Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Watsonville Nursing Center during CMS and state inspections, most recent first.
Pain medication was not administered according to physician orders for four residents with pain-related diagnoses. Acetaminophen was given by an LPN when the residents’ pain levels were above the mild-pain range specified in the orders, and the DON confirmed the MAR entries did not match the ordered parameters. The facility policy stated the medication regimen is implemented as ordered.
Food Not Palatable or Attractive: Multiple residents complained that meals tasted terrible or were inconsistent in quality, and one resident on a fortified/high protein diet described the green beans as soaked and slumpy. During a lunch tray taste test, the RD and DS both stated the green beans were overcooked, with the DS noting they needed a little salt and that the facility did not have a steamer. The facility policy required nourishing, palatable, well-balanced meals served at a safe and appetizing temperature.
Unsanitary baking pans and damaged base plate covers were observed in the kitchen and on the tray line. Four baking pans had blackish discolorations and brownish spots, and four base plate covers were dented, deformed, and discolored while staff used them to serve food to residents. The DS confirmed the findings, and the facility policy required utensils and equipment to be kept clean and in good repair.
Infection control practices were not followed in several areas. A resident with a stage II pressure injury was not placed on EBP, frozen food for a resident was stored in a refrigerator instead of the freezer, an LPN did not sanitize hands after glove removal, a treatment nurse contaminated hands while handling soiled wound care materials, soiled linen was left on a trash can, a resident’s nebulizer parts were not stored in the bag, and another resident’s oxygen concentrator filter was dusty.
A resident with paranoid schizophrenia had a positive PASRR Level I screening that required a Level II MH evaluation, but the evaluation was not completed. DHCS stated the evaluation was not scheduled because facility staff were unresponsive to repeated communication attempts within 48 hours of the Level I screening, and the AIT acknowledged the evaluation was not completed.
A resident’s comprehensive care plan did not reflect noncompliant behavior related to safety and well-being. Staff observed an extension cord, phone charger, bags, clothes, papers, a power wheelchair battery charger, and plastic bags under the resident’s bed, and the IP and DON both confirmed the resident’s behavior and that it was not care planned. The resident had diagnoses including quadriplegia, chronic pain syndrome, MDD, gait/mobility abnormalities, obesity, and an above-knee amputation, with a BIMS score of 15.
Wound care and medication handling deficiencies were identified for two residents. A cup of zinc oxide cream was left on a resident’s bedside drawers, and an LPN stated it should not have been left there. In another case, a TN cleansed a resident’s pressure ulcers with dermal wound cleanser instead of the NS ordered by the physician, and later confirmed the order called for NS.
A resident dependent on renal dialysis had a physician order for licensed nursing staff to monitor the bruit and thrill of the dialysis shunt every shift. During interview, an LVN stated she checked both by feeling the shunt with her fingers, despite the facility policy calling for staff education and training in the care of grafts and fistulas.
Unnecessary drug regimen monitoring was not ensured for two residents. One resident receiving Nuedexta for PBA had no documented monitoring of uncontrolled crying episodes, and the DON confirmed the episodes were not monitored. Another resident receiving IV Piperacillin Sod-Tazobactam for CRPA had no documented monitoring for antibiotic side effects or adverse reactions, and the IP confirmed the record lacked such monitoring.
Insufficient square footage was identified in multiple multi-resident rooms, including 2-bed rooms measuring 70 to 77 square feet per resident and 3-bed rooms measuring 70.5 to 78.5 square feet per resident. During observations, staff and residents stated the room size was not a concern, and the rooms were not observed to interfere with care.
The facility failed to maintain sanitary conditions in food storage and preparation, with black stains on steel trays and buildup in the ice machine. Dietary staff did not wear proper hairnets and beard restraints. Additionally, the facility did not follow its policy on labeling foods brought in by family, using the date received instead of a 'use by' date. These deficiencies could expose residents to contaminants.
The facility failed to develop and implement comprehensive care plans for five residents, neglecting to address specific medical and personal care needs. This included omissions in care plans for ADLs, anticoagulant therapy, UTIs, and prescribed medications such as Zoloft, Aripiprazole, and Alendronate Sodium. The lack of individualized care plans highlights a pattern of neglect in meeting residents' physical, psychosocial, and functional needs.
The facility failed to manage medications properly, with expired and unlabeled medications found in storage, and medications requiring refrigeration left unrefrigerated. Labeling issues were noted, with medications labeled only with room numbers, risking errors due to room changes. A medication order discrepancy was also identified, highlighting potential for medication errors.
