Santa Cruz Post Acute
SANTA CRUZ POST ACUTE in SANTA CRUZ, CA — inspection on February 26, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 1/30/26, at 3:30 p.m. and 2/10/26, at 2:45 p.m., with the director of nursing (DON), the DON confirmed nursing staff did not carry out the physician's order for stool culture.
There was no documented evidence that the physician canceled or discontinued collection of stools for culture.
During a review of the facility's undated policy and procedure (P&P) tilted, Lab and Diagnostic Test Results -Clinical Protocol, The staff will process test requisitions and arrange for tests. A nurse will identify the urgency of communicating with the Attending Physician.
Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON and/or Medical Director.
Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
056065 02/26/2026
Santa Cruz Post Acute 1115 Capitola Road Santa Cruz, CA 95062
During an interview on 2/24/26, at around 10:10 a.m., with the DON, she confirmed missing wound treatment as listed above. On 2/10/25, 2/19/25, 2/23/25, 3/10/25, 2/23/25, 2/24/25, 3/15/25, 3/29/25, 3/25, 4/4/25, 4/12/25, 4/13/25, 4/12/25, 4/13/25, 5/10/25, 5/11/25, 5/24/25, 5/28/25, 6/13/25, 6/21/25 and 6/26/26/25, Resident 1's TAR was not signed by the licensed nurses.
The DON admitted , if there was no signature, the treatment was not done. 2.
During a review of Resident 1's TAR in 7/2025, it indicated a wound treatment order for stage 2 pressure ulcer (is damage to the skin and underlying tissue caused by prolonged pressure) to sacrum, cleanse with NS or soap and water, pat dry, apply barrier cream, cover with foam dressing every dayshift.
Start date on 7/26/25.
During a review of Resident 1's weekly wound assessment, it indicated his sacrum wound was assessed on 7/22/25 and 7/25/25 during a wound dressing change to cleanse with NS, apply barrier cream and cover with foam dressing.During a telephone interview on 2/10/26, at 2:35 p.m., with the DON, she confirmed the St.2 pressure ulcer was found upon his return from the hospital on 7/19/25 and the staff missed to obtain a wound treatment order; hence, the wound treatment were not done on the following days: 7/20/25, 7/21/25, 7/23/25 and 7/24/25.
The DON further stated that Resident 1 had a hospitalization from 7/9/25 through 7/19/25, and the St.2 pressure ulcer was acquired during his hospital stay.During a review of the facility's undated policy and procedure (P&P) titled, Wound Care, the P&P indicated, Verify that there is a physician's order for this procedure.Apply treatments as indicated.3.
During a review of Resident 1's care plans, there was care plan developed to address the resident's St.2 pressure ulcer on his sacrum.
During an interview on 2/2/26 at 11:10 a.m. and 2/24/26 at 10:10 a.m., with the DON, the DON reviewed Resident 1's clinical record and could not find a care plan in place to address his pressure ulcer on his scrum.
During a review of the facility's policy and procedure (P&P) titled, Prevention/Management of Pressure Ulcers/Injuries, revised 2/2023, the P&P indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.
During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, dated 3/2022, the P&P 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.
056065 02/26/2026
Santa Cruz Post Acute 1115 Capitola Road Santa Cruz, CA 95062
During a review of Resident 1's SBAR (situation, background, assessment, recommendation, is a communication tool in nursing), dated 12/28/25, it indicated, Went to patients room to administer medication and noticed he was in a lot of pain. He said he had pain at his catheter site, and it feels like chilies (chills or shivering) when he urinates he wanted to go to the hospital.
Administered routine pain medicine and his pain level went down to a 5/10 but he said he still wanted to go.
During an interview on 2/23/26, at 1:35 p.m. with the DON, she stated the nurse who received the urine culture order on 12/22/25 was no longer working in the facility. DON confirmed Resident 1's urine culture order should be followed on 12/22/25 to collect urine culture, the urine specimen was delayed for follow-up. No endorsement or communication in place for the urine culture would need to be collected.
During an interview on 2/23/26, at 2:50 p.m., with the registered nurse A (RN A), RN A stated after receiving the urine culture order would need to put in their system of electronic health records for carrying out during the shift, if not able to then would need to endorse to the nurse in next shift for collecting urine specimen.
During a telephone interview on 3/2/26, at 8:38 a.m., with case manager (CM), CM stated that Resident 1's urine culture test should have been done sooner or earlier to determine the best antibiotic treatment for Resident 1 to prevent 12/28/25's ED visit.
Review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, dated 11/2018, it indicated , The staff will process test requisitions and arrange for tests. A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition.
Before contacting the physician, the person who is to communicate.be prepared to discuss the following (to the extent that such information is available) including why the lab and diagnostic tests were obtained ( for example, as a routine screen or follow-up; to assess a condition change or recent onset of sign and symptoms, or to monitor a serum medication level. 2.
During an observation on 2/23/26, at 12:55 p.m., Resident 1's urine collection bag connected to his urinary catheter was placed on the floor.
Certified nursing assistant B (CNA B) who was present inside Resident 1's room validated the observation. CNA B stated the urine bag should not be placed on the floor. It should be secured on the bed rail above the floor and below the bladder of Resident 1 to prevent infections.During a review of the facility's policy and procedure (P&P) titled, Catheter Care , Urinary, dated 8/2022, it indicated, . Be sure the catheter tubing and drainage bag are kept off the floor.
Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.