Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Post Acute Center during CMS and state inspections, most recent first.
Staff did not consistently follow infection control practices during resident care, medication administration, and meal delivery. A CNA provided hygiene and a bed bath to a resident on EBP while wearing only gloves, an LVN moved between resident rooms without sanitizing hands, oxygen concentrator filters were dirty and undated, a nurse discarded a used lancet on top of a sharps container lid, and a glucometer was used for two residents without disinfection. Additional issues included stacking medication cups, using an unclean blood pressure cuff, giving nasal spray without hand cleansing and glove changes, and leaving a lunch cart open with uncovered dessert cups during tray delivery.
RN A failed to follow medication administration standards for two residents. One resident was given meds when two lanthanum carbonate tablets were left with her instead of being directly observed swallowing them. Another resident with a J-tube was given meds without tube placement being verified, and the tube was flushed in amounts that did not match the physician order for 30 ml before and after meds.
Medication administration errors were observed at a rate of 22.22%, involving insulin pen doses given without priming, an ordered insulin dose not given when a resident’s BG met the parameter for administration, and medications mixed together and given through a J-tube. RN staff acknowledged the insulin pen and enteral tube administration errors, and one resident’s ordered glycopyrrolate was not available on hand.
Wet serving trays and plate covers were observed stacked on the counter by the steam table during a kitchen tour. The DM acknowledged the items were still wet, and an RD was present during the interview. A DA stated trays and plate covers are usually air-dried, but if they do not dry completely, blue cloth Wiper towels by vendor ? may be used to dry them. The facility P&P for dishwashing states items should be allowed to air-dry after the full cycle.
Missed Dialysis Shunt Bruit Check: A resident with dependence on renal dialysis had physician orders for licensed nursing staff to monitor the bruit and thrill of the dialysis shunt every shift and to check the left forearm shunt for tenderness, redness, or bleeding. An LVN stated she checked the thrill but did not check the bruit and said she did not know how to check it, despite facility policy requiring routine bruit checks once per shift.
A resident received insulin from an overused-by date Lantus pen that was still stored in the Station 3 med cart. During observation, an LVN confirmed the pen should have been discarded and that the resident received 10 units from that same pen, while no other Lantus pen was available in the cart.
The facility failed to implement fall-related interventions for a resident with a history of falls, resulting in an unwitnessed fall and a fractured clavicle. The pad alarm did not sound, and there was no documentation of the skid mat and sensor pad alarm placement. Additionally, there was no evidence of periodic staff training on the operation of the sensor pad alarm.
The facility failed to develop and implement care plans for two residents, one with a g-tube and on anticoagulant medication, and another with diabetes requiring insulin. This oversight was confirmed by the MDSC and an LVN, highlighting a breach in the facility's policy on Comprehensive Person-Centered Care Plans.
The facility failed to follow professional standards of practice for three residents. A resident received Levothyroxine incorrectly after G-tube feeding, another was given Lorazepam without an active physician order, and a third resident did not have a smoking assessment completed upon admission. These deficiencies were confirmed through interviews and record reviews.
The facility failed to ensure proper medication storage and labeling, including an open tuberculin vial without an open date, several bottles of supplements without open dates, and multiple loose tablets in a medication cart. These issues were confirmed by staff and violated the facility's policies.
The facility failed to ensure that a resident with severe cognitive impairment and full dependency on staff received necessary fingernail care. Despite being scheduled for showers, the resident was observed multiple times with dirty nails, and there was no documentation of a shower or refusal on one of the scheduled days. Staff interviews confirmed that nail care should be performed during baths or showers, but this was not done.
The facility failed to monitor the side effects of Apixaban for a resident with multiple diagnoses, including hemiplegia and chronic atrial fibrillation. Despite physician orders and facility policy requiring monitoring for signs of bleeding, no documentation was found, and an LVN confirmed that monitoring was not being done.
The facility failed to ensure expired food items were not stored in the residents' refrigerator. Two boxes of Jevity were found unlabeled and expired. The DSD acknowledged the expired items and stated that expiration dates should be checked. The facility's policy indicated that licensed nurses are responsible for ensuring food items are not past their expiration dates.
A facility failed to follow infection control practices when an LVN did not perform hand hygiene between tasks during medication administration for a resident. The LVN acknowledged the lapse, and the Nurse Supervisor confirmed the requirement for hand hygiene between tasks.
