Inspection·March 19, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's assessment of self-administration of medication dated 2/04/2023, indicated that Section 1 asked if the resident has expressed a desire to take his/her own medication(s) and was marked No (if No, do not proceed). 1. Review of Resident 1's Physician's admission Notes, dated 2/08/2023 indicated the resident had a past history of alcohol disorder, substance abuse (fentanyl), and opioid dependence. The note also indicated that the resident admitted having half a gallon of vodka daily, his last drink was a day before admission, along with fentanyl. Review of Resident 1's Nurse's progress notes dated 2/07/2023 at 3:12 p.m. indicated Resident took off around 11 a.m. without letting the nurse know or signing out, apparently picked up by his brother. Resident came back around 2 p.m. Reminded him that he has no pass to go out. Review of Resident 1's Nurse's progress notes dated 2/07/2023 at 5:06 p.m. indicated Patient came back to the facility after signing AMA (against medical advice) form and wants to be readmitted . Patient sent to ER for evaluation for safe return. Review of Resident 1's ER discharge instructions dated 2/07/2023, indicated that the reason for the visit was a medical screening exam, and the discharge diagnosis was chronic pain, substance abuse, and fentanyl dependence. The instructions included that it was the facility's policy that if someone leaves, they need to be evaluated in the emergency department (ED) prior to returning, and the resident has admitted to the fentanyl abuse. Review of Resident 1's Nurse's progress notes, dated 2/15/2023 indicated the resident was found unresponsive in the bathroom, had a lighter on his hand and a piece of foil, paramedics arrived and administered Narcan, and was sent to the ER. Review of Resident 1's ER Discharge instructions dated 2/15/2023, indicated that the discharge diagnoses were accidental fentanyl overdose and opioid overdose. The ER discharge instructions included the physician's order for Narcan 4 milligrams (mg, a measurement unit dose)/0.1 milliliters (ml, a measurement unit dose) 1 spray as directed, may repeat every 2 to 3 minutes until the patient responds. During an interview on 1/31/2024 at 2:27 p.m. with Licensed Vocational Nurse A (LVN A), LVN A stated that one staff (could not remember exactly the identity) reported to her that Resident 1 was found sitting on his bathroom floor on 2/15/2023. LVN A stated she went to check Resident 1 and found him unresponsive and holding a lighter and a piece of foil in his hand. Review of Resident 1's Nurse's progress notes, dated 2/20/2023, indicated, the resident was found by a Certified Nursing Assistant (CNA) to be sedated in bed with foil in one hand and possible drug paraphernalia (equipment) in the other, the resident was having whole body tremors and was verbally nonresponsive, fire and paramedics came to the facility, the resident became less sedated and was verbally responsive and refused multiple times to go to the ER, the resident admitted to using drugs. Review of Resident 1's Nurse's progress notes, dated 2/25/2023, indicated the resident was found by a CNA inside the toilet with foil in one hand, possibly drug paraphernalia. Review of Resident 1's Nurse's progress notes, dated 3/10/2023, indicated the resident was found again by a CNA inside his room with foil and a lighter in his hands, seemed he was doping, and he was (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 03/19/2024 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 sedated, and he refused to call paramedics. Level of Harm - Actual harm During an interview on 1/31/2024 at 3:42 p.m. with LVN B, he stated that he was the charge nurse for Resident 1 on 2/25/2023 and 3/10/2023. LVN B stated Resident 1 was drowsy and holding a foil in his hand when he found him sitting on the bathroom toilet, almost falling to the floor, on 2/25/2023. LVN B stated Resident 1 was drowsy and holding a lighter and foil in his hand when he found him on his bed on 3/10/2023. LVN B further stated he was aware of Resident 1's drug overdose history, but there was no adequate supervision provided to the resident. Residents Affected - Few During an interview and record review on 10/20/2023 at 11:50 a.m. with the Director of Nursing (DON), the DON confirmed she did not find any documentation regarding an IDT completed to address Resident 1's drug use overdose. The DON also stated an IDT care conference for unauthorized drug use should have been conducted and documented. The DON further stated that the facility provided 1:1 supervision for 3 days of his stay and needed to start 1:1 supervision earlier to prevent the repeated drug use. During an interview on 3/19/2024 at 11:55 a.m. with the unit manager (UM), the UM stated Resident 1 should have received 1:1 supervision since the facility was aware that he had this behavior of unauthorized drug use to prevent his unauthorized drug use. 2. Review of Resident 1's care plan for behavioral symptoms, created on 3/13/2023, indicated Resident was suspected use of drugs in the facility, and the problem start date was 2/10/2023. The interventions in the care plan included an IDT care conference were done, and risk versus (vs, against) benefits were discussed. The care plan was not updated with the repeated unauthorized drug use to prevent further unauthorized drug use. During an interview and record review on 9/07/2023 at 1:30 p.m. with the UM, she confirmed that Resident 1's care plan for the suspected drug use was not updated to include new interventions when Resident 1 had repeated episodes of drug use on 2/15/23, 2/20/23, 2/25/23 and 3/10/23. 