Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Driftwood Healthcare Center - Santa Cruz during CMS and state inspections, most recent first.
The facility failed to document entrapment risk assessments for multiple residents who had side rails, half side rails, transfer rails, or grab bars in use. Surveyors observed the rails in the upright position for several residents and reviewed orders and side rail evaluations showing inconsistent documentation, including entries marked not completed or not applicable. The DON, MS, and RNs gave conflicting descriptions of who completed the assessments and what the assessments included.
Eye drop medications for four residents were found improperly labeled during a cart inspection. Three artificial tears bottles had resident identifiers only on the boxes, not on the containers, and another resident’s eye drops had only a room number and date opened on the box with no identifier on the bottle. RN D acknowledged the potential for error, and the RPH stated the container should be labeled for identification and infection prevention.
Pureed Food Recipes Not Followed During Preparation: An employee was observed preparing pureed bread and pureed Brussels sprouts without following the recipe amounts. He added unmeasured hot water from the kitchen faucet and used a 4-oz scoop of thickener, including about 10 oz in the bread and 4 oz in the Brussels sprouts. The RD confirmed the amounts exceeded the recipe requirements, and the facility policy required pureed foods to be prepared according to menu recipes and product guidelines.
Food storage and handling practices were not sanitary. In the kitchen, multiple refrigerated items and one dry storage item were missing open dates, several refrigerated items were expired, and trash cans were left uncovered while not in use. Staff also used contaminated gloves to handle utensils, blender parts, and food, reused a blender lid after it fell into the sink, served bread with gloved hands instead of tongs, and cleaned the ice machine in a manner that did not follow the manufacturer’s instructions.
A nurse gave an injection to a resident without gloves, a CNA provided care to a resident on EBP without the required yellow gown, and an LVN performing G-tube feeding for another resident did not change gloves at key points during the procedure. The observations and interviews showed staff did not follow PPE and glove-use requirements for injections, EBP care, and enteral feeding tasks.
Accurate documentation of controlled medication administration was not maintained for two residents. For one resident, an LPN documented Norco as given on the MAR even though the medication remained in the package and the resident had refused it; for another resident, the CDR showed oxycodone was removed, but the MAR did not document administration. The facility's policies required MAR documentation of the medication details and documentation of each medication refusal.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident left the facility unsupervised through an unsecured wooden door, which was neither locked nor alarmed, leading to a deficiency in supervision. The RN confirmed the lack of security measures, and the DON acknowledged the risk posed by unlocked doors. Maintenance staff admitted the door was not regularly monitored, and there were no logs of door checks before the incident.
The facility failed to implement proper infection control practices, including staff not sanitizing hands when handling meal trays, entering COVID-19 isolation rooms without appropriate PPE, and improper handling of sterile dressings. Additionally, oxygen equipment was not maintained, and hand hygiene was neglected between resident interactions, increasing the risk of infection spread.
Three residents in an LTC facility were administered psychotropic medications without documented informed consent. Despite the facility's policy requiring verification and documentation of informed consent by the Licensed Nurse, the Director of Nursing was unable to locate the necessary consents for the medications prescribed to these residents.
The facility failed to update care plans for three residents following allegations of abuse. One resident reported missing money, another alleged verbal abuse by a roommate, and a third reported multiple incidents, including physical and verbal abuse by a CNA and financial abuse. The care plans did not reflect the interdisciplinary team's recommendations or include interventions to minimize emotional distress.
The facility failed to properly assess and document the use of bed rails for several residents, leading to potential safety risks. Bed rails were installed for residents who did not require them, without obtaining necessary physician orders, informed consent, or developing care plans. The DON confirmed these deficiencies, which violated the facility's policy and procedure for bed rail use.
The facility failed to manage a resident's behavioral health needs, as evidenced by the resident's frequent screaming episodes that disturbed other residents. Despite the resident's severe cognitive impairment and medical conditions, no care plan was developed to address the behavior, and staff did not intervene during the episodes. The facility's policy on behavior assessment and monitoring was not followed, leading to a deficiency in care.
The facility failed to provide adequate social services support for several residents, leading to unaddressed psychosocial needs. A resident reported missing money, but there was no timely follow-up. Another resident alleged verbal abuse by a roommate, yet the recommended psychological evaluation and monitoring were not implemented. A third resident reported physical and financial abuse, with no documented follow-up. Additionally, a resident's disruptive behavior was not managed, despite complaints from others. The facility did not fulfill its responsibility to address these residents' psychosocial needs.
The facility failed to provide appropriate pharmaceutical services, including the unavailability of a prescribed medication for a resident with bipolar disorder, discrepancies between controlled drug records and medication administration records for several residents, and improper handling of controlled substances. These issues were confirmed by the DON and involved missing documentation and signatures, contrary to facility policy.
A facility failed to ensure residents were free from unnecessary psychotropic medications. One resident received multiple psychotropic drugs without a gradual dose reduction (GDR) or documented rationale for contraindication, despite no exhibited behaviors. Another resident was prescribed Seroquel without specific indication or initial AIMS assessment. A third resident's GDR assessment lacked a documented rationale for contraindication. The facility's policies require specific diagnoses and documentation for antipsychotic use, which were not followed.
The facility failed to provide palatable and attractive food, as evidenced by resident complaints and a test tray evaluation. Surveyors found a breaded chicken fillet to be hard, dry, and overcooked, contrary to the facility's standards for meal preparation. The consultant dietary manager disagreed with the surveyors' assessment.
