The residents, all cognitively intact, said they repeatedly asked staff to replace the soap but were ignored.
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The resident's son told facility staff during a November 11 meeting that his father had been struck by an unidentified male certified nursing assistant.
Federal inspectors found Santa Cruz Post Acute violated wheelchair securement protocols during a November complaint investigation.
The September incident at Ocean Pointe Healthcare Center involved a resident admitted with a urinary tract infection, sepsis, and congestive heart failure.
During an observation on November 14 from 1:10 p.m.
The immediate jeopardy status was lifted on November 15, 2025 at 3:35 PM, following two days of intensive staff education and policy implementation.
The October 11 incident at Pleasant View Luther Home involved a resident assessed as having moderate fall risk just two days earlier.
The resident had been admitted to The Center at Grande on September 16 with conditions requiring careful monitoring.
The resident was discovered calling out from her room on November 16 with no facility staff in the hallway.
Resident 7 arrived at the facility in October with osteomyelitis of vertebrae, a bone infection.
Resident 14's blood glucose level reached 528 by the time testing resumed on October 22, 2025.
The wound became infected, requiring antibiotics and specialized dressing changes.