Driftwood Nursing Center

Based on interview, record review, and facility policy review, the facility failed to transmit resident assessments to the Centers for Medicare and Medicaid Services (CMS) within (14) days of completion for two (2) of (2) sampled residents (Residents #23 and #95), with the potential to affect all (14) residents who triggered for a late Resident Assessment.Findings include:A review of the facility's MDS (Minimum Data Set ) Policy, revised 1/10/24, revealed, .Standard.I. The CMS Long-Term Care Facility Resident Assessment Instrument User's Manual is the primary source of information for completion of an MDS assessment. II. Timing, scheduling, and completion of MDS assessments and entry and discharge reporting will be carried out per the guidelines set forth in the Long-Term Care Facility Resident Assessment Instrument User's Manual version 3.0. IX Transmission of MDS.Comprehensive assessments must be transmitted electronically within fourteen (14) days of the care plan completion date. All other MDS assessments must be submitted within (14) days of the MDS completion date.Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to provide the specific reason and basis for a hospital transfer in plain language for one (1) of two (2) residents sampled for hospitalization. Resident #54.Findings include:A review of the facility's policy, Transfer and Discharge (including AMA) (Against Medical Advice ) date implemented 02/05/2025, revealed, .Definitions: . 'Transfer and Discharge' includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. Policy Explanation and Compliance Guidelines: . 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge.A record review of the admission Record revealed the facility admitted Resident #54 on 12/3/25 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Progress Notes revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to maintain infection prevention and control practices by allowing a resident meal tray to be stored in a biohazard room for one (1) of two (2) observations. Findings include:A record review of the facility's policy, Infection Prevention and Control Policy Program, dated 2/1/25, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary.environment.On 01/28/2026 at 9:21 AM, during an observation with Housekeeper/Maintenance #1, there was a biohazard room on the north wing near the nurse's station. The room was marked with a biohazard logo and secured with keypad entry. Inside the room, there was a resident food tray that was placed beneath posted signage indicating food and utensils were not to be placed in the room. The tray contained a meal preference ticket identifying Resident #35 and indicated a dinner meal dated 1/27/2026. Housekeeping/Maintenance Staff #1 confirmed the tray should not have been in the biohazard room and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to ensure food temperatures were tested under sanitary conditions for one (1) of four (4) kitchen observations. Findings Include: During an observation of food temperature readings for the lunch meal on 10/30/24 at 11:45 AM in the kitchen area, the cook was observed using a thermometer to check the temperature of the macaroni and cheese. After testing the temperature, the cook wiped the thermometer on a clean towel. The same thermometer was then used to test the baked chicken, green peas, pureed chicken, and mashed potatoes, with the cook wiping the thermometer on the same towel after each test without sanitizing it. During an interview on 10/31/24 at 09:00 AM, the cook stated she had been cooking at the facility for six (6) months and had been cleaning the thermometer with a clean, dry towel during that time. She was uncertain if she had been specifically trained on sanitizing the thermometer, mentioning that numerous in-services were conducted, but she could not recall specific sanitation training. The cook further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was clinically indicated for one (1) of four (4) residents observed with catheters. (Resident #87) Findings Include: A review of the facility's Appropriate Use of Indwelling Catheters Policy, dated 03/01/17, revealed: .An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization is necessary. Policy Explanation and Compliance Guidelines .4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary .6. Documentation to support decision-making will be included in the medical record, including but not limited to: a. Clinical or medical conditions demonstrating the need for an indwelling catheter. b. Assessment of incontinence .d. Services provided to restore normal bladder function to the extent possible .7. Indwelling urinary catheters will be used on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to use enhanced barrier precautions (EBP) by not wearing the appropriate personal protective equipment (PPE) during catheter care for one (1) of four (4) residents reviewed for catheter care. (Resident #87) Findings Include: A review of the facility's policy titled Enhanced Barrier Precautions, dated 05/01/24, revealed, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: 'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities . Policy Explanation and Compliance Guidelines .2. Initiation of Enhanced Barrier Precautions .b. an order for enhanced barrier precautions will be obtained for residents with any of the following .i .indwelling medical devices (e.g .urinary catheters . During an observation on 10/28/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from misappropriation when facility staff used a resident's credit card to purchase goods or services without the consent or authorization of the resident for one (1) of five (5) sampled residents, Resident #1. Based on the facility's implementation of corrective actions, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) as of 6/29/24, prior to the SA's entrance on 8/19/24. Findings Include: A review of the facility's policy, Abuse Neglect and Exploitation, dated 10/01/22, revealed that .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent .exploitation of resident property .Definitions .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .Prevention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and the facility policy review, the facility failed to develop appropriate interventions for a cognitively impaired resident after a fall to prevent reoccurrence for one (1) of three (3) sampled residents. Resident #1 Findings include: A record review of the facility's policy Fall Risk Assessment with revised date 01/05/24 revealed . It is the policy of this facility to provide an environment that is free from accidents and hazards .Policy Explanation and Compliance Guidelines: . 4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident . A record review of the Witnessed Fall Report dated 05/15/24 revealed Resident #1 had a fall in the hallway. When the staff asked Resident #1 what had happened, he indicated that he did not know. A record review of the Witnessed Fall Report dated 05/23/24 revealed Resident #1 had a fall in his room. The resident's roommate stated that the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record reviews, and facility policy review, the facility failed to transmit Minimum Data Set (MDS) Assessments by their target date, for 19 of 24 residents reviewed for MDS assessments. Resident #1, #2, #4, #17, #25, #32, #36, #37, #62, #65, #69, #72, #74, #78, #79, #83, #86, #93, and #104. Findings include: Review of the Memorial Driftwood Nursing Center MDS Policy with a revision date of 06/30/2019 revealed, Standard: .IX. Transmission of MDS .All MDS will be transmitted .i. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan completion date .ii. All other MDS assessments must be submitted within 14 days of the MDS completion date . Record review of MDS Assessments on 2/27/23, revealed the following: 1. The quarterly assessment for Resident #1 with a target date of 1/23/23, and the discharge MDS with a target date of 1/24/23, had not been transmitted. 2. The quarterly assessment for Resident # 2, with a target date of 1/20/23, had not been transmitted. 3. The quarterly assessment for Resident #4, with a target…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review and facility policy review, the facility failed to ensure a resident had ready and reasonable access to personal funds for one (1) of 24 sampled residents, Resident #68 Findings include: A review of the facility's policy, (Proper Name of Facility) - Resident Personal Funds, implemented on 2/1/22, revealed the policy did not contain information regarding ready and reasonable access to personal funds for residents. On 02/27/23 at 11:39 AM, in an interview with Resident #68, he stated that he cannot get money from his personal funds on the weekend because the office staff is not at the facility on weekends. On 03/02/23 at 10:42 AM, in an interview with the Administrative Assistant (AA), she stated she is responsible for the residents' personal trust fund accounts. She said that the Activities Director (AD) also has access to $85 and will issue personal funds to the residents. The AA stated that she works Monday through Friday, from 8:00 AM until 4:30 PM and the AD works on the weekends at times. On 03/02/23 at 10:50 AM, in an interview with the AD,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff and resident interviews, record review and facility policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) Level II for one (1) of three (3) PASRRs reviewed. Resident #6 Findings include: Record review of the facility policy titled, (Proper Name of Facility)-Resident Assessment in Coordination with PASRR Program with a revision date of 02/01/2019 revealed, .Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .a. ii. Positive Level I Screen-necessitates a PASRR Level II evaluation prior to admission. b. PASRR Level II-a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD (Mental Disorder) , ID (Intellectual Disorder) or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.