The facility failed to follow food safety standards, as wet pans and bowls were improperly stored, a cup was left in a sugar container, and unpasteurized eggs were used during breakfast service. The CDM and RD confirmed these practices were against facility policies, posing a risk of foodborne illness to residents.
The facility failed to keep the dumpster lid closed, potentially attracting pests. Observations revealed that a staff member left the lid open after disposing of garbage, and the dumpster was overflowing with boxes, preventing closure. The dietary supervisor confirmed the lids should be closed, aligning with the facility's policy on food waste disposal.
The facility failed to ensure call buttons were accessible for seven residents, potentially delaying assistance. Observations revealed call buttons were often placed out of reach, such as on the floor or covered by items, despite staff acknowledging they should be within reach. This issue was confirmed by multiple staff members and contradicted the facility's policy.
The facility failed to maintain a safe and sanitary environment, with a resident's room having bent window screens, a large hole in the wall, and a leaking toilet pipe. Two other residents had peeling walls exposing drywall. These issues were not addressed despite being reported, posing potential health and safety risks.
The facility failed to ensure that two residents were informed about having an advance directive and that their POLST forms were completed. One resident, with diagnoses including cerebral infarction and dementia, had an incomplete POLST, and the absence of an advance directive was confirmed. Another resident, with conditions such as sepsis and diabetes, had neither a POLST nor an advance directive documented. The facility's policy required social services to facilitate the advance directive process, which was not followed in these cases.
A breach of resident confidentiality occurred when a nurse left computer screens open and unattended, displaying sensitive health information for two residents. This happened while the nurse was providing care, leaving the information exposed in a busy hallway, contrary to the facility's confidentiality policy.
A facility failed to create a comprehensive care plan for a resident prescribed Eliquis for DVT prevention. Despite the resident's history of mood disorder and traumatic brain injury, no care plan was developed to include goals, interventions, and monitoring for bleeding symptoms. The DON confirmed the absence of a care plan, which violated the facility's policy.
The facility failed to provide necessary care for two residents. One resident had open skin areas on her face without a treatment order, and another resident, at high risk for falls, lacked a physician-ordered floor mat at his bedside. These deficiencies were confirmed by an LVN.
A resident's indwelling catheter was not properly secured, and the urinary tube was filled with thick yellow sediments. Observations revealed inadequate securing of the catheter stabilization device and dried blood on the resident's thigh. Interviews with staff highlighted inconsistencies in catheter care practices, and the resident's records lacked documentation of catheter and device changes, contrary to facility policies.
The facility failed to ensure the Consultant Pharmacist identified and reported drug irregularities during monthly medication regimen reviews for two residents. One resident received two loop diuretics simultaneously for over a year without a documented rationale, while another was on five psychotropic medications without attempts at gradual dose reduction, despite no exhibited behaviors. The physician disagreed with the CP's recommendations without providing a clinical rationale, contrary to facility policy.
A resident was prescribed both furosemide and torsemide, two loop diuretics, for over a year without clear justification, leading to unnecessary medication use. The consulting pharmacist was unsure of the rationale, and the facility's policy emphasized safe medication administration, highlighting a deficiency in medication management.
A medication error rate of 7.41% was identified in an LTC facility due to two errors involving a resident. An LVN administered an incorrect dosage of Lamictal due to a stock issue, and improperly administered olopatadine eye drops by not following the correct procedure. The errors were observed during a medication pass, and the facility's policies were not adhered to.
The facility failed to properly store medications and biologicals, as an emergency kit contained expired lorazepam, and a treatment cart was left unlocked in the hallway. An LVN confirmed the expired medication should have been replaced, and a policy requires outdated medications to be removed. Additionally, an RN left a treatment cart unsecured while attending to a resident's wound care, contrary to the facility's policy requiring medication supplies to be locked when unattended.
A resident on a pureed diet, who disliked fish, was served pureed fish for lunch despite their documented preference. The RD confirmed the oversight, noting that an alternative should have been provided according to facility policy.
A resident on antibiotics experienced stomach upset and was unable to receive crackers at night, leading to refusal of medication. The facility lacked proper snack storage and did not assess the resident's food preferences upon admission, as confirmed by the DON and RD.
A resident's bed had a loose and wobbly headboard and footboard, compromising safety. The DON and the resident confirmed the issue during an observation. LVN A mentioned that faulty equipment should be logged and followed up, while the DO stated that maintenance should check the binder daily. However, no work order was found for the resident's bed in the maintenance log for June.
A resident with multiple diagnoses and severe cognitive impairment fell and fractured her cervical vertebra due to the facility's failure to provide adequate supervision and develop a proper care plan. The resident was not checked frequently, and her fall care plan was not tailored to her needs, leading to the incident.
