Santa Cruz Post Acute Complaints, Violations and Inspection Records

May 11, 2026, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity D)

March 11, 2026, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

• F0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (scope and severity D)

February 26, 2026, complaint inspection

3 deficiencies cited. Surveyors cited the facility for provide appropriate pressure ulcer care and prevent new ulcers from developing, ensure services provided by the nursing facility meet professional standards of quality, and provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

• F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing. (scope and severity E)
• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)
• F0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (scope and severity D)

November 26, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure services provided by the nursing facility meet professional standards of quality.

• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)

November 14, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity G)

November 6, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity G)

July 8, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that residents are fully informed and understand their health status, care and treatments.

• F0552Ensure that residents are fully informed and understand their health status, care and treatments. (scope and severity D)

March 3, 2025, standard inspection

20 deficiencies cited. Surveyors cited the facility for develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, provide appropriate treatment and care according to orders, resident’s preferences and goals, and provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity E)
• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity E)
• F0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (scope and severity E)
• F0700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. (scope and severity E)
• F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (scope and severity E)
• F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (scope and severity E)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity E)
• F0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (scope and severity E)
• F0757Ensure each resident’s drug regimen must be free from unnecessary drugs. (scope and severity E)
• F0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (scope and severity E)
• F0759Ensure medication error rates are not 5 percent or greater. (scope and severity E)

• F0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (scope and severity E)
• F0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (scope and severity E)
• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity E)
• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (scope and severity D)
• F0554Allow residents to self-administer drugs if determined clinically appropriate. (scope and severity D)
• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity D)
• F0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (scope and severity D)
• F0836Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. (scope and severity D)

December 26, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide appropriate treatment and care according to orders, resident’s preferences and goals and not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity E)
• F0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (scope and severity D)

December 9, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide care and assistance to perform activities of daily living for any resident who is unable.

• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity E)

October 23, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training and ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0728Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. (scope and severity E)
• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)

August 6, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections and safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

• F0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (scope and severity D)
• F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (scope and severity D)

August 2, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured and provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity D)

July 31, 2024, complaint inspection

3 deficiencies cited. Surveyors cited the facility for honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice, ensure services provided by the nursing facility meet professional standards of quality, and try different approaches before using a bed rail. if a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) correctly install and maintain the bed rail.

• F0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (scope and severity D)
• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)

• F0700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. (scope and severity D)

July 5, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

• F0559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. (scope and severity E)

June 25, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity G)

June 19, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

• F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (scope and severity F)

June 18, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide appropriate pressure ulcer care and prevent new ulcers from developing and ensure services provided by the nursing facility meet professional standards of quality.

• F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing. (scope and severity G)
• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity E)

March 7, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure services provided by the nursing facility meet professional standards of quality.

• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)

January 12, 2024, complaint inspection

3 deficiencies cited. Surveyors cited the facility for ensure services provided by the nursing facility meet professional standards of quality, prepare residents for a safe transfer or discharge from the nursing home, and develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity E)
• F0624Prepare residents for a safe transfer or discharge from the nursing home. (scope and severity D)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)

November 30, 2023, complaint inspection

6 deficiencies cited. Surveyors cited the facility for provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights, ensure services provided by the nursing facility meet professional standards of quality, and provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (scope and severity E)
• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)
• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity D)
• F0692Provide enough food/fluids to maintain a resident's health. (scope and severity D)
• F0711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (scope and severity D)
• F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (scope and severity D)

October 13, 2023, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure services provided by the nursing facility meet professional standards of quality.

• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)

May 12, 2023, standard inspection

17 deficiencies cited. Surveyors cited the facility for honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist, and ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

• F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (scope and severity E)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity E)
• F0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (scope and severity E)

• F0759Ensure medication error rates are not 5 percent or greater. (scope and severity E)
• F0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (scope and severity E)
• F0814Dispose of garbage and refuse properly. (scope and severity E)
• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity D)
• F0642Ensure a qualified health professional conducts resident assessments. (scope and severity D)
• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)
• F0685Assist a resident in gaining access to vision and hearing services. (scope and severity D)
• F0687Provide appropriate foot care. (scope and severity D)
• F0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (scope and severity D)
• F0694Provide for the safe, appropriate administration of IV fluids for a resident when needed. (scope and severity D)
• F0757Ensure each resident’s drug regimen must be free from unnecessary drugs. (scope and severity D)
• F0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (scope and severity D)
• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity D)
• F0880Provide and implement an infection prevention and control program. (scope and severity D)

January 24, 2020, standard inspection

9 deficiencies cited. Surveyors cited the facility for provide for the safe, appropriate administration of iv fluids for a resident when needed, provide safe and appropriate respiratory care for a resident when needed, and provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

• F0694Provide for the safe, appropriate administration of IV fluids for a resident when needed. (scope and severity D)
• F0695Provide safe and appropriate respiratory care for a resident when needed. (scope and severity D)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity D)
• F0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (scope and severity D)
• F0759Ensure medication error rates are not 5 percent or greater. (scope and severity D)
• F0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (scope and severity D)

• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity D)
• F0880Provide and implement an infection prevention and control program. (scope and severity D)
• F0919Make sure that a working call system is available in each resident's bathroom and bathing area. (scope and severity D)