The facility failed to ensure food was prepared to conserve nutritive value and appearance, as evidenced by resident complaints and a test tray evaluation. Residents reported food being cold, bland, and improperly textured. A test tray evaluation confirmed these issues, with food temperatures below recommended safe levels, contrary to facility guidelines. This deficiency had the potential to negatively impact residents' nutritional status.
The facility failed to implement proper infection control practices, with CNAs not performing hand hygiene while serving lunch trays, and improper management of medical equipment such as nebulizers and glucometers. Additionally, a humidifier bottle was found on the floor, and a NA did not perform hand hygiene between assisting residents. These actions were confirmed through observations and staff interviews, indicating non-compliance with infection control policies.
A resident's dignity was compromised when their suprapubic catheter drainage bag was left uncovered, displaying urine. The resident, who has End Stage Renal Disease and obstructive uropathy, was found in this state after returning from dialysis. Staff, including a CNA and LVN, acknowledged the oversight, confirming that the bag should have been covered with a privacy bag, as per facility policy.
The facility failed to obtain informed consent for lorazepam for a resident with Major Depressive Disorder and Catatonic Schizophrenia. The consent form lacked the name of the person who gave consent, contrary to the facility's policy requiring documentation of consent by the resident or their representative.
A facility failed to develop a baseline care plan for a resident's oxygen use within 48 hours of admission, as required by CMS. The resident, admitted with multiple health issues, had a physician's order for oxygen at specific levels, but was observed receiving a higher amount. Interviews confirmed the absence of a care plan, leading to improper oxygen administration.
The facility failed to follow physician's orders for oxygen administration for three residents, leading to potential complications. One resident received a higher oxygen flow than prescribed, and the 'Oxygen in Use' sign was not properly displayed. Another resident was administered oxygen at a higher rate than ordered, and a third resident received oxygen at a higher rate than needed for shortness of breath. These deviations from prescribed oxygen levels were confirmed by staff and did not align with the facility's policy on oxygen administration.
The facility failed to ensure proper use of bed rails for two residents, lacking physician orders, assessments, and care plans. One resident used 1/4 bilateral side rails without documentation, while another used 1/4 mid bilateral side rails for assistance without necessary orders or assessments. These omissions violated the facility's policy requiring informed consent and assessments before bed rail use.
A resident with Major Depressive Disorder and catatonic schizophrenia did not receive necessary follow-up psychological evaluations due to the Social Services Director's failure to schedule appointments. Despite an initial attempt to arrange an evaluation, no further action was taken after the assigned clinician was on leave, leading to unmet psychosocial care needs.
A resident was prescribed Seroquel for dementia with psychotic disturbance without sufficient documentation to support the diagnosis. The facility's policy requires that psychotropic medications are only prescribed for diagnosed and documented conditions, but there were no psychiatrist notes or active diagnosis to justify the medication. Interviews with staff confirmed the need for clarification with the prescribing doctor.
A medication error rate of 5.88% was identified in an LTC facility when a resident did not receive medications as ordered. An LVN administered Zaditor eye drops without an open date and gave an incorrect dose of Levetiracetam, contrary to the physician's orders. The facility's policy requires medications to be administered as prescribed, including recording open dates and verifying dosages.
The facility failed to ensure dietary staff had the necessary skills for food safety. A pair of tongs with residues was found in a drawer, and a dietary cook couldn't explain the cool down process. A dietary aide incorrectly tested the dish machine's chemical concentration. In-service meetings were attended, but documentation lacked specific steps.
The facility failed to follow the recipe for a pureed diet, potentially compromising residents' nutritional needs. A Dietary Aide was observed preparing pureed bread without measuring the water added, contrary to the facility's menu instructions, which specify adding one cup of warm milk or water for every five portions. This oversight was noted during an observation with a Registered Dietician.
The facility failed to report suspected abuse and theft allegations in a timely manner for two residents. One resident's missing money was not reported to the appropriate authorities when initially reported, and another resident's incident of striking another resident was reported late. Both incidents were not reported according to the facility's policy, which requires immediate reporting of such allegations.
A deficiency was identified in the facility's compliance with room size requirements, as multiple multi-resident rooms provided less than the required 80 square feet per resident. Despite this, observations indicated that the room sizes did not inhibit care, and both staff and residents reported no concerns about the room sizes.