Missing Bed Rail Entrapment Risk Assessments
Penalty
Summary
The facility failed to ensure proper use of bed rails for 12 of 15 residents because there was no documented evidence that side rail entrapment risk assessments were completed for those residents. The report states that residents 64, 11, 80, 51, 71, 8, 9, 14, 17, 26, 35, and 36 had side rails or grab bars in use, and surveyors found no documented entrapment risk assessments for them. The deficiency was identified through observation, interview, and record review. During observations, Resident 64, Resident 71, Resident 11, Resident 80, Resident 51, Resident 35, Resident 14, Resident 9, Resident 36, Resident 26, Resident 6, and Resident 17 were observed with bilateral side rails, half side rails, transfer rails, or grab bars in the upright position. Physician orders for these residents indicated side rail use to enable independent repositioning and transfers, or transfer rails/grab bars when in bed. The DON confirmed multiple observations and reviewed side rail documentation for several residents. Record review showed that some residents had side rail evaluation forms completed on various dates, but several entries indicated that entrapment risk was not completed or was marked not applicable. For example, Resident 64's side rail evaluation did not show how entrapment risk was assessed, and the DON confirmed the assessment was not done. Resident 71's entrapment risk assessment was not done, Resident 11's was not done, and Resident 80's assessment was not done because grab bars were considered less restrictive. For Resident 51, the side rail evaluation indicated the resident did not require side rails at the time of evaluation, with no documented evidence of an entrapment risk assessment on the date referenced in the report. The MS stated he completed annual entrapment risk assessments for beds with or without residents and would attach side rails for a new resident once nursing staff informed him, but would not do the entrapment risk assessment after the side rails were attached. RN A stated there was no checklist or form for entrapment risk assessment and described only checking whether a hand could get trapped or whether movement was restricted. RN D stated maintenance placed the side rails and a supervising nurse would do the entrapment assessment, but no evidence was provided describing what the assessment included.
Eye Drop Medications Not Properly Labeled in Medication Carts
Penalty
Summary
The facility failed to ensure that eye drop medications for four residents were appropriately stored and labeled. During an observation and concurrent interview, medication carts one, two, and three were inspected and three bottles of artificial tears for three residents were found in medication cart one with the box labeled with the resident name, date opened, and room number, but with no resident identifiers on the bottle. In medication cart three, one box of artificial tears for another resident had only a room number and date opened on the box and no identifier on the bottle. RN D confirmed there was a potential for error when only the boxes had resident identifiers. The pharmacist stated the eye drops should have a label on the container in case the box is lost and for infection prevention so the wrong eye drop container is not used on residents. The facility policy for multi-dose medications stated each container must have the resident's name, medication name, dose, route, dispensing pharmacy label, and expiration date.
Pureed Food Recipes Not Followed During Preparation
Penalty
Summary
The facility failed to ensure pureed food recipes were followed during cooking for 14 of 84 residents who received pureed diets. During an observation in the kitchen on December 9, 2025, [NAME] A was seen adding hot water from the kitchen faucet to the blender to prepare pureed bread without measuring the amount added. [NAME] A was also observed adding 1 scoop (4 ounces) of food thickener to pureed Brussels sprouts and approximately 2 1/2 scoops (10 ounces) of food thickener to pureed bread. During an interview on December 10, 2025, [NAME] A confirmed that he added water from the kitchen faucet instead of using a measuring cup and used a 4-ounce scoop to add food thickener. He acknowledged that he added approximately 10 ounces of thickener to the pureed bread and approximately 4 ounces to the pureed Brussels sprouts, which was more than required by the recipes. The RD reviewed the recipes for Wheat Bread Conv PU and Brussels Sprouts FZN PU and confirmed that the amounts used did not match the recipe requirements. The facility policy stated that pureed food preparation should follow menu recipes and use product guidelines for thickening.
Food Storage and Handling Sanitation Failures
Penalty
Summary
Food items were found stored in the kitchen walk-in refrigerator and dry storage room without required dating, and several refrigerated items were expired. During observation, five items in the walk-in refrigerator had no open date, including sweet pickle relish, horseradish, Italian dressing, BBQ sauce, and heavy-duty mayonnaise, and three items were expired, including vinaigrette dressing, tartar sauce, and honey mustard dressing. One partially used bag of corn flakes in the dry storage room was also observed without an open date. The Dietary Services Manager confirmed these observations and stated that opened food items should be labeled and expired items removed to ensure food safety. The kitchen was also observed with two trash cans without lids while not in use. The Dietary Services Manager confirmed the observation and stated that trash cans should be covered with lids to help prevent the spread of infection. The Registered Dietitian later stated that food items in the refrigerator should be labeled with received, opened, and use-by dates, and that the opened bag of corn flakes should have been labeled with the open date. The facility policy stated that food should be dated and labeled with received, open, and use-by dates and that garbage containers should always be closed. Multiple food handling practices were observed that involved contaminated gloves and improper handling of food-contact equipment. A kitchen employee used the same gloves to touch utensils, the blender handle, the blade assembly, and cooked chicken, then continued using the same gloves while preparing finely chopped chicken, pureed Brussels sprouts, and pureed bread. The Registered Dietitian confirmed the contaminated food was removed from the tray line. In another observation, the Dietary Services Manager continued blending Brussels sprouts after the blender lid fell into the sink and was placed back on without washing or replacing it. During tray line service, another employee used gloved hands that had touched multiple utensil handles to grab bread instead of using tongs. The ice machine was also observed and reviewed; the Maintenance Supervisor stated he cleaned it with hot water and wiping, while the manufacturer’s manual required a sanitizer and lukewarm water solution for cleaning.
