Driftwood Healthcare Center

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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 REDACTED] 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).

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