Pain Medication Given Outside Ordered Pain Parameters
Penalty
Summary
The facility failed to provide safe, appropriate pain management for four residents when licensed nurses administered acetaminophen contrary to the physician-ordered pain parameters. Resident 6 had a diagnosis of right hip pain and an order for acetaminophen 325 mg, 2 tablets every 4 hours as needed for mild pain level 1-3, but the MAR showed the medication was given when the resident’s pain level was higher than 3 on multiple occasions. The DON reviewed the MAR and confirmed the medication was administered when the pain level exceeded the ordered range. Resident 4 had phantom limb syndrome with pain and an order for acetaminophen 500 mg every 6 hours as needed for mild pain level 1-3, yet the MAR showed the medication was administered when pain was higher than 3 on 11/6/25 and 12/20/25. Resident 46 had chronic pain and an order for acetaminophen 500 mg every 4 hours as needed for mild pain level 1-3, but the MAR showed it was administered when pain was higher than 3 on 1/2/26. Resident 47 had left hip osteoarthritis and an order for acetaminophen 500 mg every 6 hours as needed for mild pain level 1-3, but the MAR showed repeated administrations when pain was higher than 3 across multiple dates. The DON reviewed the records and confirmed these administrations did not match the physician orders; the facility policy stated the medication regimen is implemented as ordered.
Food Not Served Palatable or Attractive
Penalty
Summary
The facility failed to ensure food served was palatable and attractive for three residents, including Resident 2, Resident 17, and Resident 72. During interviews, Resident 2 stated the food tasted terrible, especially the chicken, and Resident 17 stated the food was sometimes good and sometimes not good. Resident 72, who was on a fortified/high protein diet with regular texture, stated the facility's food was terrible and described the green beans as soaked and slumpy. Because of multiple resident complaints about the food, surveyors observed a lunch test tray with the Registered Dietician and Dietary Supervisor present. The regular test tray included green beans, and both the Dietary Supervisor and Registered Dietician stated the green beans were overcooked; the Dietary Supervisor also stated they needed a little salt and that the facility did not have a steamer. The Registered Dietician stated the overcooked green beans would affect the nutritive value of the food if overcooked. The facility policy stated residents are to be provided a nourishing, palatable, well-balanced diet and that food should appear palatable and attractive and be served at a safe and appetizing temperature.
Unsanitary and Damaged Kitchen Equipment
Penalty
Summary
Food items were not stored and prepared in accordance with professional standards for food safety when unsanitary baking equipment was observed in the kitchen. During the initial kitchen tour, four baking pans were observed with blackish discolorations and brownish spots. The Dietary Supervisor stated the pans were used for baking and removed one to wash it. During a later interview, the Dietary Supervisor stated the four baking pans would be replaced with new pans. During tray line observation, four base plate covers were observed to be dented, deformed, and discolored, and staff used them to serve food to residents during lunch. During a concurrent observation and interview, the Dietary Supervisor confirmed the finding and stated the base plate covers should be removed and replaced with new ones. Review of the facility policy titled Sanitation stated that utensils, counters, shelves, and equipment are to be kept clean and maintained in good repair, and that damaged or broken equipment that cannot be repaired is discarded.
Infection Control Practices Not Followed
Penalty
Summary
The facility failed to implement infection prevention and control practices in multiple areas. Resident 13 had a stage II pressure injury to the right heel and, during observation, there was no blue sticker outside the room indicating Enhanced Barrier Precautions were in place. The infection preventionist reviewed the record and confirmed the resident was not on EBP, stating that residents with stage II pressure injuries should have EBP. The facility policy stated EBP are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. In the dietary area, a box of chicken and mashed potatoes labeled "Perishable. Keep Frozen" and identified with Resident 8's name was found stored in a refrigerator unit instead of the freezer. The infection preventionist stated it should have been stored in the freezer, and the dietary supervisor reviewed the photo and stated the item should have been in the freezer unless it had a thawing date. The facility's food storage policy required foods to be stored in a manner that complies with safe food handling practices and that frozen foods be maintained frozen solid. Additional infection control lapses were observed during resident care and equipment handling. After administering insulin to Resident 30, an LVN removed gloves and then used the medication cart computer without sanitizing hands. During wound care for Resident 2, a treatment nurse opened the trash bag with a hand while handling soiled gauze from pressure ulcer treatment. A CNA placed Resident 19's soiled linen on top of a trash can and against the wall instead of in the soiled linen bin. Resident 46's nebulizer mask and tubing were stored outside the bag, and Resident 47's oxygen concentrator filter was dusty. The facility's hand hygiene, laundry, nebulizer storage, and oxygen equipment practices were not followed as observed.
