Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pacific Coast Manor during CMS and state inspections, most recent first.
A resident with obstructive sleep apnea was admitted with a physician's recommendation to continue CPAP therapy, but no active order or documentation for CPAP use was found, and the resident did not have access to a CPAP machine during their stay. Nursing and medical staff were aware of the need but did not ensure the resident received the prescribed treatment.
A facility failed to update the PASARR Level I Screening for a resident who was newly diagnosed with PTSD, anxiety disorder, and unspecified psychosis after admission. Despite these new diagnoses, no new PASARR Screening was conducted, contrary to facility policy. Interviews with the DRA and ED confirmed the need for a new screening, which was not completed.
A resident approved to self-administer their albuterol inhaler was found storing it in an unsecured, zippered bag on their bedside table, contrary to facility policy requiring lockable storage. Despite being cognitively intact, the resident shared a room with others, and the inhaler was sometimes left unattended. Staff interviews confirmed the oversight, as lockboxes were available but not provided to the resident.
A facility failed to notify the Office of State Long-Term Care Ombudsman when a resident was transferred to an acute care hospital following aggressive behavior. The clinical record lacked evidence of fax confirmation for the notification, and the administrator confirmed the oversight, stating the medical record manager was responsible for such notifications. The facility's policy required notification to the Ombudsman before transfers, but no evidence was maintained.
The facility failed to conduct comprehensive psychosocial assessments for two residents, leaving questions about their history of trauma and stressors unanswered. Despite having intact cognition, both residents confirmed that staff did not inquire about their mental health history. Facility staff acknowledged the incomplete assessments, which were required by the facility's policies to ensure resident-centered care.
The facility failed to protect residents from physical abuse, resulting in two incidents where a resident was hit in the face and another was kicked in the leg by the same resident. Both incidents were witnessed by staff and other residents, and the involved residents have cognitive impairments.
Failure to Provide Prescribed CPAP Therapy for Resident with OSA
Penalty
Summary
A resident with a diagnosis of obstructive sleep apnea (OSA) was admitted to the facility following a fall at home, with medical documentation indicating the need to continue home CPAP therapy. Despite this, there were no active orders for a CPAP machine in the resident's order summary, and the medication administration record showed no documentation of CPAP use during the resident's stay. Observations confirmed that no CPAP machine was present in the resident's room, and the resident reported not having access to a CPAP machine at night. Multiple progress notes and interviews revealed ongoing concerns from medical staff regarding the resident's lack of CPAP therapy, including reports of cognitive issues potentially related to not using the CPAP. Nursing staff acknowledged the absence of the CPAP and indicated attempts to obtain one, while the DON and physicians expressed uncertainty or deferred responsibility regarding the process for securing the necessary equipment and orders. The deficiency centers on the facility's failure to provide appropriate treatment and care in accordance with physician orders and the resident's diagnosed needs.
Failure to Update PASARR Screening for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASARR) Level I Screening for a resident who was newly diagnosed with serious mental disorders. The resident was admitted to the facility with no serious mental illness indicated in the initial PASARR screening. However, after admission, the resident was diagnosed with post-traumatic stress disorder (PTSD), anxiety disorder, and unspecified psychosis. Despite these new diagnoses, the facility did not complete a new Level I PASARR Screening to reflect these changes. Interviews with the Director of Resident Assessment and the Executive Director confirmed that the resident's condition warranted a new Level I Screening, which was not conducted. The facility's policy required that any resident exhibiting a newly evident serious mental disorder be referred for a Level II Resident review, which did not occur in this case. The oversight was identified during a review of the resident's medical records, which lacked documentation of an updated PASARR Screening following the new diagnoses.
