Health inspection·November 5, 2025

DRIFTWOOD HEALTHCARE CENTER The following reflects the findings of the California Department of Public Health during the investigation of a complaint and facility reported incident. Complaint: CA00961481(2472934) and Facility Reported Incident: CA00962565 (2472930) Representing the Department, HFEN 50855 Citation B was written. REGULATORY VIOLATIONS: F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 5/15/2025, 5/16/2025 and 8/22/25 unannounced visits were conducted at the facility to investigate a complaint and facility reported incidents regarding resident abuse, quality of care, misappropriation of property and resident rights. 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 being 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. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. Findings: 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. During a review on 5/15/2025 of Resident 1's "Face sheet (FS, document that summarizes a person's information such as medical history), the FS indicated Resident 1 was initially admitted on 6/21/2018 to the facility with diagnoses including urinary tract infection, anxiety disorder unspecified (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), and major depressive disorder (a serious mood disorder characterized by persistent feelings of sadness, loss of interest or pleasure, and other symptoms that impair daily functioning). Review of Resident 1's admission minimum data set (MDS- a resident assessment tool) dated 4/8/2025, indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition level) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an interview on 5/15/25 at 3:31 p.m., with the Social Service Director (SSD), the SSD stated she met with Resident 1. The SSD stated Resident one invited Resident 2 to her room, and they talked about spouses then Resident 1 asked Resident 2 to leave the room because it made her uncomfortable. During a review of Facility's Grievance (a standardized document that an individual, typically an employee, uses to formally report a complaint or concern about unfair treatment, a policy violation, or a breach of their employment contract or collective bargaining agreement) form dated 4/28/25 indicated, "Resident states she invited resident [room AA] into her room-Started talking about his wife and children. He came towards me and feeling my leg. At- Which point I quickly escorted him out of the Room." During a concurrent interview and record review on 5/16/25 at 3:22 p.m. of Resident 1's grievance form dated 4/28/25, with the SSD, the SSD stated Resident 1 came to her office and she helped Resident 1 fill up the grievance form. The SSD further stated those are Resident 1 words she just helped her write it. During the follow-up interview on 5/16/25 at 2:43 p.m., with Resident 1, she stated she was sitting in her bed, then Resident 2 came forward to her, and started talking about his family. He [Resident 2] started stroking her right leg, she pushed him away and yelled at him, he back away and started making mouth gestures. Resident 1 stated she reported it to the night nurse and the night social worker on Friday. Resident 1 stated she was told this gentleman will leave on Tuesday. Resident 1 stated she felt like she was violated, and she didn't give him consent to touch her. During an interview on 5/16/25 at 3:44 p.m., with the Director of Nursing (DON), the DON stated it's not reported, from her understanding she [Resident 1] invited him [Resident 2] to her room so it's consensual, the DON further stated she only talked to Resident 2, and he denied it on 5/1/25. During an interview on 5/16/25 at 3:55 p.m., with the Administrator (ADM), The ADM stated there was no further concern from Resident 1. ADM stated Resident 1 was okay that Resident 2 will be discharged the following day. The ADM stated they thought it was not abuse, and she (Resident 1) just wanted to let them know. During an observation on 5/15/2025 at 12:50 p.m., noted Resident 2 was still in the facility. During another observation on 8/22/2025 at 11:25 a.m., Resident 2 was observed still in the facility but has been moved to another room further away from Resident 1. During a review of Resident 2's clinical records on 8/22/2025, Resident 2's clinical records indicated he was admitted on 2/27/2025 with diagnoses including cerebral infarction unspecified (a medical term that refers to a stroke where the specific cause of the blockage in a brain artery is unknown) and type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications and he was never discharged from the facility as of 8/22/2025. A Review of Facility's Five-Day summary dated 5/20/2025 indicated "Based on initial and further investigation beginning on 4/28/25 that included interviews with staff and residents, the facility was unable to substantiate the allegation of abuse." During a concurrent interview and record review on 8/22/25 at 12:18 p.m., with the Nurse Supervisor (NS), the NS reviewed Resident 1's progress notes from 4/21/25 to 4/30/25, she confirmed that there was no documentation the allegation was reported to CDPH, Ombudsman, and Law enforcement. The NS further stated she did the SBAR and progress notes about this allegation of abuse between Resident 1 and Resident 2 only on 5/15/2025 and reported it to CDPH, Law enforcement and Ombudsman only on 5/15/25. During a review of the facility's policy and procedure titled, "Abuse Investigation & reporting," undated, indicated, " All allegations of resident abuse, neglect, exploitation, misappreciation of resident property, mistreatment and/or injuries of unknown source("abuse") shall be promptly reported to the appropriate local, state and/or federal agencies (as defined by current regulations) and thoroughly investigated by Company management. Findings of abuse investigations will also be reported to local law enforcement and the Office of Ombudsman...2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but no later than: a) Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b) Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury." This failure resulted in Resident 1's allegation of abuse not being 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.