Failure to Complete PASRR Level II Mental Health Evaluation
Penalty
Summary
The facility failed to ensure that Resident 61 completed a Level II Mental Health Evaluation as part of the PASRR process. Resident 61’s clinical record showed diagnoses including paranoid schizophrenia. The preadmission PASRR Level I screening dated 11/26/25 indicated a positive Level I screening and that a Level II Mental Health Evaluation was required. A letter from the California Department of Health Care Services, dated 11/29/25, stated that the Level II evaluation was not completed and was not scheduled because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. During an interview on 1/09/2026 at 11:13 a.m., the AIT stated the PASRR Level II evaluation was not completed and that the facility should have followed up with PASRR.
Care Plan Did Not Address Resident’s Noncompliant Safety Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one of 28 sampled residents, Resident 35, because the resident’s noncompliant behavior related to safety and well-being was not reflected in the care plan. During a concurrent observation and interview, the IP confirmed that an extension cord, phone charger, bags, clothes, papers, a power wheelchair battery charger, and plastic bags were placed under Resident 35’s bed. The IP stated that Resident 35 had noncompliant behavior and that this behavior should have been documented and care planned. During a concurrent interview and record review, the DON stated that Resident 35 preferred to put everything on his bed and described the resident as noncompliant to potential accident hazard. The DON confirmed there was no care plan addressing Resident 35’s noncompliant behavior related to removal of potential accident hazards, including the power strip, excess electrical cords, and power wheelchair battery charger in the resident’s bed. Resident 35 was admitted with diagnoses including quadriplegia, chronic pain syndrome, major depressive disorder, other abnormalities of gait and mobility, personal history of other mental and behavioral disorders, obesity, and acquired absence of the left leg above the knee. The record also showed a BIMS score of 15, indicating intact cognition.
Wound Care and Medication Handling Deficiencies
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two residents. For one resident, a medicine cup containing white substance identified by the LVN as zinc oxide cream for treatment was observed on top of the resident’s bedside drawers during an observation and interview. The LVN stated the cup should not have been left with the resident. The report also cited California Board of Registered Nursing requirements stating registered nurses should ensure the safety and protection of residents and the administration of medications and therapeutic agents necessary to implement physician-ordered treatment and disease prevention. For another resident admitted with pressure ulcers of the right hip and left buttock, physician orders directed the licensed nurse to cleanse the right hip and left ischium pressure ulcers with normal saline, pat dry, apply Dakin-moistened gauze, dry gauze, and border foam dressing twice daily and as needed. During a treatment observation, the TN cleansed the wounds with dermal wound cleanser instead of normal saline. When interviewed, the TN reviewed the orders and confirmed the physician had ordered normal saline, but he had used dermal wound cleanser and stated he should have used normal saline as ordered. The facility policy on wound care stated to apply treatment as indicated.
Dialysis Shunt Assessment Not Performed as Ordered
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not ensured when licensed vocational nurse C did not know how to check Resident 19's bruit. Resident 19 was admitted with a diagnosis of dependence on renal dialysis, and a physician order dated 12/21/25 directed licensed nursing staff to monitor the bruit and thrill of the dialysis shunt every shift. During an interview on 1/8/26, LVN C stated she checked both the bruit and thrill by feeling the dialysis shunt with her fingers. The facility policy for care of a resident with end-stage renal disease stated that staff education and training includes the care of grafts and fistulas.
Unnecessary Drug Regimen Monitoring Deficiencies
Penalty
Summary
Unnecessary drug regimen monitoring was not ensured for a resident receiving Nuedexta for pseudobulbar affect. The resident was admitted with a diagnosis of PBA and had a physician order for Nuedexta 20/10 mg twice daily for episodes of uncontrolled crying, but the clinical record did not show that the episodes of uncontrolled crying were monitored. During interview and record review, the DON confirmed that the resident’s episodes of uncontrolled crying were not monitored and stated they should have been monitored. A second resident did not have adequate monitoring for side effects and adverse reactions while receiving Piperacillin Sod-Tazobactam IV for CRPA. The resident had diagnoses including carrier or suspected carrier of methicillin resistant staphylococcus aureus and a physician order for Piperacillin Sod-Tazobactam 3-0.375 gram IV every 6 hours for 7 days. During concurrent interview and record review, the IP stated the IV antibiotic had started and confirmed there were no monitoring measures in the medical record for side effects or adverse reactions of the antibiotic therapy.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
Multiple multi-resident rooms were found to provide less than the required 80 square feet per resident. Based on observation, interview, and record review, the cited rooms included several 2-bed rooms measuring 70 to 77 square feet per resident and several 3-bed rooms measuring 70.5 to 78.5 square feet per resident. The report identified numerous rooms by number, each listed as having insufficient square footage for the number of beds present. During multiple observations from 1/5/2026 through 1/9/2026, none of the rooms were observed to inhibit staff from providing care. Staff and residents stated that the square footage of the rooms was not a concern. The report concluded that continuance of the room waiver is recommended.
