Inspection·December 9, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Occupational Therapist (OT- a healthcare provider who helps a person meet goals to develop, recover, improve, and maintain skills needed for daily living and working) 1 accurately documented on the OT Discharge Summary Note the discharge goals for one of three sampled residents (Resident 3). OT 1 documented on 9/13/2024, Resident 3 tolerated thin hand rolled washcloth for four hours in her left hand without irritation or skin breakdown, when it should have been the documented for the right hand. This deficient practice resulted in inaccurate documentation of Resident 3's OT Discharge Summary Note and had the potential to affect Resident 3's plan of care and treatment. Findings: During a review of the Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted on [DATE] with the diagnosis of generalized muscle weakness. During a review of Resident 3's Minimum Data Set (MDS – a resident assessment tool) dated 9/13/2024, the MDS indicated Resident 3's cognition was moderately impaired, and Resident 3 was dependent (helper does all the effort) on facility staff to complete Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 3's OT Discharge Summary Note dated 9/13/2024, indicated Resident 3 tolerated a thin hand rolled washcloth for four hours in her left hand without irritation or skin breakdown. During an interview on 12/6/2024 at 10:50 a.m., Resident 3 stated that she did not want and could not open her left hand. Resident 3 stated her hands were frozen in time. During a concurrent interview and record review on 12/9/2024 at 11:53 a.m., with OT 1, Resident 1's OT Discharge Summary Note dated 9/13/2024 was reviewed. The OT Discharge Summary Note indicated Resident 3 tolerated a thin hand rolled washcloth for four hours in her left hand without irritation or skin breakdown. OT 1 stated the discharge goal should have been documented for the right hand and not the left hand. OT 1 stated if the resident's medical records are not accurate there might be a miscommunication and confusion within the care team regarding treatment and orders affecting Resident 3's plan of care because of the incorrect documentation. During an interview on 12/9/2024 at 12:00 p.m., the Director of Rehabilitation (DOR) stated the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555114 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 555114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Driftwood Healthcare Center 4109 Emerald St Torrance, CA 90503 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)