Driftwood Healthcare Center - Santa Cruz

In the surveyor’s words

From the most serious findings on record at Driftwood Healthcare Center - Santa Cruz, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 19, 2024

  Based on interview and record review, the facility failed to provide adequate supervision to prevent unauthorized drug use for one of two sampled residents (Resident 1) when: 1. The interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) did not conduct an IDT meeting to discuss Resident 1's concerns regarding unauthorized drug use of fentanyl (an opioid drug to treat pain); 2. The care plan for unauthorized drug use was not updated; 3. The care plan for alcohol abuse (overuse of alcohol), opioid abuse (overuse of a broad range of drugs used to reduce pain, including illegal drugs), and/or non-compliance behavior of unauthorized drug use was not developed; 4. […]

• Actual harm, isolatedF689Mar 4, 2024

  Based on interview and record review, the facility failed to assign the recommended one-on-one staff to one of 2 sampled residents (Resident 1) for adequate monitoring, as was indicated in the plan of action of the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients), following an incident on 6/9/23 where Resident 1 was found to have consumed an un-prescribed (not prescribed by a medical practitioner) Diazepam [Valium; a controlled medication to treat anxiety, alcohol withdrawal, and seizures (convulsions)]. […]

• Actual harm, isolatedF755Jan 18, 2024

  Based on interview and record review, the facility failed to follow their policy and procedure (P&P) and manufacturer's instructions for medication administration to ensure safe medication dosage administration for one of two residents (Resident 1) when it was discovered Resident 1 had an excess of buprenorphine patches (adhesive patch with opioid [opium-like; opium is a natural substance found in the poppy plant that works in the brain to relieve pain sensation, among a variety of other effects] medication on it for pain relief when applied to the skin) simultaneously applied to his skin. […]

• No harm, potential for more than minimal, widespreadF880Jun 24, 2024

  Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The registered dietician (RD) walked in the hallway to the big dining room with gloves on; 2. The rehab director (RHD) checked the residents' lunch tickets on the lunch trays, passed lunch trays to certified nursing assistant N (CNA N) and certified nursing assistant O (CNA O) to bring to the residents in their rooms without sanitizing her hands; CNA N and CNA O carried lunch trays to the residents without sanitizing their hands; licensed vocational nurse A (LVN A) checked the residents' lunch tickets on the lunch trays and opened the lids of the lunch trays to check on the food without sanitizing her hands; and the infection preventionist (IP) checked the residents'… […]

• No harm, potential for more than minimal, widespreadF801Aug 19, 2022

  Based of observation, interview, and facility document review, the facility failed to ensure there was effective oversight for the Food and Nutrition Department as evidenced by: 1. Lapses in the delivery of services associated with staff competency (Cross-reference F802), accommodating resident food preferences (Cross-reference F806), food safety and sanitation (Cross-reference F812), and equipment maintenance (cross-reference F908); and 2. A lack of an effective system to determine portion sizes for therapeutic diets ordered in the facility. […]