Sanitation and Labeling Deficiencies in Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas, as evidenced by several observations during a survey. Steel trays with black stains were found inside the kitchen freezer, indicating a lack of proper cleaning and maintenance. Additionally, the ice machine had a black substance buildup and a yellow stain on the baffle, suggesting inadequate cleaning practices. The facility's policy on sanitization, which requires all utensils, counters, shelves, and equipment to be kept clean and in good repair, was not adhered to. Furthermore, dietary staff were observed not wearing appropriate hairnets and beard restraints, contrary to the facility's policy on employee hygiene and sanitary practices. The facility also failed to follow its policy regarding the labeling of foods brought in by family or visitors. During an inspection of the refrigerator storing these foods, it was found that the items were labeled with the date they were received rather than the date they should be discarded, as required by the facility's policy. This oversight was confirmed by the Director of Nursing, who acknowledged that the policy mandates labeling with a 'use by' date. These deficiencies had the potential to expose residents to contaminants that could cause foodborne illness.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, leading to deficiencies in addressing their specific medical and personal care needs. For Resident 19, the facility did not create a care plan for activities of daily living (ADLs) related to hygiene, despite the resident's need for assistance with personal hygiene and upper body dressing. Additionally, the facility did not implement the care plan for anticoagulant therapy, as there was no documentation of monitoring for signs and symptoms of bleeding, which was a critical aspect of the resident's care. Resident 66 was admitted with a urinary tract infection (UTI) and a physician's order for Ciprofloxacin Hydrochloride, but the facility failed to develop a care plan addressing the UTI and the prescribed medication. Similarly, Resident 78, who was also diagnosed with a UTI and prescribed Cephalexin, did not have a care plan developed for the infection or the medication. These omissions indicate a lack of proper assessment and planning for the residents' medical conditions and treatments. For Resident 238, the facility did not develop care plans for the use of Zoloft and Aripiprazole, medications prescribed for anxiety, depression, and dementia. Resident 59 also lacked care plans for osteoporosis treatment with Alendronate Sodium and the use of a concave mattress as a fall intervention. These failures demonstrate a pattern of neglect in creating individualized, person-centered care plans that address the residents' physical, psychosocial, and functional needs, as required by the facility's policies and procedures.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper medication management in two out of three medication rooms and two out of three medication carts. An outdated vial of Tuberculin was found in the medication refrigerator, with an open date exceeding the 30-day discard period. Additionally, an open Ozempic injection pen was found unlabeled, posing a risk of medication error if the box label was lost. These observations were confirmed by the Licensed Vocational Nurse (LVN) present during the inspection. Further deficiencies were noted in the storage of medications requiring refrigeration. Two unopened bottles of latanoprost ophthalmic solution and an unopened Insulin Glargine U 100 pen were found unrefrigerated in medication cart BB, contrary to the manufacturer's instructions. Similarly, an unopened Insulin Humalog 100-unit pen was found unrefrigerated in med cart EE. The Interim Director of Nursing (IDON) confirmed that new medications should be refrigerated until used. Additionally, expired items such as antiperspirants and a biohazard spill kit were found in med storage CC. Labeling issues were also identified, with two over-the-counter eye medication bottles labeled only with room numbers, lacking resident names, which could lead to medication errors due to room changes. A discrepancy was found in the medication order for Eplerenone, where the blister pack label did not match the physician's order. The IDON emphasized the importance of following the 5 Rights of medication administration to prevent errors. These practices had the potential to result in medication errors and reduced potency of medications.
