Santa Cruz Post Acute
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
process, Resident 1 fell from the bed onto the floor mat on 8/14/2025. Resident 1's X-ray result dated August 17, 2025, revealed comminuted distal tibia and fibula fractures, and Resident 1 was transferred to
the hospital for treatment the same day. The DON further stated that the CNA should have kept Resident 1 safe during care.During a phone interview with the Assistant Director of Nursing (ADON) on October 13, 2025, at 11:50 a.m., the ADON confirmed that the Minimum Data Set (MDS) Section GG, dated July 18, 2025, indicated Resident 1 was dependent and required the helper do all the effort or the assistance of two or more helpers for toilet transfers, sitting to lying, lying to sitting on side of bed, and rolling left and right.
The ADON further confirmed that only one CNA was providing care to Resident 1 at the time of the fall incident on 8/14/2025, and that Resident 1 needed two-person assistance when rolling him to his left and right sides during care to prevent falls.During a phone interview with the MDS Coordinator (MDSC) on October 16, 2025, at 3:10 p.m., The MDSC confirmed that Minimum Data Set (MDS) Section GG, dated July 18, 2025, indicated Resident 1 was dependent and she further stated that Resident 1 had impairment
on one of his upper extremity and both lower extremities, he need another helper to ensure safety when rolling left and right. A review of the facility's policy and procedure (P&P), Revision Date March 2018, titled Falls and Fall Risk, Managing indicated: .Several possible interventions may be identified considering resident fall risks, and staff may prioritize certain interventions based on the circumstances .2. A review of Resident 1's SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) Communication Form and Progress Note dated March 23, 2025, indicated an unwitnessed fall when a nurse was doing rounds and found Resident 1 was sitting on the floor next to his bed.A review of Resident 1's Fall Risk assessment dated [DATE REDACTED], indicated a score of 14 (scores of 16-42 indicate high fall risk). The assessment documented no falls within the last 90 days; however, the March 23,2025 fall incident occurred within that period of 90 days.During a phone interview with the Assistant Director of Nursing (ADON) on October 13, 2025, at 11:44 a.m., the ADON confirmed the fall risk assessment done on April 21, 2025, was inaccurate because
it should have reflected one fall within the last 90 days.A review of the facility's policy and procedure (P&P), revision date March 2018, titled Fall Risk Assessment indicated: .the nursing staff and the physician will
review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff will ask the resident and/or his/her family about any history of
the resident falling.3. A review of Resident 1's care plan, initiated on November 23, 2023, indicated that Resident 1 was at risk for falls related to confusion, gait and balance problems, incontinence, crawling to
the floor, refusal to use the call light, difficulty walking, muscle wasting and atrophy, seizures, and abnormal gait. The care plan interventions included: Ensure that the resident is properly positioned in bed.During a phone interview with the ADON on October 15, 2025, at a.m., the ADON confirmed that the care plan interventions indicated, Ensure that the resident is properly positioned on bed. The ADON stated that the staff should have implemented the intervention to ensure that Resident was positioned properly on the bed to prevent fall when turned to his side. A review of the facility's policy and procedure (P&P), revision date March 2022, titled Care Plans, Comprehensive Person-Centered indicated: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .
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SANTA CRUZ POST ACUTE in SANTA CRUZ, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANTA CRUZ, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SANTA CRUZ POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.