Infection Control Lapses During Resident Care, Medication Passes, and Meal Service
Penalty
Summary
Infection control practices were not consistently followed during resident care and medication administration. During an observation on 8/25/25, CNA E provided toileting hygiene and a bed bath to Resident 20, who was on enhanced barrier precautions, while wearing only gloves. CNA E confirmed the resident was on EBP and stated she should have worn a gown and gloves when cleaning and giving the bed bath. The infection preventionist stated CNAs should wear gowns and gloves when cleaning and giving residents bed baths, and the facility’s EBP policy identified hygiene, changing linens, changing briefs, and assisting with toileting as high-contact activities requiring gown and glove use. Hand hygiene and equipment cleaning were also not followed. LVN B went from Resident 58’s room to Resident 31’s room without sanitizing her hands after checking the oxygen concentrator filter. The oxygen concentrator filters for Residents 31, 49, 58, and 60 were dirty and the filter boxes were not dated. The infection preventionist stated staff should sanitize their hands when leaving residents’ rooms and that oxygen concentrator filters should be kept clean and cleansed every week; the facility’s oxygen concentrator guide listed a 7-day cleaning interval for filter door vents. In addition, RN D threw a used lancet on top of the sharps container lid after a fingerstick blood glucose check, and RN D did not disinfect the glucometer between checking Resident 94 and Resident 6. The facility’s fingerstick glucose policy required lancets to be disposed of in the sharps container and reusable equipment to be cleaned and disinfected between uses. Medication administration and resident care equipment handling also showed lapses. RN A placed one medication cup on top of another cup of medications while bringing them to Resident 54 and did not disinfect the blood pressure cuff before taking the resident’s blood pressure. LVN B later administered fluticasone nasal spray to Resident 32 without cleansing her hands and changing gloves after providing other care and taking the resident’s blood pressure. During meal service, CNA F left the lunch cart door open while bringing trays to Resident 11 and two roommates, and the dessert cups on the trays were uncovered. The infection preventionist stated the cart door should have been closed while staff were in the resident’s room.
Medication Administration and J-Tube Procedure Errors
Penalty
Summary
The facility failed to provide services that met professional standards of quality when RN A administered medications to Resident 54 and left two tablets of lanthanum carbonate with the resident without observing the resident take them. During the medication pass, RN A placed the lanthanum carbonate in a medicine cup along with the resident’s other medications, handed the cups to Resident 54, and then left the two lanthanum carbonate tablets with the resident while she went back to the medication cart to chart blood sugar and draw insulin lispro. When RN A returned, the tablets were no longer there. RN A acknowledged that she should not have left the tablets with Resident 54 and should have stayed to observe the resident taking them. The facility also failed to follow the physician’s order for Resident 2’s J-tube medications. Resident 2 had an order dated 3/21/25 for the licensed nurse to flush the J-tube with 30 ml of water before and after medication administration. During the medication pass, RN A did not verify placement of the J-tube before giving medications through it. RN A flushed the tube with 20 ml of water before medication and then with 40 ml twice after medication, for a total of 80 ml after medication. RN A reviewed the physician orders and acknowledged that she should have verified J-tube placement and flushed with 30 ml of water before and after medication as ordered.
Medication Administration Errors Exceeded Acceptable Rate
Penalty
Summary
A medication error rate of 22.22% was identified after 6 medication errors were observed during 27 medication administration opportunities for four residents. During a medication pass observation, RN D checked Resident 3’s blood sugar at 229 and administered 4 units of insulin lispro without priming the insulin pen. RN D later acknowledged that the pen should have been primed with 2 units before giving the dose, and the facility’s insulin pen instructions indicated to dial 2 units, point the pen up, and press the thumb button to check that the pen needle is attached correctly. During another observation, RN D checked Resident 6’s blood sugar at 78 and did not administer the ordered 10 units of insulin lispro for lunch when the blood sugar was less than 120. RN D later acknowledged that the insulin should have been given. RN A also administered 6 units of insulin lispro to Resident 54 without priming the insulin pen, and she acknowledged that the pen should have been primed with 2 units first. In addition, RN A did not have glycopyrrolate available for Resident 2 and crushed midodrine, mixed it with sucralfate and water, and administered the medications together through the resident’s J-tube, although the facility’s enteral tube medication policy stated each medication should be administered separately and flushed between medications.
Wet Food Service Items Stacked Before Air-Drying
Penalty
Summary
Food serving items were not air-dried before being stacked, as serving trays and plate covers were observed wet during the initial kitchen tour on 8/25/2025 at 9:49 a.m. The wet trays and wet plate covers were stacked on the counter by the steam table. During interview, the dietary manager acknowledged that the trays and plate covers were wet and stated they should have been air-dried, and if still wet they would have been dried with blue cloth Wiper towels by vendor ?. The registered dietician was present during this interview. A dietary aide stated that trays and plate covers are usually air-dried, but if they do not dry completely, it was okay to use the blue Wiper towels by vendor ? to dry them. Review of the facility policy and procedure titled Dishwashing Machine Use, revised 03/2010, indicated that after running items through the entire cycle, they are to be allowed to air-dry.