Deficiency in Food Preparation and Temperature Control
Penalty
Summary
The facility failed to ensure that food was prepared in a manner that conserved its nutritive value and appearance, as evidenced by multiple resident complaints and a test tray evaluation. Eight out of 18 residents reported that the food was served cold, lacked flavor, and was not at the appropriate texture. Specific complaints included food being inedible, meat being tough, and chicken being too dry. During interviews, residents expressed dissatisfaction with the taste and temperature of the meals, with some describing the food as bland and hard to chew. A test tray evaluation conducted with a Registered Dietician and Dietary Supervisor confirmed the residents' complaints. The evaluation revealed that both regular and pureed meals were bland, with the pureed chicken being particularly dry. The food temperatures were below the recommended safe levels, with hot food items measuring between 112.9 F and 118 F, and cold milk at 50.8 F. This was contrary to the facility's in-service training, which emphasized that hot food should be at 135 F or above and cold food at 41 F or below. These deficiencies had the potential to decrease residents' food intake and negatively impact their nutritional status.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during various instances involving staff and residents. Certified Nursing Assistants (CNAs) N and O did not perform hand hygiene while serving lunch trays to residents, despite handling potentially contaminated surfaces such as food carts. This was confirmed through interviews with the CNAs and the infection preventionist, who emphasized the importance of hand hygiene in preventing the spread of infections. Additionally, the facility did not properly manage medical equipment, as seen with Resident 187's nebulizer mask, which was undated and improperly stored, and Resident 238's outdated nebulizer tubing left on a bedside table. The Licensed Vocational Nurse (LVN) C also failed to disinfect a blood pressure apparatus between residents, and a Registered Nurse (RN) I did not follow the manufacturer's instructions for disinfecting a glucometer, using an incorrect disinfectant wipe. These lapses were confirmed through observations and interviews with staff, including the infection preventionist and the Director of Nursing. Further deficiencies were noted with Resident 50's humidifier bottle, which was found on the floor, and Nursing Assistant (NA) P's failure to perform hand hygiene between assisting residents during lunch. These actions were observed and confirmed through interviews with the involved staff, highlighting a pattern of non-compliance with the facility's infection control policies, which are designed to prevent healthcare-associated infections.
Failure to Cover Urinary Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident 12, by leaving their suprapubic catheter drainage bag uncovered. This deficiency was observed during a survey when Resident 12 was found lying in bed with the urine bag visibly hanging on the right side of the bed, displaying yellow-colored urine. The resident had recently returned from dialysis, and the drainage bag was not covered, which was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) during interviews. Both staff members acknowledged that the urinary drainage bag should have been covered with a privacy or dignity bag at all times. Resident 12's medical history includes a diagnosis of End Stage Renal Disease and obstructive uropathy, necessitating the use of a suprapubic catheter. The facility's Director of Nursing (DON) also confirmed that the urinary drainage bag should always be covered, both inside and outside the facility, in accordance with the facility's policy and procedure on dignity, revised in February 2023. This policy mandates that residents are treated with dignity and respect at all times, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of lorazepam to Resident 44, who was diagnosed with Major Depressive Disorder and Catatonic Schizophrenia. The physician's order for lorazepam was dated 7/4/2023, and the informed consent form was signed by the physician on 7/10/2023. However, the form indicated that consent was obtained by phone on 7/4/2023, but it did not specify whether the consent was given by Resident 44 or a surrogate decision maker. During an interview and record review on 8/14/2024, the Director of Nursing confirmed that the informed consent form lacked the name of the person from whom consent was obtained. The facility's policy and procedure on psychotropic medication use and informed consent, dated March 2004, requires that the prescriber personally examine the resident and obtain written consent signed by the resident or their representative. If the resident or representative cannot sign, a licensed nurse must document the name of the person who gave consent and the date, which was not done in this case.
Failure to Develop Baseline Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a baseline care plan for a resident's oxygen use within the required 48 hours of admission, as mandated by CMS guidelines. Resident 190, who was admitted with a supracondylar fracture of the left femur, morbid obesity, and obstructive sleep apnea, had a physician's order for oxygen administration at 0.5 liters per minute via nasal cannula at bedtime, which was later adjusted to 1 liter per minute. However, during an observation, it was noted that the oxygen was being administered at 1.5 liters per minute, indicating a deviation from the prescribed order. Interviews with the registered nurse and the minimum data set nurse revealed that there was no baseline care plan in place for the resident's oxygen use, despite the order being present since admission. The director of nursing acknowledged that the baseline care plan should have been developed within 72 hours, but CMS guidelines require it within 48 hours. This oversight resulted in improper oxygen administration, which could potentially lead to adverse effects such as oxygen toxicity.
