Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manresa Healthcare Center during CMS and state inspections, most recent first.
Dishwasher sanitizer testing was not performed according to the test strip instructions. A dietary aide showed he was dipping the strip into standing water on recently washed dishware and holding it there for 10 seconds before reading the color chart, even though the vial instructions said to dip and remove quickly, blot immediately, and compare at once.
Wet food service equipment was found stacked in the dry storage area during a kitchen tour with the RD and CDM. More than 10 steam pans, 3 cookie sheets, and 3 muffin tins were observed wet on shelves, and both the RD and CDM acknowledged the items had not been fully air dried. The facility’s policy stated that utensils, pots, and pans should be air dried after cleaning and sanitizing and not nested or stacked until fully dry.
Incorrect isolation signage was posted outside a resident’s room even though the resident had a physician order for contact isolation related to C. diff. In the dining area, CNAs helped more than one resident eat at the same time and touched another resident’s cup without performing hand hygiene between residents.
Two residents received medications that were listed as allergies in their records without physician documentation authorizing administration. One resident was given atorvastatin for hyperlipidemia despite an atorvastatin allergy, and another resident received acetaminophen despite an acetaminophen allergy. The CP stated the medications should not have been given without a physician note, and the DON confirmed both residents received the medications despite the listed allergies.
Unnecessary drug regimen: A resident received Acyclovir 400 mg BID for prophylaxis without a clear indication. The DON confirmed the order was for prophylaxis but could not identify what it was preventing, and the CP noted the antiviral needed a clear indication. The facility policy required each resident's meds to have a clear indication and be limited to those necessary to treat existing conditions and risks.
The facility failed to submit a follow-up investigation report to the SSA within five days after an altercation between two residents. The Director of Nursing and the MDS Coordinator were unaware of the requirement, and the Administrator confirmed no report was sent, citing a lack of awareness of the policy. The facility's policy mandates a follow-up report within five business days, detailing investigation results and corrective actions.
The facility failed to ensure proper food safety, service, and sanitation practices, did not follow approved menus and recipes for therapeutic diets, and the Certified Dietary Manager lacked required state education on dietetic services. These deficiencies were observed during kitchen tours and interviews, revealing non-compliance with facility policies and state regulations.
The facility failed to ensure staff competency in the food and nutrition service, with kitchen aides improperly testing dishwasher sanitizer levels, dumping trash into sinks with dirty dishes, and washing hands inadequately. A cook incorrectly calibrated a thermometer and did not follow proper food cool down procedures, while a preparatory cook lacked knowledge of cooling techniques for cold foods. These deficiencies risked exposing residents to foodborne illnesses.
The facility failed to follow food safety practices, including storing a dirty utensil with clean ones, improper ice machine sanitation, unlabeled food in the refrigerator, lack of a 3-compartment sink, absence of air gaps to prevent backflow, and inconsistent dish machine temperatures. These issues could expose residents to foodborne illnesses.
The facility failed to submit the required PBJ staffing information to CMS for Q4 2023. The Payroll Clerk admitted to being late and missing the February 14th deadline. The facility's policy mandates daily collection and quarterly reporting of staffing information, which was not followed.
The facility failed to follow its oxygen administration policies for seven residents. One resident did not have an 'oxygen in use' sign outside his room, and six other residents had undated oxygen humidifier bottles and tubing, contrary to the facility's policy requiring weekly changes and proper labeling.
The facility failed to follow standardized recipes and menus approved by the RD, serving rice instead of sodium-free noodles for a Liberal Renal diet and inappropriate pureed vegetables for a puree diet. These deviations were confirmed through observations and interviews with the CDM and RD, highlighting non-compliance with facility policies.
The facility failed to implement proper infection control practices, including hand hygiene and the availability of PPE carts, for four residents. A nurse did not perform hand hygiene when handling a resident's PICC line, and PPE carts were missing outside the rooms of three residents requiring PPE.
The facility failed to follow its policies on medication self-administration for a resident with moderately impaired cognition. The resident used an expired Ventolin inhaler, which was ineffective, and the facility did not conduct an IDT assessment to determine if it was safe for the resident to self-administer medications. The expired medication was not removed from the resident's bedside as required by policy.
The facility failed to develop a care plan to address smoking for a resident admitted with multiple diagnoses, including cellulitis and arthritis. Despite the resident having a scheduled smoking routine, no care plan was developed, which was confirmed by the DON. Facility policies require comprehensive care plans within 48 hours of admission.
