Health inspection·November 25, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Responsible Party (RP), who was a Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation), appointed by the Los Angeles County Office of the Public Guardian, for one of four sampled residents (Resident 1) was informed of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) and allowed to give their consent for Resident 1 to continue use of the medication, versus providing this information to Resident 1's FM and allowing her to give consent for Resident 1's use of the medication. This deficient practice resulted in Resident 1's Conservator being unaware of medications Resident 1 was prescribed and the inability to make decisions regarding Resident 1's care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/12/2025, the MDS indicated Resident 1's cognition was severely impaired, and Resident 1 was dependent (helper does all of the effort) on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Letter of Conservatorship dated 6/27/2025, the Letter of Conservatorship indicated the Los Angeles County Office of the Public Guardian, appointed Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation) of the person and estate of the named Conservatee (a person who is deemed by a court to be unable to manage their own personal and/or financial affairs, and for whom a judge has appointed a conservator to make decisions on their behalf) , Resident 1, effective as of 6/11/2025. During a review of Resident 1's Physician Orders, the Physician's Orders indicated the following medication prescribed to Resident 1: 1. 9/5/2025 - Quetiapine Fumarate (antipsychotic medication used to treat schizophrenia) 25 mg one tablet by mouth every eight hours as needed for agitation. 2. 9/8/2025 - Aripiprazole (antipsychotic medication used to treat mental conditions such as schizophrenia) 20 milligrams ([mg] a unit of measurement) one tablet once a day for schizophrenia manifested by predominant negativity as evidenced by a blunted affect (reduced or diminished ability to show feelings)/lack of motivation to perform daily activities. During a review of Resident 1's Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) dated 9/5/2025, the Informed Consent form indicated the signature allowing Resident 1 to use Quetiapine Fumarate was obtained from Resident 1's FM, not Resident 1's Conservator. During a review of Resident 1's Informed Consent dated 9/8/2025, the Informed Consent form indicated the signature allowing Resident 1 to use Aripiprazole was Residents Affected - Few Page 1 of 3 555114 555114 11/25/2025 Driftwood Healthcare Center 4109 Emerald St Torrance, CA 90503

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few obtained from Resident 1's FM, not Resident 1's Conservator. During an interview on 11/25/2025 at 3:02 p.m., the Director of Nursing (DON) stated the informed consent for Quetiapine Fumarate Quetiapine Fumarate and Aripiprazole should have been obtained from Resident 1's Conservator, not Resident 1's FM. The DON stated the facility staff were not [NAME] that Resident 1 had a Conservator. During a review of the facility's Policy and Procedure (P/P) titled Surrogate Decision Maker- Informed Consent dated 11/14/2025, the P/P indicated the facility will identify a person (who is unaffiliated with the facility) to serves as a representative of the Resident, including public guardians. 555114 Page 2 of 3 555114 11/25/2025 Driftwood Healthcare Center 4109 Emerald St Torrance, CA 90503

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Responsible Party (RP), who was a Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation), appointed by the Los Angeles County Office of the Public Guardian, for one of four sampled residents (Resident 1) was involved in the development of Resident 1's a discharge plan to reflect Resident 1's discharge needs, goals, and treatment preferences. This deficient practice resulted in Resident 1 being inappropriately discharged from the facility with a Family Member (FM), who was not Resident 1's Conservator and placed Resident 1 at risk for decline in health and non-continuity of care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/12/2025, the MDS indicated Resident 1's cognition was severely impaired, and Resident 1 was dependent (helper does all of the effort) on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Letter of Conservatorship dated 6/27/2025, the Letter of Conservatorship indicated the Los Angeles County Office of the Public Guardian, appointed Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation) of the person and estate of the named Conservatee (a person who is deemed by a court to be unable to manage their own personal and/or financial affairs, and for whom a judge has appointed a conservator to make decisions on their behalf) , Resident 1, effective as of 6/11/2025. During a review of Resident 1's Physician Order dated 11/6/2025, the Physician Order indicated Resident 1 could be discharged on 11/7/2025, per Resident 1's FM's request. During a review of Resident 1's Discharge Planning Review Form dated 11/7/2025, the Discharge Planning Review Form indicated Resident 1's FM was contacted regarding Resident 1's discharge planning and Resident 1 was discharge to his FM's care, per the request of the FM. During an interview on 11/25/2025 at 12:06 p.m., the Social Services Director (SSD) stated she was not aware that Resident 1 had a Conservator. The SSD stated if she had known Resident 1 had a Conservator, she would have communicated with and included the Conservator in the discussion regarding discharge plans for Resident 1. During an interview on 11/25/2025 at 3:02 p.m., the Director of Nursing (DON) stated facility staff were unaware that Resident 1 had a Conservator because there was no information regarding a Conservatorship provided when Resident 1 was admitted to the facility. The DON stated Resident 1's discharge planning should not have been discussed with Resident 1's FM and Resident 1 should not have been allowed to discharge with his FM. During a review of the facility's Policy and Procedure (P/P) titled Discharge Planning dated 7/2020, the P/P indicated if the Interdisciplinary team ([IDT] a group of professionals from different fields who work together to achieve a common goal) and the Attending Physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with the IDT, the resident, and the Responsible Party (RP). 555114 Page 3 of 3