Oxygen Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen administration for three residents, leading to potential complications. Resident 190, who was admitted with conditions including a displaced supracondylar fracture, morbid obesity, and obstructive sleep apnea, had a physician's order for oxygen at 1 liter/min at bedtime. However, during an observation, the resident was found to be receiving oxygen at 1.5 liter/min. Additionally, the 'Oxygen in Use' sign was not properly displayed, as it was obscured by another sign, making it not visible to all passersby. Resident 18, diagnosed with congestive heart failure, acute and chronic respiratory failure, and obstructive sleep apnea, had a physician's order for continuous oxygen at 4 liter/min. During an observation, the resident was found to be receiving oxygen at 4.5 liter/min, which was confirmed by a registered nurse upon review of the records. This deviation from the prescribed oxygen level was not in accordance with the physician's order. Resident 36, with diagnoses including cerebrovascular disease, chronic congestive heart failure, and COPD, had an order for oxygen at 3 liter/min as needed for shortness of breath. However, observations revealed that the resident was receiving oxygen at 3.5 liter/min, both while asleep and when seated at the edge of the bed. The registered nurse confirmed that the oxygen administration did not align with the physician's order. The facility's policy on oxygen administration emphasizes the importance of following physician's orders and ensuring proper signage, which was not adhered to in these cases.
Failure to Ensure Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use of bed rails for two residents, leading to potential safety risks. For both residents, there were no physician orders obtained prior to the use of bed rails, and no side rail assessments were completed. Additionally, there were no care plans in place regarding the use of side rails for these residents. These omissions were observed during facility visits and confirmed through interviews with staff, including the Interim Director of Nursing (IDON) and the Minimum Data Set Nurse (MDSN). Resident 78 was observed with 1/4 bilateral side rails on her bed, but her Side Rails Utilization Assessment was blank, and there was no physician's order or care plan documented. Similarly, Resident 39 was using 1/4 mid bilateral side rails for assistance with repositioning and activities of daily living, yet there was no physician order, care plan, or side rail assessment indicating their use. The facility's policy requires informed consent, physician orders, and assessments before the installation of bed rails, which were not adhered to in these cases.
Failure to Schedule Follow-Up Psychological Evaluation
Penalty
Summary
The facility failed to provide adequate social services for a resident diagnosed with Major Depressive Disorder and catatonic schizophrenia. The resident was admitted with these diagnoses, which require regular psychological evaluations to address their mental health needs. However, since admission, only one psychological evaluation was conducted, dated several months prior to the survey. This lack of follow-up was confirmed during interviews with the Interim Director of Nursing and the Social Services Director, who acknowledged the oversight. The Social Services Director was responsible for scheduling follow-up appointments but failed to arrange a subsequent psychological evaluation after the initial one. Although an attempt was made to schedule an appointment, the assigned clinician was on leave, and no further action was taken to reschedule. The Director of Nursing confirmed that residents with psychological diagnoses should be seen regularly, either monthly or bi-weekly, and that the Social Services Director should have ensured the follow-up appointment was scheduled. This inaction resulted in the resident's psychosocial care needs potentially being unmet.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication. Specifically, the facility did not provide sufficient documentation to support a diagnosis of dementia with psychotic disturbance manifested by paranoia for one resident. The resident was prescribed Quetiapine fumarate (Seroquel), an antipsychotic medication, for dementia with psychotic disturbance, but there was no active diagnosis or psychiatrist notes to justify this prescription. The facility's policy requires that psychotropic medications are only prescribed when necessary to treat a specific, diagnosed, and documented condition. The resident in question was admitted with diagnoses including hemiplegia, hemiparesis, unspecified depression, and severe vascular dementia with other behavioral disturbances. Despite the continuation of Seroquel for agitation as noted in the facility physician's notes, there was no documentation from a psychiatrist to support the use of this medication for the stated condition. Interviews with the Medical Records Director and the Director of Nursing confirmed the lack of psychiatric evaluation and the need for clarification with the prescribing doctor regarding the medication's indication.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 5.88% during a medication administration observation involving one resident. The first error occurred when a Licensed Vocational Nurse (LVN) administered Zaditor Ophthalmic Solution to a resident without an open date on the bottle, which is against the facility's policy. The LVN acknowledged the oversight and stated she would inform the physician to obtain a new order for the medication. The facility's policy requires that medications be administered safely, timely, and as prescribed, including recording the open date on multi-dose containers. The second error involved the administration of Levetiracetam (Keppra) to the same resident. The LVN administered 1500 mg of Levetiracetam, while the physician's order required 2000 mg every 12 hours for the treatment of generalized idiopathic epilepsy. This discrepancy was confirmed during a review of the resident's clinical record and a concurrent interview with another LVN. The facility's policy mandates that any concerns about medication dosage be discussed with the prescriber or attending physician, which was not adhered to in this instance.
