Santa Cruz Post Acute

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 .

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.

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