A facility failed to ensure a resident remained free from accident hazards due to the use of a bed rail without a proper assessment. The resident, admitted with palliative care, dementia, and diabetes, was observed with half side rails raised on the bed. The DON and an LVN confirmed that no assessment was conducted, contrary to the facility's policy on bed safety.
The facility failed to maintain a medication error rate of less than 5%, with an LVN administering brimonidine and dorzolamide eye solutions to a resident without waiting the required 5 minutes between different eye medications, resulting in an 8% error rate.
Dishwasher Sanitizer Test Strip Instructions Not Followed
Penalty
Summary
The facility failed to ensure kitchen personnel were properly trained on checking the dishwasher sanitizer when the manufacturer's instructions for the test strip were not followed. During an observation in the kitchen with a dietary aide, the aide demonstrated how he checked the chlorine sanitizer for the dishwasher by dipping the test strip into standing water on dishware that had just been run through the dishwasher and holding it there for 10 seconds before comparing it to the color patches on the vial. Review of the test strip container instructions showed that the strip was to be dipped and removed quickly, blotted immediately with a paper towel, and compared to the color chart at once. When asked whether he followed those directions, the dietary aide stated that he did not and then re-did the test following the instructions on the vial.
Wet Food Service Equipment Stacked Before Drying
Penalty
Summary
Food service equipment was observed stacked wet in the dry storage area during the initial kitchen tour with the RD and CDM. More than 10 steam pans, 3 cookie sheets, and 3 muffin tins were seen stacked while still wet on shelves. The RD and CDM acknowledged that the items were wet and stated the facility had ordered new drying racks and was waiting for them. A review of the facility’s undated Dishware, Utensils, and pans Drying Policy stated that dishware, utensils, pots, and pans should be air dried after cleaning and sanitizing, placed on clean, sanitized racks or shelves in an inverted position to drain, and not nested or stacked until fully dry.
Incorrect Isolation Signage and Hand Hygiene Lapses During Resident Care
Penalty
Summary
Infection prevention and control practices were not implemented when incorrect isolation precaution signage was posted outside a resident’s room. The resident had diagnoses including asthma and fatigue, and the physician’s order indicated contact isolation related to C. diff. Despite this order, Enhanced Standard Precaution signage remained posted outside the entrance on two observations. The DON confirmed the contact isolation order and reported the resident had multiple loose bowel movements on 9/21/25 and 9/22/25. The IP stated residents on contact isolation should have contact isolation signage posted and should wear a gown before entering the room even without touching anything inside the room. In the dining area, CNAs were observed helping more than one resident eat at the same time without using hand hygiene between residents. One CNA helped two residents and then grabbed the juice cup of a third resident without hand hygiene. Another CNA touched the cup of a second resident while helping one resident eat without hand hygiene. A third CNA helped two residents eat at the same time without hand hygiene between them. During interviews, the CNAs acknowledged they did not perform hand hygiene between residents and stated they should have done so.
Medication Administration Despite Listed Allergies
Penalty
Summary
The facility failed to ensure that two residents had physician authorization for medications listed as allergies in their medical records. Resident 10’s facesheet listed an allergy to atorvastatin, yet the medication review report showed an order for atorvastatin calcium 20 mg daily for hyperlipidemia beginning 6/1/24, and the MAR documented daily administration in June and July 2024 and again in October 2024. During interview, the consultant pharmacist stated the resident had a listed allergy and should not have received atorvastatin without a physician note indicating it was okay to give. The medical record contained no note from the physician or staff indicating atorvastatin was okay to give before the medication was administered. Resident 12’s facesheet listed an allergy to acetaminophen, yet the medication review report showed an order for acetaminophen 325 mg, two tablets by mouth every 4 hours as needed for mild pain or temperature greater than 100 degrees Fahrenheit. The MAR documented acetaminophen administration on 7/25/25 at 1557. The consultant pharmacist stated the resident had a listed allergy and should not have received the medication without a physician note indicating it was okay to give, and the medical record contained no such note before administration. The DON stated both residents received medications with listed allergies and should not have been given those medications.
Unclear Indication for Acyclovir
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when Resident 3 received Acyclovir without a clear indication. Resident 3 was admitted with diagnoses including bilateral primary osteoarthritis of the knees. A physician order dated 7/31/25 directed Acyclovir 400 mg by mouth twice daily for prophylaxis, but the record did not identify what condition the medication was intended to prevent. During interview and record review on 9/25/25, the DON reviewed the order and confirmed Resident 3 was receiving Acyclovir for prophylaxis, stating she would ask the doctor what it was prophylaxis for. The Consultant Pharmacist's medication regimen review dated 7/31/25 also noted Acyclovir for shingles prophylaxis and stated that antibiotics and antivirals should have clear indications. The facility policy titled Medication Therapy stated each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks and that the regimen should be reviewed to identify whether there is a clear indication for treatment.