Infection Control PPE and Glove Use Failures
Penalty
Summary
A licensed nurse failed to wear gloves while giving an injection to Resident 36 during a medication pass observation. The nurse stated that she usually wears gloves, and the facility policy for subcutaneous injections indicated to put on gloves. The facility also failed to follow enhanced barrier precautions for two residents. For Resident 71, who had an order for EBP due to an IV to the left hand, a CNA removed the resident’s blanket and heel booties without wearing the required yellow gown, and the Medical Records Director confirmed the CNA was not wearing the gown and reminded her to wear the PPE. For Resident 11, who had orders for EBP due to a G-tube feeding, an LVN wore gloves and a yellow gown, prepared the tube feeding, then changed gloves before checking residual and later connected the primed tubing to the G-tube without changing gloves again; the LVN confirmed she did not change gloves before those steps. The Infection Preventionist stated the LVN should have changed gloves before checking residual and again before connecting the tubing because she had touched other things.
Inaccurate Documentation of Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medication administration for two sampled residents. For Resident 7, the Controlled Drug Record showed hydrocodone-acetaminophen 5-325 mg was removed on 12/10/25 at 8:28 a.m., but a concurrent count of the medication package showed the Norco was still in the package and therefore had not been administered. The MAR for December 2025 nevertheless showed the medication as administered at 8:28 a.m. For Resident 37, the Controlled Drug Record showed oxycodone HCL 5 mg was removed on 9/1/25 at 12:00 a.m. and again on 9/25/25 at 2:00 p.m., but the 9/2025 MAR did not show documentation that the medication had been administered. The physician order dated 8/4/25 directed oxycodone HCL 5 mg, 1 tablet every 6 hours as needed for moderate to severe pain. The facility's Medication Pass Guidelines required recording the name, dose, route, and time on the MAR and initialing after administration, and the Refusal of Treatment policy required documentation each time a resident refused medication.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Resident Elopement Due to Unsecured Exit
Penalty
Summary
The facility failed to provide adequate supervision for a resident who managed to leave the facility without supervision, putting the resident at risk for accidents. On the day of the incident, the resident, who uses a walker, was able to exit the facility through a wooden door that led to the street. This door was accessible from the resident's room via a sliding door that opened to a patio. The wooden door was neither locked nor equipped with an alarm, allowing the resident to leave unnoticed. Further investigation revealed that the facility's Registered Nurse confirmed the absence of a lock and alarm on the wooden door. Additionally, a glass door near another room was found ajar, and its alarm system was not functioning. The Director of Nursing acknowledged that unlocked doors posed a risk to residents. The facility's maintenance staff admitted that the wooden door was not included in their regular monitoring prior to the incident, and there were no logs of door checks before the date of the incident. The facility's policy required daily testing of door alarms, but policies on accident hazards were not provided.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances, leading to potential infection spread. The registered dietician was observed walking in the hallway with gloves on after leaving the kitchen, acknowledging the oversight. Additionally, multiple staff members, including the rehab director, CNAs, and the infection preventionist, handled lunch trays and checked meal tickets without sanitizing their hands, despite acknowledging the need for hand hygiene. In COVID-19 isolation rooms, staff members, including the activity director and CNAs, entered without appropriate personal protective equipment. Some wore surgical masks instead of N95 respirators, and one CNA entered without a gown. These actions were contrary to the facility's policy requiring enhanced transmission-based precautions, including the use of N95 masks, gowns, gloves, and eye protection. Other deficiencies included undated oxygen tubing and dusty concentrator filters for residents on supplemental oxygen, improper handling of sterile dressings by a registered nurse, and failure to perform hand hygiene between assisting different residents with meals. Additionally, a CNA was observed not wearing a face mask during a COVID-19 outbreak, and another CNA used dirty gloves to handle clean items during incontinent care, further risking cross-contamination.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents received informed consent before the administration of psychotropic medications. Resident 39, diagnosed with psychosis and depression, was prescribed olanzapine and trazodone without documented informed consent. Similarly, Resident 48, with diagnoses of psychosis and mood disorder, was given Depakote and olanzapine without informed consent documentation. Resident 64, diagnosed with a psychotic disorder, was administered valproic acid without the necessary informed consent. The Director of Nursing (DON) was unable to locate the informed consents for these medications in the clinical records of the three residents. Despite reviewing the records and checking with medical records, the informed consents were not found. The facility's policy requires that the Licensed Nurse verify with the Physician that informed consent has been obtained and documented, which was not adhered to in these cases.
Failure to Update Care Plans for Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that care plans related to alleged abuse were reviewed and updated by the interdisciplinary team (IDT) for three residents. Resident 61, who was admitted with chronic obstructive pulmonary disease, asthma, and shoulder pain, reported missing money from his wallet. Although the IDT discussed the issue, the care plan was not updated to include interventions to prevent complications related to the missing money. The Director of Nursing confirmed that the care plan should have been updated following the IDT meeting. Resident 63, admitted with sepsis, candidiasis, major depressive disorder, and multiple sclerosis, alleged verbal abuse by a roommate. The IDT recommended several actions, including alert charting and a psychological evaluation, but the care plan was not updated to reflect these interventions. The nursing supervisor confirmed that the care plan should have been revised to include the IDT's recommendations. Resident 75, with a history of a femur fracture, traumatic amputation, and brain hemorrhages, reported multiple incidents, including physical and verbal abuse by a CNA, financial abuse, and being accused of verbal abuse. The care plans for these incidents lacked interventions to minimize emotional distress and did not reflect the IDT's recommendations. The nursing supervisor acknowledged that the care plans were not updated as required. The facility's policy mandates that care plans be re-evaluated and modified to reflect changes in care, service, and treatment.