3. Review of Resident 1's care plans indicated there was no care plan for alcohol abuse, opioid abuse, or non-compliance behavior of unauthorized drug use. During an interview and concurrent record review with the UM on 9/07/2023 at 1:30 p.m., the UM reviewed Resident 1's medical record and did not find any care plan for the non-compliance behavior on unauthorized drug use. The UM also stated the non-compliance behavior care plan should have been developed. During a follow up interview and concurrent record review with the UM on 11/03/2023 at 12:50 p.m., the UM confirmed the care plan for alcohol abuse, opioid abuse or non-compliance behavior of unauthorized drug use was not developed for Resident 1. The UM acknowledged that a care plan for alcohol abuse, opioid abuse and non-compliance behavior of unauthorized drug useshould have been developed. 4. Review of Resident 1's elopement risk assessment dated [DATE] indicated Resident 1 had no substance abuse/psych (involving mental illness) history and was considered not at risk. During an interview and concurrent record review on 10/20/2023 at 11:50 a.m. with the DON, she confirmed that Resident 1's elopement risk assessment dated [DATE] was not accurate because Resident 1 had diagnoses including major depressive disorder, alcohol abuse with alcohol-induced mood disorder, (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 03/19/2024 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 and opioid abuse. Level of Harm - Actual harm During an interview and concurrent record review with the UM on 11/03/2023 at 11:40 a.m., the UM confirmed Resident 1 eloped from the facility on 2/07/2023 and came back the same day. The UM confirmed there was no care plan developed regarding Resident 1's elopement episode that happened on 2/07/23. The UM acknowledged that a care plan for elopement should have been developed. Residents Affected - Few 5. Review of Resident 1's ER Discharge instructions dated 2/15/2023, included the physician's order for Narcan 4 milligrams (mg, a measurement unit dose)/0.1 milliliters (ml, a measurement unit dose) 1 spray as directed, may repeat every 2 to 3 minutes until the patient responds. During an interview and concurrent record review with the UM on 11/03/2023 at 12:00 p.m., the UM confirmed Resident 1 had a physician's order of Narcan spray when he came back from the ER on [DATE]. The Narcan order was not carried out in the facility. The UM acknowledged that the order should have been carried out. During a follow-up interview with the UM on 3/7/2024 at 2:05 p.m., the UM stated, the physician's order for Narcan spray dated 2/15/23 from the ER was not clarified with Resident 1's attending physician and was not transcribed for Resident 1's use if needed. During a review of the facility's policy and procedure (P&P) titled Care Planning-Interdisciplinary Team, approved 12/2020, the P&P indicated, Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. During a review of the facility's undated policy and procedure (P&P) titled Risk Meeting, the P&P indicated, The risk meeting is designed to bring current resident issues to the interdisciplinary team for discussion, potential alterations to the care plan, notification to all disciplines regarding current status of residents, and to develop proactive approaches designed to prevent acute episodes from occurring. During a review of the facility's undated policy and procedure (P&P) titled Behavior Assessment, Intervention and Monitoring, the P&P indicated, Assessment: as part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. During a review of the facility's undated policy and procedure (P&P) titled Resident Elopement, the P&P indicated, The facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for elopement. Upon return of the resident, the Director of Nursing or charge nurse will update the resident's care plan with preventive interventions for elopement. During a review of the facility's undated policy and procedure (P&P) titled Comprehensive Plan of Care, the P&P indicated, Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial (involving both psychological and social factors) needs identified during the comprehensive assessment. The comprehensive plan of care must address the resident's individual needs, strengths, and preferences; be periodically reviewed and revised by the interdisciplinary team as changes in the resident's needs. Develop goals and approaches for each problem and/or condition. Re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055109 If continuation sheet Page 4 of 4