Failure to Submit Follow-Up Investigation Report to SSA
Penalty
Summary
The facility failed to submit a full investigation report to the State Survey Agency (SSA) within five days after an initial report of an altercation between two residents. This deficiency was identified during an interview and record review involving the Director of Nursing (DON) and the Minimum Data Services Coordinator (MDSC). The MDSC indicated that the person who witnessed the event should send the initial report to the SSA, but they assist in sending it. However, the MDSC was unaware of any follow-up report being done after five days, suggesting that the abuse coordinator, who is also the Administrator, would have that information. During an interview with the Administrator, it was confirmed that no report was sent five days after the initial report. The Administrator expressed a lack of awareness regarding the requirement to send a follow-up report within five days. The facility's policy, titled 'Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,' last revised in September 2022, clearly states that a follow-up investigation report should be provided within five business days of the incident, detailing the results of the investigation and any corrective actions taken if the allegation was verified.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the Food and Nutrition Services Department staff were able to correctly demonstrate kitchen tasks in food safety, service, and sanitation. During observations, staff were unable to correctly test the sanitizer strength for the dish machine, and the cool down process for cooked food was not properly followed or documented. Additionally, the ice machine was not cleaned according to the manufacturer's guidelines, and a proper 3-compartment sink system for cleaning, rinsing, and sanitizing was not established. These failures were observed during multiple kitchen tours and interviews with staff, revealing a lack of adherence to facility policies and standards of practice. The facility also did not follow approved menus and recipes for residents with therapeutic diets. During meal preparation and service, staff served incorrect side dishes and did not use standardized recipes for pureed vegetables, which included inappropriate ingredients. These discrepancies were confirmed through observations, interviews, and record reviews, indicating a failure to meet the nutritional and dietary needs of residents as per the facility's policies. Furthermore, the Certified Dietary Manager (CDM) did not meet the required state of California education requirements for dietetic services. The CDM admitted to not having the necessary hours of education on Title 22 regulations and was unfamiliar with these requirements. This lack of proper qualifications and training was acknowledged by both the CDM and the Registered Dietitian (RD), highlighting a significant oversight in the facility's compliance with state regulations for dietary services supervision.
Deficiencies in Food and Nutrition Service Staff Competency
Penalty
Summary
The facility did not ensure that staff performed their job functions competently according to standards of practice in the food and nutrition service. Two kitchen aides were observed improperly testing the level of dishwasher sanitizer, with one aide using standing water on the counter and another using standing water in the dishwashing machine compartment. Both aides were unaware of the correct parts per million (PPM) levels required for effective sanitization. Additionally, one kitchen aide was seen dumping trash can debris into a sink compartment containing dirty dishes, and another was observed washing his hands with only water after handling garbage, then touching dishes needing to be cleaned. These actions indicate a lack of adherence to proper sanitization and infection control procedures as outlined in the facility's policies and job descriptions. A cook was observed calibrating a thermometer incorrectly and was unable to verbalize the proper cool down process for food. The cook believed the thermometer should read 30 degrees when calibrated, contrary to the facility's in-service training which specifies the boiling point method at 212 degrees Fahrenheit and the ice point at 32 degrees Fahrenheit. The cook also failed to mention the required time frames for cooling down food, which should be from 135 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and from 135 degrees Fahrenheit to 41 degrees Fahrenheit within 6 hours. The facility's cool down log sheet for April 2024 was found to be blank, indicating a lack of proper documentation and monitoring. A preparatory cook was interviewed and did not specify time intervals or cooling techniques when preparing cold foods such as tuna salad or chicken salad. The facility's in-service training and FDA Food Code require that such foods be cooled down to 41 degrees Fahrenheit within 4 hours if prepared from ingredients at ambient temperature. The preparatory cook's lack of knowledge and adherence to these guidelines further highlights the deficiencies in staff training and competency. These failures to follow proper food safety and infection control procedures had the potential to expose residents to foodborne illnesses.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility did not ensure food safety practices were followed according to facility policy and standards of practice. A dirty cooking utensil was stored with clean utensils, and the ice machine reservoir tray had black colored debris and was not sanitized correctly. Additionally, food in the walk-in refrigerator was not labeled with an opened-on date and use-by date. The kitchen also lacked a 3-compartment sink system for manually washing, rinsing, and sanitizing dishes, and the 2-compartment sink used did not have an air gap to prevent backflow of dirty water. Furthermore, the low-temperature dish machine did not consistently reach 120 degrees Fahrenheit over three cycles. These failures had the potential to expose vulnerable residents to potential contaminants that may cause foodborne illnesses. During an initial kitchen tour, a whisk with brown food debris was observed hanging with other clean utensils. The