Improper Use of Bed Rails in LTC Facility
Penalty
Summary
The facility failed to ensure the proper use of bed rails for five residents, leading to potential safety risks. Residents 81 and 285 had bed rails installed despite their evaluations indicating they did not require them. The Director of Nursing (DON) confirmed that there were no documented alternatives offered, no physician orders or informed consent obtained, and no care plans developed for the use of bed rails for these residents. Additionally, the facility's policy requires a side rail evaluation, informed consent, and a physician's order, none of which were followed in these cases. Similarly, Residents 22, 26, and 28 had bed rails installed without the necessary physician orders or completed side rail evaluations. The DON confirmed that Resident 22's evaluation indicated she did not require bed rails, and the evaluation process was not completed for Residents 22 and 28. Resident 26 also lacked a physician's order for bed rails. These oversights in following the facility's policy and procedure for bed rail use placed the residents at risk of entrapment and serious injury.
Failure to Manage Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately monitor, evaluate, and manage the behavior of Resident 285, who exhibited episodes of screaming that resembled a baby crying. This behavior was observed on multiple occasions, causing discomfort to other residents in the same hallway. Despite the noticeable distress caused by Resident 285's screaming, no nursing staff or certified nursing assistants intervened to check on the resident during these episodes. Resident 285's medical history includes diagnoses such as sepsis, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, unspecified dementia, dysphagia, and gastrostomy status. The resident's admission minimum data set indicated severe cognitive impairment. The Director of Nursing confirmed that Resident 285 did not have an admission care conference, and the behavior was not addressed in a care plan. Additionally, the interdisciplinary team conducted a risk meeting but failed to address the behavior. The facility's policy on behavior assessment, intervention, and monitoring requires that behavioral symptoms be identified and evaluated, with a care plan developed accordingly. However, this protocol was not followed, as the behavior was neither documented nor communicated to the physician, and no safety strategies were implemented to protect the resident and others from harm.
Failure to Provide Adequate Social Services Support
Penalty
Summary
The facility failed to provide appropriate social services support for four residents, leading to deficiencies in addressing their psychosocial needs. Resident 61, who was admitted with chronic obstructive pulmonary disease, asthma, and shoulder pain, reported missing money from his wallet. Despite the report being made to the social services director (SSD), there was no timely follow-up or documentation to address the potential psychosocial effects of the incident. The director of nursing confirmed that the SSD's documentation was delayed and only completed after the surveyor began the investigation. Resident 63, diagnosed with sepsis, candidiasis, major depressive disorder, and multiple sclerosis, alleged verbal abuse by a roommate. Although the interdisciplinary team (IDT) recommended a psychological evaluation and monitoring for emotional distress, the SSD did not implement these plans. Similarly, Resident 75, who had a history of traumatic injuries and cognitive impairment, reported physical and verbal abuse by a certified nursing assistant and financial abuse. The SSD failed to document any follow-up actions to address these allegations or the resident's emotional distress. Resident 285, with diagnoses including sepsis, anemia, diabetes, dementia, and dysphagia, exhibited screaming behavior that disturbed other residents. Despite observations and complaints from other residents, the facility did not conduct an admission care conference or develop a care plan to manage the behavior. The SSD acknowledged that the behavior should have been addressed, but no actions were taken to assess or manage the resident's psychosocial needs. The facility's job description for social services emphasized the responsibility for addressing residents' psychosocial needs, which was not fulfilled in these cases.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services, as evidenced by several deficiencies in medication management. A medication, Lamictal, prescribed for a resident with bipolar disorder, was not available in the required dosage, leading to missed doses on consecutive days. The Licensed Vocational Nurse (LVN) responsible for administering the medication confirmed the absence of the 200 mg dosage and had reordered it from the pharmacy, but it was still unavailable the following day. This failure to provide the prescribed medication in a timely manner was contrary to the facility's policy on pharmaceutical services. Additionally, discrepancies were found between the controlled drug records (CDR) and the medication administration records (MAR) for four residents. Instances were noted where medications were recorded in the CDR but not documented as administered in the MAR. The Director of Nursing (DON) verified these discrepancies and emphasized the importance of accurate documentation in both records to avoid mismatches. Interviews with LVNs revealed that some signatures were missing due to oversight or being in a hurry, which is against the facility's policy requiring immediate documentation of controlled medication administration. Further issues included the improper handling of controlled substances, such as the destruction of medications without the required witness signatures. For one resident, a controlled substance was wasted with only one nurse's signature instead of the required two. Moreover, the destruction records for three residents lacked a registered nurse's signature, only having the consulting pharmacist's signature. Another resident's controlled medications did not have a CDR initiated, which is necessary for accountability. These lapses in procedure had the potential for misuse or diversion of medications, as noted in the report.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 2 was administered five psychotropic medications without a gradual dose reduction (GDR) and without documented clinical rationale for why the GDR was contraindicated. Despite the resident not exhibiting any behaviors for which the medications were indicated over a six-month period, there were no attempts to reduce the dosage or discontinue the medications. Interviews with staff confirmed the absence of mood changes or anxiety in the resident, yet the physician's notes repeatedly stated that GDR was contraindicated without providing a clinically pertinent explanation. Resident 41 was prescribed Seroquel without a specific and documented indication, and there was no initial AIMS assessment conducted. The diagnosis of psychotic disorder was deemed non-specific, and the facility's policy required a comprehensive assessment and specific diagnosis for antipsychotic medication use. The Director of Nursing (DON) confirmed the absence of an AIMS assessment in the resident's medical record, which is required upon initiation of antipsychotic medication and every six months thereafter. For Resident 59, the GDR assessment for the use of Seroquel lacked a physician-documented clinical rationale for why the GDR was contraindicated. The DON expressed concerns about the lack of explanation for the contraindication, which is necessary to communicate with the resident's family. The facility's policy mandates that the physician must document why the benefits of the medication outweigh the risks if a GDR is contraindicated, but this documentation was not provided.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and attractive, as evidenced by multiple resident complaints about the quality of the meats served, specifically noting that they were hard and dry. A test tray evaluation was conducted during a lunch service, where four surveyors, along with the consultant dietary manager (CDM), sampled a breaded chicken fillet. The fillet was found to be very hard, difficult to cut, and overcooked, with a dark brown breading and dry meat inside. All four surveyors agreed on these observations, while the CDM stated that the chicken tasted fine. The facility's job descriptions for the cook and registered dietician indicate responsibilities for preparing palatable, nourishing, and well-balanced meals that meet residents' nutritional and dietary needs. However, the observations during the test tray evaluation suggest a failure to meet these standards, potentially affecting residents' food intake and nutritional health.