Failure to Securely Store Self-Administered Medications
Penalty
Summary
The facility failed to ensure the secure storage of medications for a resident who was deemed capable of self-administering their medication. Resident #247, who was cognitively intact with a BIMS score of 14, was assessed and approved to self-administer their albuterol inhaler. However, observations revealed that the inhaler was stored in an open, zippered bag on the resident's bedside table, which lacked a locking mechanism. The resident shared a room with two other residents, and at times, the inhaler was left unattended while the resident was outside the room. Interviews with facility staff, including a case manager, registered nurses, the Director of Nursing, and the Executive Director, confirmed that the facility's policy required medications to be stored in a lockable container to prevent access by other residents. Despite this policy, Resident #247 was not provided with a lockable storage option for their inhaler. The Director of Nursing acknowledged the oversight and noted that lockboxes were available but had not been offered to the resident. The Executive Director reiterated the importance of storing medications in a lockbox to ensure they are not accessible to other residents.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of the Office of State Long-Term Care Ombudsman when a resident was transferred to an acute care hospital. The deficiency involved Resident 1, who was admitted to the facility and later transferred to the hospital following an episode of aggressive and combative behavior. The clinical record of Resident 1 did not contain documented evidence of a fax confirmation for the notification of the transfer to the Ombudsman. During an interview, the facility's administrator confirmed the absence of documentation for the fax confirmation and stated that the medical record manager was responsible for notifying the Ombudsman via fax for such transfers. The facility's policy, revised in July 2023, required that notice be provided to the resident, their representative, and the Ombudsman as soon as practicable before a transfer or discharge. However, the facility did not maintain evidence that the notice was sent to the Ombudsman, as required by their policy.
Failure to Conduct Comprehensive Psychosocial Assessments
Penalty
Summary
The facility failed to adhere to its policy and procedure for assessing the history of psychosocial, trauma, and stressors that could trigger an event for two residents. Resident 1, who was admitted and readmitted to the facility, had diagnoses of depression, anxiety, and insomnia. Despite having intact cognition, as indicated by a BIMS score of 14 out of 15, the initial admission and readmission social service assessments for Resident 1 were incomplete, with questions regarding psychosocial history left unanswered. Resident 1 confirmed that the facility staff did not inquire about their mental health history or trauma. Similarly, Resident 2, who had diagnoses including depression, anxiety, insomnia, bipolar disorder, Parkinson's disease, and adult failure to thrive, also had incomplete social service assessments. The assessments left questions about psychosocial history, trauma, and stressors unanswered, despite Resident 2 having an intact cognition with a BIMS score of 15 out of 15. Resident 2 also confirmed that the facility staff did not ask about their history of trauma or mental health concerns. Interviews with facility staff, including the LVN/CM and SSD, confirmed that the social service assessments for both residents were incomplete and that the necessary questions were not asked. The Director of Nursing acknowledged that social service staff were responsible for completing these assessments upon admission, readmission, and quarterly to ensure a resident-centered plan of care. The facility's policy and procedure documents outlined the requirement for comprehensive social history assessments, which were not followed in these cases.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two incidents involving Resident 3. In the first incident, Resident 1 was hit in the face by Resident 3, leading to a minor laceration that required medical care. This altercation was witnessed by Resident 4, who reported that Resident 1 had grabbed Resident 3's arm before being struck. Both Resident 1 and Resident 3 have a history of involvement in resident-to-resident altercations and are cognitively impaired, with Resident 1 rarely understood and Resident 3 having a BIMS score indicating severe cognitive impairment. Staff responded to the incident, and the facility's records confirmed the occurrence of physical abuse between the residents involved. In the second incident, Resident 2 was kicked in the leg by Resident 3 after an altercation in the hallway. LVN A witnessed the event, noting that Resident 2 approached Resident 3 in a threatening manner before being kicked, resulting in a skin tear on Resident 2's shin. Resident 2 has moderate cognitive impairment, as indicated by a BIMS score. The facility's policy on abuse clearly states that residents have the right to be free from physical abuse, including hitting and kicking, yet these incidents demonstrate a failure to uphold this standard, leading to physical harm to the residents involved.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 265 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Capitola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redwood Grove Post Acute | 1.3 mi | ★★★★★ | 1 | 0 |
| Driftwood Healthcare Center - Santa Cruz | 1.4 mi | ★★★★★ | 18 | 0 |
| Santa Cruz Post Acute | 1.7 mi | ★★★★★ | 8 | 0 |
| Watsonville Nursing Center | 11.2 mi | ★★★★★ | 12 | 0 |
| Watsonville Post Acute Center | 11.2 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.