kitchen aide and certified dietary manager acknowledged the whisk was dirty and should not have been stored with clean utensils. The ice machine reservoir tray was found to have black sediment residue, and the maintenance assistant admitted to not following the manufacturer's cleaning instructions. Food items in the walk-in refrigerator and a smaller refrigerator were found without proper labeling, and the certified dietary manager confirmed that all food must be labeled with an opened date and a use-by date. The kitchen was observed to have a 2-compartment sink instead of the required 3-compartment sink for manual dishwashing. The certified dietary manager was unaware of the need for three compartments. Additionally, the 2-compartment sink, ice machine, and vegetable washing sink did not have air gaps to prevent backflow. The low-temperature dish machine was observed to not consistently reach the required temperature of 120 degrees Fahrenheit, and the kitchen aide confirmed the temperature should be between 120-150 degrees Fahrenheit. These deficiencies indicate a failure to adhere to proper food safety practices, potentially exposing residents to foodborne illnesses.
Failure to Submit PBJ Staffing Information for Q4 2023
Penalty
Summary
The facility failed to submit the required Payroll Based Journaling (PBJ) staffing information to the Centers for Medicare and Medicaid Services (CMS) for the last quarter of 2023, covering October, November, and December. This deficiency was identified during a review of the PBJ Staffing Data Report, which indicated that the data for the specified quarter was not submitted. During an interview, the Payroll Clerk responsible for submitting the data admitted to being late and failing to submit the information before the February 14th deadline. The facility's Policy & Procedure on Reporting Direct Care Staffing Information, dated 2022, mandates that staffing information be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting period, which was not adhered to in this instance.
Failure to Follow Oxygen Administration Policies
Penalty
Summary
The facility failed to follow its Policy and Procedure as well as professional standards of practice regarding oxygen administration for seven residents. Specifically, Resident 23 did not have an 'oxygen in use' sign outside his room, which is necessary to alert staff and visitors of the oxygen being used in the room. This was confirmed during an interview with an LVN who stated that Resident 23 had started receiving oxygen after returning from the hospital. The facility's policy on oxygen administration, dated 2010, requires 'No Smoking/Oxygen in Use' signs to be displayed when oxygen is being administered. Additionally, the facility did not properly label and promptly replace oxygen humidifiers and tubing for six other residents. Observations revealed that the oxygen humidifier bottles for Residents 2, 10, 16, 25, 46, and 157 were undated. Resident 16's nasal cannula was also found to be dated 3/30/24, indicating it had not been replaced in a timely manner. Interviews with LVNs and the DON confirmed that the humidifier bottles and tubing should be dated and changed weekly, as per the facility's policy on oxygen administration. The failure to adhere to these guidelines was evident in the observations and interviews conducted during the survey.
Failure to Follow Standardized Recipes and Menus
Penalty
Summary
The facility failed to follow standardized recipes and menus approved by the facility's Registered Dietitian (RD). Specifically, rice was served instead of sodium-free noodles for a resident on a Liberal Renal diet, and the puree diet did not receive an appropriate pureed vegetable for the lunch meal. These deviations from the approved menu and recipes were observed during meal times and confirmed through interviews with the Certified Dietary Manager (CDM) and the RD. The CDM admitted to having all necessary ingredients in stock but could not explain the substitution of rice for noodles. The RD confirmed that sodium-free noodles should have been served as per the menu for the Liberal Renal diet. Additionally, the CDM prepared a mixture of cooked broccoli and tomatoes for the pureed diet without following a standardized recipe. The facility's therapeutic menu spreadsheet and the pureed recipe preparation policy explicitly stated that fibrous vegetables like broccoli should be omitted from pureed diets. The RD acknowledged that the residents should not have received the pureed cooked broccoli and tomato mixture. The facility's policies on food preparation and menu planning were reviewed, indicating that approved recipes and standardized methods should be used to meet residents' nutritional needs. These failures had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the residents' nutritional status.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices for four of seven sampled residents. Specifically, a registered nurse did not perform hand hygiene when handling a resident's peripherally inserted central catheter (PICC) line. During a medication observation, the nurse administered an antibiotic via the PICC line and subsequently touched the overbed table and IV pump without performing hand hygiene. When an alarm indicated air in the IV line, the nurse disconnected the IV tubing from the PICC line without washing hands or applying new gloves. The nurse acknowledged the failure to perform hand hygiene during a concurrent interview. The facility's hand hygiene policy requires handwashing after contact with inanimate objects in the patient's vicinity, which was not followed in this instance. Additionally, the facility did not have personal protective equipment (PPE) carts outside the rooms of three residents who required PPE for care. Observations revealed that there were no PPE carts outside the rooms of these residents, despite signage indicating the need for PPE. Both a licensed vocational nurse and the infection preventionist confirmed the absence of PPE carts. The facility's policies and the Centers for Disease Control and Prevention (CDC) guidelines require the availability of PPE and hand hygiene at the point of care, which were not adhered to in these cases.