Food Safety Violations in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. Pans and bowls used for food preparation and service were found stacked and stored while still wet, which was confirmed by the consultant dietary manager (CDM) as a violation of the facility's policy that requires air drying before stacking. Additionally, a Styrofoam cup was found inside a sugar container, which the dietary supervisor (DS) acknowledged should not have been there, as scoops or cups should not be stored inside food bins. Furthermore, the facility used unpasteurized eggs during a breakfast meal service. Observations in the walk-in refrigerator revealed eggs with no markings to indicate pasteurization, and the CDM confirmed that the facility should be using pasteurized eggs. The cook was unaware of the pasteurization status of the eggs and had served fried and over easy eggs to residents. The registered dietician (RD) later confirmed that the eggs were not pasteurized, which is against the facility's policy that recommends using pasteurized egg products for the elderly due to their increased susceptibility to foodborne illnesses.
Improper Dumpster Lid Management
Penalty
Summary
The facility failed to ensure that the dumpster lid was kept closed, which had the potential to attract pests. During an observation from the director of nursing's (DON's) office, it was noted that a staff member opened the dumpster lid to dispose of garbage and left it open. A follow-up observation confirmed that the lid remained open. Additionally, during a concurrent observation and interview with the dietary supervisor (DS), it was observed that the dumpster was overflowing with cartons of boxes, preventing the lid from closing. The DS confirmed that all dumpster lids should be kept closed to prevent attracting pests. The facility's undated policy and procedure titled 'Food Handling Practices' indicated that proper food waste disposal practices should be followed, including keeping lids/doors to dumpsters closed when not dumping garbage.
Inaccessible Call Buttons for Residents
Penalty
Summary
The facility failed to ensure that call buttons were easily accessible for seven residents, potentially causing delays in attending to their needs. Resident 285, who had severe cognitive impairment and multiple health issues, was observed struggling to reach her call button, which was caught between the mattress and bed rail. Certified Nursing Assistant O confirmed that the call button should be within the resident's reach. Resident 286, with severe cognitive impairment, had her call button covered by towels and socks on a bedside drawer, making it inaccessible. Similarly, Resident 6, who had severe cognitive impairment and was seated in a wheelchair, had her call button clipped to a pillow at the head of the bed, far from her reach. Both situations were confirmed by CNA O and Resident 6's caregiver, who acknowledged the call buttons were not within reach. Other residents, including Resident 80, Resident 40, Resident 13, and Resident 49, also had inaccessible call buttons due to their placement on the floor or at the head of the bed, out of reach. These observations were confirmed by staff members, including CNA O, RN R, and CNA I, who all stated that call buttons should be within residents' reach. The facility's policy also indicated that call lights should be placed within residents' reach, highlighting a systemic issue in ensuring accessibility.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents. Specifically, Resident 59's room had bent window screens, a large hole in the wall, and a leaking toilet pipe that wet the floor every time it was flushed. Despite informing the staff, these issues were not addressed, leading to potential health and safety risks. Additionally, the walls at the heads of the beds of two other residents were peeling, exposing the drywall beneath. These deficiencies were observed during a survey, and the regional maintenance director acknowledged that these issues should have been fixed.
Failure to Ensure Advance Directives and POLST Completion for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 6 and 284, were informed about having an advance directive (AD) and that their Physician Orders for Life-Sustaining Treatment (POLST) forms were completed and readily available. For Resident 6, who was admitted with diagnoses including cerebral infarction, developmental delay, dementia, and parkinsonism, the POLST was found incomplete during a review by the Director of Nursing (DON) and the Social Service Director (SSD). The sections regarding medical interventions, artificially administered nutrition, and information and signatures were not marked completely. The SSD confirmed that Resident 6 did not have an advance directive, and the issue was not addressed during the initial care conference with the resident's responsible party. Similarly, for Resident 284, who was admitted with diagnoses including sepsis, open wounds, depression, and type 2 diabetes mellitus, the POLST was not present in the chart or the electronic health record. The DON and SSD confirmed the absence of both the POLST and an advance directive for Resident 284. The facility's policy and job descriptions indicated that the social services department was responsible for facilitating the advance directive decision-making process and ensuring that residents or their representatives were informed and assisted in formulating an advance directive if needed.
