Driftwood Healthcare Center - Santa Cruz

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 [DATE REDACTED] 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.

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