Santa Cruz Post Acute
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to provide services that met professional standards of quality when pre-operative instructions were not followed prior to a scheduled procedure for one of three residents (Resident 1). This failure resulted in Resident 1's procedure cancellation and had the potential to result in health complications.Findings: Review of Resident 1's Office Visit Progress Notes, dated 8/11/25 indicated Patient 1 was scheduled for right ureteroscopy (procedure used to treat kidney stones) with possible laser endopyelotomy (procedure that opens up a blockage in the kidney) with ureteral stent placement (a procedure that places a flexible tube into the ureter [tube that drains urine from the kidney to
the bladder] to allow urine to drain. The notes also indicated, Stop Eliquis [apixaban, anticoagulant that thins blood to treat and prevent blood clots] 3 days before surgery. Review of Resident 1's Physician Orders indicated she had an order dated 3/28/25 for apixaban 5 milligrams (mg, unit of measurement) one tablet by mouth two times a days for blood clot prevention. The orders also indicated she had an order dated 9/1/25 Resident 1 has surgical procedure on 9/2/25 pick up time is 5:15 have resident ready. Review of the Resident Calendar, dated 9/9/25 indicated Resident 1 had an appointments on 9/2/25 with instructions to arrive at 6 a.m. for a 7:30 a.m. surgery with urology and 9/8/25 with instructions to arrive at 6 a.m. for ureteroscopy surgery at 7:30 a.m. with pick up at 5:15 a.m. Review of Resident 1's September 2025 Medication Administration Record (record of medications given) indicated apixaban was not given on 9/1/25 and 9/2/25. It further indicated apixaban was given to Resident 1 twice a day from 9/3/25 to 9/8/25.
During an interview on 9/9/25 at 2:22 p.m., the director of nursing (DON) stated on 9/2/25, transportation did not arrive to take Resident 1 to her appointment, so it was missed. She stated Resident 1's appointment was rescheduled for 9/8/25. She stated there was some miscommunication when it was rescheduled and there was no order to discontinue Eliquis prior to the 9/8/25 appointment. The DON stated it should have been communicated to the nurses. She stated Resident 1 was transported to her 9/8/25 appointment but her procedure was cancelled because Eliquis was given. The DON stated usually resident's scheduled appointments are reviewed during the morning meeting with department heads, but Resident 1's 9/8/25 was not. The DON stated there was no process to review Monday appointments that are added to the calendar on a Friday afternoon. She stated she did not know about the appointment until 9/8/25. During an
interview on 9/9/25 at 2:30 p.m., the receptionist stated Resident 1's family member informed her about the Resident 1's rescheduled appointment. She stated she scheduled transportation and added Resident 1's 9/8/25 appointment to the Resident Calendar. Review of the facility's undated policy, Surgery-Related (Preand Postoperative) Management, indicated, As needed, the physician will evaluate a resident who is scheduled to undergo surgery and the assessment will focus on pertinent items including . identifying significant medication-related risks (for example, stopping anticoagulation .
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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.