CNAs, charge nurses) to check Resident 1's room for medications and instructed CNAs to monitor the resident for anything suspicious. The DON stated the monitoring that was provided by the CNAs was on and off, in between their patient care duties. The DON stated it might not provide the same level of monitoring and supervision provided by the one-on-one staff who stay with and watch the resident all the time. The DON also stated Resident 1 was already being monitored for falls, sleep, pain, behavior, which the DON felt was already enough at that time. Upon review of the Alert charting notes and Nurse's progress notes, the DON confirmed there was no proof of documentation that the 72-hour monitoring was done by the nursing staff, after Resident 1's overdose episode on 6/9/23. The DON also stated that Resident 1 can be very sneaky and manipulative, and that Resident 1 was capable of hiding medications in his pocket or taking medications while in the bathroom. The surveyor inquired about implementing the one-on-one staff to Resident 1 due to his manipulative and sneaky behavior. The DON stated that providing one-on-one staff might help. The surveyor inquired if the reason the IDT recommended the one-on- one staff to monitor Resident 1 was to prevent the recurrence of the overdose incident from 6/9/23, the DON agreed. Review of Review of Resident 1's Care Plan, dated 6/12/2023, indicated that Resident 1 had Medication overdose. The interventions included health teaching on medication administration effect and benefits of medication including adverse effects, physiological referral .Resident is taking medication that is not prescribed to him. The interventions included, consulted with MD for alternatives to evaluate if current regimen is effective. Offered resident drug rehab. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055109 If continuation sheet Page 3 of 4 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 03/04/2024 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 0689 Level of Harm - Actual harm Review of Resident 1's Physician's Order, dated 6/14/2023, indicated, Monitor the resident for s/sx (signs and symptoms) of altered mentation due to overdose and or consumption of non-prescribed medication. Special instructions: For resident monitoring illicit drug use every shift .Routine room checks/sweeps for drugs and or medications not prescribed. Special instructions: For prevention of illicit drug use. Every shift . Residents Affected - Few Review of Resident 1's Observation Detail List Report: Risk Meeting Notes Initial Week One, dated 6/12/23, indicated, .on 6/12/23 Staff contacted 911 for this resident due to overdose of medication labeled Diazepam (10 mg) .Plan of Action: 1) The resident admitted to the hospital for self administered non prescribed medication overdose. 2) One on one for this resident upon return to the facility for monitoring and prevention of another incident of illicit drug use. 3) Out on pass (temporary permission for resident to leave the facility) revoked. Resident requires a facility designed chaperone to accompany him to all necessary appointments outside of the facility . 6) Q-shift (every shift) monitoring for s/sx of being under the influence. 7) Q shift room sweep for narcotics. Q-shift monitoring for s/sx of emotional distress. 8) Q- shift monitoring for drug seeking behavior . Review of facility's policy and procedure, titled, Risk Meeting, dated 12/8/23, The Risk Meeting is designed to bring current resident/patient issues to the interdisciplinary team for discussion, potential alterations to the care plan, notification to all disciplines regarding current status of residents/patients, and to develop proactive approaches designed to prevent acute episodes from occurring. Review of facility's policy and procedure, titled, Safety Supervision of Residents, dated 9/24/23, indicated, Individualized, Resident -Centered Approach to Safety .2.The interdisciplinary care team shall analyze information obtained from assessmentsand observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adquate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of intervetions shall include the following: a. Ensuring that interventions are implemented correctly and consistently . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055109 If continuation sheet Page 4 of 4