Deficiencies in Dietary Staff Competency and Food Safety Procedures
Penalty
Summary
The facility failed to ensure that the dietary staff possessed the necessary competencies and skills to effectively carry out the functions of the food and nutrition services. During an initial kitchen tour, a pair of tongs with visible residues was found in a kitchen drawer, which the Dietary Supervisor acknowledged should not have been stored there if unclean. Additionally, during an interview, Dietary Cook E was unable to articulate the cool down process for food, despite having attended an in-service meeting on food safety that covered this topic. Furthermore, Dietary Aide G demonstrated an incorrect method for checking the chemical sanitation concentration of the dish machine. Instead of testing the strip on a plate, as stated by the Dietary Supervisor, DA G tested it on the running water from the dish machine's drain. Although DA G attended an in-service meeting on the dishwasher, the document did not include specific steps on how to check the chemical concentration, and the manufacturer's recommendation document was not provided.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that the recipe for a pureed diet was followed, which could potentially lead to inadequate nutritional value and nutritional requirements for the residents. During an observation and interview in the facility kitchen, a Dietary Aide (DA) was seen preparing pureed bread by placing a whole loaf of bread into a food processor and then transferring the processed bread into a steel container. The DA then added water from a hot water machine without measuring the amount. When questioned, the DA admitted to not measuring the water, while the Registered Dietician (RD) mentioned that typically a recipe is followed, but they also watch for consistency. A review of the facility's menu for Pureed Bread indicated that the recipe requires placing portions of bread and margarine into a food processor to create fine crumbs, and for every five portions needed, one cup of warm milk or water should be added. The failure to follow this recipe as specified could result in the residents not receiving the appropriate nutritional content in their meals.
Delayed Reporting of Abuse and Theft Allegations
Penalty
Summary
The facility failed to report a suspected allegation of resident abuse in a timely manner for two residents. For Resident 196, the alleged missing money was not reported to the California Department of Public Health (CDPH), Adult Protective Services (APS), and the Office of the Long Term Care Ombudsman (LTCO) when it was first reported to the Social Services Director (SSD) on November 18, 2022. The resident, who had a BIMS score indicating moderate cognitive impairment, reported missing money that was brought to her by a friend. Despite the resident's request to file a police report, the SSD only educated her about financial responsibility. It was not until December 13, 2022, after a follow-up by the LTCO, that a report was filed. Interviews with the SSD, Director of Nursing (DON), and Administrator confirmed the delay in reporting. For Resident 24, an incident of resident-to-resident abuse occurred when the resident, who had severe cognitive impairment, randomly struck another resident in the face. This incident, which took place on December 31, 2022, was not reported to CDPH, the Ombudsman, and law enforcement until January 3, 2023. The DON acknowledged the late reporting and stated that such incidents should be reported immediately or within two hours. The facility's policy on abuse prevention requires prompt reporting of all alleged violations of abuse, neglect, exploitation, or mistreatment. The facility's policies and procedures, as reviewed, clearly outline the requirement for immediate reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment. However, in both cases, there was a failure to adhere to these policies, resulting in delayed reporting of the incidents. This delay had the potential to hinder the identification and implementation of appropriate corrective actions, thereby putting residents at risk for abuse.
Room Size Deficiency in Multi-Resident Rooms
Penalty
Summary
The report identifies a deficiency in the facility's compliance with room size requirements for residents. Specifically, multiple multi-resident rooms were found to provide less than the required 80 square feet per resident. The rooms in question varied in size, with some providing as little as 70 square feet per resident. Despite this, during observations conducted over a week, it was noted that the room sizes did not inhibit staff from providing care, and both staff and residents reported that the room sizes were not a concern. The deficiency was observed through a combination of observation, interviews, and record reviews. The surveyors noted that the rooms, although smaller than the required size, did not impede the movement of staff or residents. The report suggests that the facility may continue with a room waiver, indicating that the current room sizes have not been problematic in terms of care delivery or resident satisfaction.
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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 Post Acute Center | 0 mi | ★★★★★ | 10 | 0 |
| Manresa Healthcare Center | 0.6 mi | ★★★★★ | 12 | 0 |
| Pacific Coast Manor | 11.2 mi | ★★★★★ | 0 | 0 |
| Driftwood Healthcare Center - Santa Cruz | 12 mi | ★★★★★ | 18 | 0 |
| Redwood Grove Post Acute | 12.5 mi | ★★★★★ | 1 | 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.