Breach of Resident Confidentiality Due to Unattended Computer Screens
Penalty
Summary
The facility failed to protect the confidentiality of residents' protected health information (PHI) when a licensed nurse left computer screens open and unattended on the treatment cart. This occurred for two residents, Resident 31 and Resident 64. During an observation, it was noted that a registered nurse (RN K) left the computer screen open displaying Resident 31's physician's treatment orders, which included wound treatments, while attending to the resident's care. The computer was left unattended in a busy hallway, potentially exposing sensitive information to unauthorized individuals. The Director of Nursing (DON) confirmed that nurses are expected to sign out from the computer before entering a resident's room, especially in high-traffic areas. Similarly, for Resident 64, RN K left the computer screen open with the resident's wound treatment information while providing care. The facility's policy on confidentiality, which was undated, emphasized the importance of protecting residents' privacy and ensuring that medical information is not accessible to unauthorized persons. The failure to adhere to these policies resulted in a breach of confidentiality for the residents involved.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was prescribed Eliquis, an anticoagulant medication, for the prevention of deep vein thrombosis (DVT). The resident, who had a history of unspecified mood disorder and traumatic brain injury, was admitted with a physician's order for Eliquis to be administered twice daily. However, a review of the resident's medical record revealed that there was no care plan in place to address the use of Eliquis, including goals, approaches, interventions, and monitoring for signs and symptoms of bleeding. During an interview, the Director of Nursing acknowledged the absence of a care plan for the medication, which was contrary to the facility's policy requiring a comprehensive care plan to be completed within seven days after the comprehensive assessment.
Failure to Provide Necessary Care and Services for Residents
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. Resident 10, who was admitted to the facility with open skin areas on her face, did not have a treatment order for these areas. Observations over several days confirmed the presence of these open skin areas without any treatment orders being initiated. This lack of action was acknowledged by a licensed vocational nurse, who confirmed the absence of a treatment order for Resident 10's condition. Similarly, Resident 184, who was at high risk for falls due to a dementia diagnosis, did not have a floor mat at his bedside as ordered by his physician and recommended by the interdisciplinary team. Despite being identified as a necessary intervention in his fall care plan, observations revealed the absence of the floor mat on multiple occasions. This oversight was also confirmed by a licensed vocational nurse, who acknowledged the missing floor mat despite its documented necessity in the resident's care plan.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter. The resident's catheter was not properly secured, and the urinary tube connected to the drainage bag was filled with thick yellow sediments. This was observed during a wound treatment session, where it was noted that the catheter stabilization device was inadequately secured with surgical tape, and there was a small amount of dried blood on the resident's left thigh. The facility's policy indicated that routine catheter care should be performed daily, and the catheter should be inspected for any problems, with enough slack provided before securing to prevent tension on the tubing. Interviews with the RN and the DON revealed discrepancies in the catheter care practices. The RN stated that the urine bag should be changed at least monthly or as needed, while the DON indicated it should be changed weekly and as needed for blockage, leakage, or sediment buildup. The catheter stabilization device was also supposed to be changed weekly and as needed. However, the resident's clinical records lacked documentation of when the catheter, urine bag, and stabilization device were last changed, indicating a failure to adhere to the facility's policies and procedures for catheter care.
Failure to Identify and Report Drug Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported drug irregularities during the monthly medication regimen review (MRR) for two residents. Resident 29 was receiving two loop diuretics, Furosemide and Torsemide, simultaneously for over a year without a documented risk/benefit assessment or clinical rationale. The CP admitted to not identifying this duplicate therapy as an irregularity during the monthly MRR, which was confirmed during an interview with the Director of Nursing (DON). Resident 2 was prescribed five psychotropic medications for conditions such as bipolar disorder and brief psychotic disorder. Despite the resident not exhibiting any behaviors for which these medications were indicated over a six-month period, there was no documented evidence of attempts to gradually reduce the doses (GDR) of these medications. The physician repeatedly marked GDR as contraindicated without providing a clinical rationale for this decision, even after the CP recommended a dose reduction. The facility's policy requires that medication regimen review recommendations and findings be documented and acted upon, with the physician providing a rationale if they reject the CP's recommendations. However, in the case of Resident 2, the physician disagreed with the CP's recommendations without offering a clinical rationale, which was confirmed by the DON and nursing supervisor during the survey.
