Santa Cruz Post Acute

In the surveyor’s words

From the most serious findings on record at Santa Cruz Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF757Mar 3, 2025

  Based on observation, interview, and record review, the facility failed to ensure 13 out of 40 sampled residents (Residents 10, 19, 38, 39, 47, 53, 60, 67, 72, 93, 104, 111, and 121) were free from unnecessary medications when there was inadequate monitoring and systemic failure in the management of antihypertensive (medication to manage high blood pressure) and antiarrhythmic (medication to manage arrhythmia [abnormal or irregular heartbeats]) medications, and lack of monitoring for signs and symptoms related to the use of anticoagulants (medication to prevent blood clots). They are as follows: 1. […]

• Actual harm, isolatedF689Nov 14, 2025

  Based on interview and record review, the facility failed to ensure resident safety to prevent accidents resulting in a fall for one of three residents (Resident 1) when the facility van's wheelchair securement system (a safety device installed in accessible vehicles used to keep a wheelchair in place during transport and also secure the wheelchair user with safety straps) used to transport Resident 1 did not meet Code of Federal regulations, Title 49, Part 38 (49 CFR S 38.23(d)(7), Americans with Disabilities Act [ADA] Accessibility Specifications for Transportation Vehicles), and the facility used three staff members (maintenance supervisor [MS], central supply staff [CSS], and the maintenance assistant [MA]) that were not qualified and/or were not trained to transport residents using… […]

• Actual harm, isolatedF689Nov 6, 2025

  The facility failed to ensure the safety of one of three sampled residents (Resident 1) during in-bed care (a wide range of activities to ensure the health, comfort, and hygiene of someone who is bedridden), when:1. The facility failed to maintain Resident 1's safety during in-bed care.2. The facility failed to accurately complete Resident 1's fall risk assessment; and3. The facility failed to implement Resident 1's ADL (activities of daily living like bed bath, shower, transfer, positioning, etc.) care plan intervention to Ensure proper position.These failures resulted in Resident 1 sustaining comminuted fractures (a broken bone where the bone is shattered into more than two pieces) to the right tibia and fibula (the two bones in the right lower leg), requiring hospital transfer on August… […]

• Actual harm, isolatedF689Jun 25, 2024

  Based on interview and record review, the facility failed to ensure supervision and assistance were provided for one of three sampled residents (Resident 1), who was dependent on staff for transferring, when Resident1 was left sitting in her wheelchair in her room and fell on the floor on 2/19/2024 without staff watching and/or supervising her. This failure resulted in Resident 1 falling on the floor and sustaining a laceration (a deep cut or tear in skin) on her forehead that required hospital transfer on 2/19/2024 where she had 18 stitches (a way doctors can close certain types of cuts). […]

• Actual harm, isolatedF686Jun 18, 2024

  Based on interview and record review the facility failed to ensure care and services were provided in accordance with professional standards of practice in performing accurate skin assessment to help prevent pressure ulcers (injury to skin and tissue below the skin caused from prolonged pressure on the skin) and provide necessary pressure treatment for one of three residents when staff failed to identify the presence of pressure ulcers for Resident 1. This failure resulted in Resident 1 not receiving pressure ulcer treatment and nursing interventions to aid in wound healing. […]