Missed Dialysis Shunt Bruit Check
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when LVN B did not check Resident 7's bruit at the dialysis shunt. Resident 7 was admitted with dependence on renal dialysis, and physician orders dated 1/2/25 directed licensed nursing staff to monitor the bruit and thrill of the dialysis shunt every shift and to monitor the left forearm shunt for tenderness, redness, or bleeding every shift. During interview on 8/28/25, LVN B stated she checked the thrill at the dialysis shunt but did not check the bruit, and she stated she did not know how to check the bruit. The facility policy for renal dialysis care indicated access site care is to be provided by a licensed nurse, access site condition and patency are to be checked every shift, and routine access checks for bruit are to occur once per shift.
Outdated insulin remained in medication cart
Penalty
Summary
The facility failed to ensure medications were stored appropriately when an overused-by date insulin Lantus pen was found in Station 3 medication cart. During an observation on 8/25/25 at 12:55 p.m., LVN B observed one insulin Lantus 100 units/mL pen for Resident 32 that was dated to be discarded on 8/23/25. During the concurrent observation, interview, and record review, LVN B confirmed the pen should have been discarded on 8/23/25 and confirmed that Resident 32 received 10 units of insulin Lantus from that same pen on 8/24/25. Resident 32 had no other insulin Lantus pen in the Station 3 medication cart. Review of the facility policy, Medication Labeling and Storage, dated 2/2023, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.
Failure to Implement Fall-Related Interventions
Penalty
Summary
The facility failed to implement fall-related interventions for Resident 32, who had a history of falls and was at risk for further incidents. On 6/17/23, Resident 32 experienced an unwitnessed fall in the hallway, resulting in a fractured clavicle. The investigation revealed that the resident's pad alarm did not sound, and there was no documentation to confirm the placement and functioning of the skid mat and sensor pad alarm as per physician orders. Additionally, the facility did not provide evidence of periodic staff training on the operation of the sensor pad alarm and daily device testing as recommended by the manufacturer. Resident 32 had multiple diagnoses, including dementia and chronic obstructive pulmonary disease, and required extensive assistance with bed mobility and transfers. The resident had a significant history of falls, with 11 incidents in 2022, 12 in 2023, and two in 2024. Despite these risks, the facility failed to ensure that the prescribed fall interventions were consistently documented and implemented. The Treatment Administration Record for June 2023 showed a lack of documentation for the skid mat placement on the evening shift of 6/17/23, and the Medication Administration Record and Treatment Administration Record lacked documentation for the pad alarms' placement and functioning. Interviews with the nurse supervisor and other staff confirmed that it was their responsibility to check and document the fall interventions, but the pad alarm orders were not transcribed in the administration records. The director of staff development could not provide evidence of in-service training on the operation of pad alarms, and the only available training focused on checking placement rather than usage. The facility's policy on managing falls and fall risks emphasized the need for licensed staff to implement relevant interventions, but this was not adequately followed in Resident 32's case.
Failure to Develop and Implement Care Plans for Critical Conditions
Penalty
Summary
The facility failed to develop and implement care plans for two residents, leading to potential oversight of critical care needs. For Resident 38, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, chronic atrial fibrillation, and dysphagia, there was no care plan addressing the long-term care of her gastrostomy tube (g-tube) or the use of the anticoagulant medication Apixaban. This resident had multiple emergency department transfers due to issues with the g-tube, including dislodgement and redness at the site. During a review, it was confirmed that the care plans did not include necessary measures for the g-tube or anticoagulation medication, which was acknowledged by the Minimum Data Set Coordinator (MDSC) and a Licensed Vocational Nurse (LVN). Similarly, Resident 66, who was admitted with diabetes and hypertension, did not have a care plan addressing her diabetes or the use of insulin. This resident had physician orders for insulin administration, including a sliding scale insulin regimen. However, the care plans lacked any mention of diabetes management or monitoring for hyperglycemia and hypoglycemia. The MDSC confirmed the absence of a diabetes care plan for Resident 66, acknowledging that such a plan should be in place to monitor the resident's condition effectively. The facility's policy on Comprehensive Person-Centered Care Plans, which mandates the development and implementation of measurable objectives and timetables to meet residents' needs, was not adhered to in these cases.