Failure to Implement Medication Self-Administration Policies
Penalty
Summary
The facility failed to implement their policies on medication self-administration for Resident 157. The resident, who had moderately impaired cognition with a BIMS score of 9, was found with an expired Ventolin inhaler in her slightly open purse on top of her bed. The resident confirmed using the expired inhaler for difficulty breathing, which was ineffective, leading to the need for supplemental oxygen. The facility did not conduct an IDT assessment to determine if it was safe for the resident to self-administer medications, and the expired medication was not removed from the resident's bedside as required by the facility's policy. During an observation and interview, the DON confirmed the expiration of the inhaler and acknowledged the importance of regularly checking medications stored at bedside. The resident was unaware of the expiration date and insisted the inhaler was still usable. The facility's policy mandates that the IDT assess each resident's ability to self-administer medications and ensure safe storage, which was not followed in this case. This oversight had the potential for unsafe and improper administration of medications.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan to address smoking for Resident 255, who was admitted with diagnoses including cellulitis of the right lower limb, arthritis due to other bacteria in the right knee, an unspecified right hip open wound, and a history of smoking. Despite the resident having a scheduled smoking routine outside the facility, accompanied by staff, there was no care plan developed to address this need. The Director of Nursing (DON) confirmed that a smoking assessment was completed on 4/3/24, but a baseline care plan was not developed within the required 72-hour timeframe. The facility's policy and procedure titled 'Care Plans - Baseline' requires that a comprehensive care plan be developed within 48 hours of the resident's admission. Additionally, the policy titled 'Care Planning-Interdisciplinary Team' mandates that comprehensive, person-centered care plans be based on resident assessments and developed by an interdisciplinary team (IDT). The failure to develop a care plan for Resident 255's smoking needs was verified by the DON during a concurrent interview and record review.
Failure to Conduct Bed Rail Assessment
Penalty
Summary
The facility failed to ensure that Resident 30 remained free from accident hazards due to the use of a bed rail without a proper assessment. Resident 30, who was admitted with diagnoses including palliative care, unspecified dementia, and type 2 diabetes mellitus with diabetic nephropathy, was observed with half side rails raised on the bed. However, no assessment for the use of side rails was conducted, as confirmed by the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). Both acknowledged that an assessment should have been done for the safety of the resident. The facility's policy on bed safety and bed rails indicates that the use of bed rails is prohibited unless specific criteria are met and alternatives have been attempted. Despite this policy, the necessary interdisciplinary evaluation and risk assessment for Resident 30 were not performed. This oversight had the potential to put Resident 30 at risk for entrapment and serious injury, as the required safety protocols were not followed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by 2 medication errors out of 25 opportunities, resulting in an 8% error rate for one resident observed during medication administration. Specifically, a licensed vocational nurse (LVN) administered brimonidine and dorzolamide eye solutions to a resident without waiting the required 5 minutes between different eye medications. This action was contrary to the facility's policy and accepted professional standards of practice. The Director of Nursing confirmed that the nursing staff should wait 5 minutes between administering different eye medications, as per the facility's guidelines revised in January 2014.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Watsonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Watsonville Nursing Center | 0.6 mi | ★★★★★ | 12 | 0 |
| Watsonville Post Acute Center | 0.6 mi | ★★★★★ | 10 | 0 |
| Pacific Coast Manor | 11.7 mi | ★★★★★ | 0 | 0 |
| Gilroy Healthcare Center | 12.5 mi | ★★★★★ | 2 | 0 |
| Driftwood Healthcare Center - Santa Cruz | 12.5 mi | ★★★★★ | 18 | 0 |
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