Duplicate Loop Diuretics Prescribed to a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, as evidenced by the administration of two medications from the same therapeutic class for over a year. The resident, who was admitted with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, and chronic congestive heart failure, was prescribed both furosemide and torsemide, which are loop diuretics. The physician orders indicated that furosemide was prescribed on one date, and torsemide on another, leading to duplicate therapy. During interviews, the consulting pharmacist expressed uncertainty about the rationale for the resident being on both medications and acknowledged that there are no current standards of practice supporting the use of double loop diuretics simultaneously for the same or different medical conditions. The facility's policy on pharmaceutical services emphasized that medications should be administered safely and only those necessary to treat existing conditions should be included in a resident's medication regimen. This oversight in medication management had the potential to expose the resident to unnecessary medication and increased risk of adverse effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 7.41% during a medication administration observation, exceeding the acceptable threshold of 5%. This was due to two medication errors involving one resident. The first error occurred when a Licensed Vocational Nurse (LVN) administered an incorrect dosage of Lamictal to a resident. The resident was supposed to receive a total of 250 mg of Lamictal, but only received 50 mg because the 200 mg dosage was not in stock. The LVN had reordered the medication from the pharmacy the previous day, but it was still unavailable the following day, resulting in the resident missing a dose. The second error involved the improper administration of olopatadine eye drops. The LVN did not apply the drops into the conjunctival sac as required and failed to instruct the resident to close their eyes slowly or compress the tear ducts after administration. The LVN was unaware of the correct procedure, which was confirmed by the Director of Nursing, who stated that eye drops should be applied to the conjunctiva sac and pressure applied to the lacrimal gland post-administration. The facility's policy on eye drop administration, which outlines these steps, was not followed, leading to the medication error.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, as evidenced by two specific incidents. First, during a medication storage inspection, an emergency medication kit was found to contain expired lorazepam tablets, with an expiration date of 04/2024. This was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the expired medication should have been replaced. The facility's policy on medication storage, dated 1/2024, mandates that outdated medications be immediately removed from stock and reordered from the pharmacy. In a separate incident, a treatment cart containing wound care supplies was left unlocked and with a drawer open in the hallway. This occurred while a registered nurse (RN) was treating a resident with wounds on the gluteal folds. The RN had left the cart unattended to retrieve a skin protectant packet, leaving the cart unsecured. The facility's policy from 2007 requires that medication supplies remain locked when not in use or attended by authorized personnel. Both incidents highlight lapses in adherence to the facility's medication storage policies.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which led to a deficiency in dietary services. Resident 46, who was on a pureed diet, had a documented dislike for fish. Despite this, during a tray line observation, it was noted that a kitchen staff member plated pureed fish on Resident 46's lunch tray. The registered dietician confirmed that the tray card indicated the resident's dislike for fish and acknowledged that an alternative entree should have been provided. The facility's policy requires that residents be offered substitute food items of similar nutrient value when they dislike a menu item, but this was not adhered to in this instance.
Failure to Provide Snacks According to Resident Preferences
Penalty
Summary
The facility failed to provide snacks in accordance with a resident's needs, preferences, and requests, specifically for a resident who was on antibiotics that caused stomach upset. The resident reported that the night staff did not have crackers available when requested, leading to the resident stopping the antibiotic treatment. The resident's medical history included acute on chronic systolic heart failure, hypertension, and gastro-esophageal reflux disease. The resident's medication administration record showed refusals of the antibiotic doses due to the lack of snacks to alleviate stomach upset. Observations and interviews revealed that the facility did not store snacks at nurse stations or medication rooms, and the kitchen staff discarded evening snacks in the morning. The director of nursing confirmed the lack of snack storage and reliance on kitchen staff for snack provision. Additionally, there was no documentation of a dietary assessment for the resident's food preferences upon admission, as required by the facility's policy. The registered dietitian confirmed the absence of a nutrition assessment for the resident, highlighting a failure to meet the resident's dietary needs and preferences.
Unsafe Bed Conditions for a Resident
Penalty
Summary
The facility failed to provide a safe and comfortable environment for Resident 81 due to loose and wobbly headboard and footboard on the resident's bed. During an observation and interview with the Director of Nursing (DON) and Resident 81, it was noted that the wooden headboard was tilted to the left with a screw on the right side about to come off, and the footboard was leaning forward and wobbly when touched. Both the DON and Resident 81 confirmed these observations. Licensed Vocational Nurse A (LVN A) stated that staff should report faulty equipment, such as a malfunctioning bed, to the maintenance log at the nurse station and follow up if the work order is not completed. The Director of Operations (DO) indicated that faulty equipment should be recorded in the maintenance binder, which should be checked daily by maintenance staff. However, a review of the maintenance log at nurse station AA revealed no work order regarding Resident 81's bed, and no work orders were entered for the entire month of June 2024.
Failure to Prevent Resident Fall and Injury
Penalty
Summary
The facility failed to prevent accidents for a resident who had multiple diagnoses, including Leigh's disease, dementia, and osteoporosis, among others. The resident was assessed to have a severe cognitive impairment and required limited assistance with transfers and walking. Despite being identified as high risk for falls, the facility did not develop a care plan for Activities of Daily Living (ADL) functional/rehabilitation potential and did not implement resident-centered interventions for falls. This lack of proper planning and supervision led to the resident experiencing a fall that resulted in a fracture of the second cervical vertebra and a facial laceration. The resident's clinical records indicated that she was not steady and required staff assistance for walking and turning around. However, on the night of the incident, the resident was found on the ground in another resident's room with a laceration on her eyebrow. Interviews with staff revealed that the resident was not checked frequently and did not receive the required assistance. The resident's fall care plan was not tailored to her specific needs, and there was no ADL care plan in place, which was confirmed by the Registered Nurse and other staff members. Further review of the facility's policies indicated that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The facility's fall management policy also emphasized the need for resident-centered approaches to managing falls, which were not implemented in this case. The lack of supervision and appropriate care planning directly contributed to the resident's fall and subsequent injuries.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 224 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Cruz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Cruz Post Acute | 1 mi | ★★★★★ | 8 | 0 |
| Pacific Coast Manor | 1.4 mi | ★★★★★ | 0 | 0 |
| Redwood Grove Post Acute | 1.5 mi | ★★★★★ | 1 | 0 |
| Watsonville Nursing Center | 12 mi | ★★★★★ | 12 | 0 |
| Watsonville Post Acute Center | 12 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Driftwood Healthcare Center - Santa Cruz.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.