Failure to Follow Medication Administration and Smoking Assessment Protocols
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for three residents. For Resident 38, Levothyroxine, a medication for hypothyroidism, was administered immediately after G-tube feeding, contrary to the manufacturer's specifications that it should be given on an empty stomach and not within 4 hours of calcium or iron-containing products. This was confirmed by a Licensed Vocational Nurse and a review of the resident's medication administration record and the facility's policy on administering medications. For Resident 47, Lorazepam, a medication for anxiety, was signed out of the resident's Controlled Drug Record on three occasions when there was no active physician order for the medication. This was confirmed by a registered nurse and the Nurse Supervisor, who acknowledged that the nurse failed to verify the active orders in the Medical Administration Record. The facility's policy on administering medications was not followed, as medications are required to be administered in accordance with prescriber orders. Resident 61, who was a smoker, did not have a smoking assessment completed upon admission. The resident's admission data incorrectly indicated that he did not smoke, and subsequent questions regarding smoking habits and safety were left blank. This was confirmed by the Minimum Data Set Coordinator, who acknowledged that a smoking assessment should have been completed. The facility's smoking policy requires an evaluation of the resident's smoking status upon admission, including smoking frequency, method of tobacco consumption, desire to quit, and ability to smoke safely with or without supervision.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as evidenced by several observations. An open box of tuberculin vial was found in the medication refrigerator without an open date, confirmed by both the Licensed Vocational Nurse (LVN) and the Nurse Supervisor (NS). The Pharmacy Consultant stated that best practice is to put the open date on the vial once it is opened. The facility's policy indicated that multi-dose vials should be dated and discarded within 28 days unless specified otherwise by the manufacturer. Additionally, during an inspection of Medication Storage Station #3, several bottles of supplements were found without open dates, which was verified by LVN B and confirmed by the NS. The facility's policy requires that the date opened be recorded on the container of multi-dose medications. Furthermore, during an inspection of a medication cart, multiple loose tablets were observed in the drawers, which was verified by LVN A. The Director of Nursing (DON) stated that the assigned nurse should clean the medication cart and dispose of the loose medications in the drug buster. The facility's policy mandates that medication storage areas be maintained in a clean, safe, and sanitary manner. These failures had the potential to compromise residents' health and safety by exposing them to medications with reduced efficacy and inadequately monitored or unlabeled medications.
Failure to Provide Necessary Fingernail Care
Penalty
Summary
The facility failed to ensure that Resident 38 received necessary care to maintain good grooming and personal hygiene, specifically fingernail care. Resident 38, who has multiple diagnoses including hemiplegia, hemiparesis, muscle weakness, and dysphagia, was observed on multiple occasions with a brown/black substance under the nails of her right hand. The resident's Minimum Data Set indicated severe cognitive impairment and full dependency on staff for personal hygiene. Despite being scheduled for showers on Mondays and Thursdays, there was no documentation of a shower or bed bath on one of the scheduled days, nor was there any documented refusal from the resident. Interviews with various staff members, including CNAs and the Nursing Supervisor, confirmed that nail care should be performed during baths or showers and that any refusals should be documented. However, the task list for the relevant period showed that Resident 38 did not receive a bath/shower/bed bath on one of the scheduled days, and there was no indication of a refusal. The facility's policies on nail care and bathing were reviewed and indicated that regular cleaning and trimming of nails are necessary to prevent infections, and that any refusals of showers should be documented. The failure to adhere to these policies resulted in Resident 38 not receiving proper fingernail care, potentially impacting her overall health.
Failure to Monitor Side Effects of Anticoagulant Therapy
Penalty
Summary
The facility failed to monitor the side effects related to the use of Apixaban for one resident. The resident was admitted with multiple diagnoses, including hemiplegia, hemiparesis following cerebral infarction, and chronic atrial fibrillation. The physician's orders indicated that the resident should receive Apixaban via G-tube twice a day for CVA prophylaxis. However, during a review of the resident's medical record, it was found that there was no documentation of monitoring for signs and symptoms of bleeding, which is a critical aspect of managing patients on anticoagulant therapy. During an interview with an LVN, it was confirmed that monitoring for bleeding was not being done for the resident. The facility's policy on anticoagulation therapy clearly states that staff and physicians should monitor for adverse drug reactions and signs of bleeding. Despite this policy, the necessary monitoring was not documented, indicating a failure to adhere to the established protocol. This lapse had the potential to affect the resident's physical well-being while in the facility.
Expired Food Items Found in Residents' Refrigerator
Penalty
Summary
The facility failed to ensure expired food items were not stored in the residents' refrigerator, as observed during a survey. Two boxes of Jevity, a therapeutic nutrition product, were found unlabeled and expired in the residents' refrigerator. During an interview, the Director of Staff Development (DSD) acknowledged the presence of the expired items and stated that the expiration dates should be checked. The facility's policy indicated that licensed nurses are responsible for ensuring food items in refrigerators and freezers are not past their expiration dates. This failure had the potential to result in contaminated food and foodborne illnesses for the residents.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration for one of three residents. During a medication pass observation, a licensed vocational nurse (LVN A) took the blood pressure of Resident 293 and sanitized the blood pressure cuff but did not perform hand hygiene before preparing and administering the resident's medications. LVN A acknowledged the lapse in hand hygiene during an interview. The Nurse Supervisor confirmed that hand hygiene should be performed between each task when administering medication. The facility's policy on hand hygiene, revised in October 2023, mandates hand hygiene immediately before touching a resident and after contact with contaminated surfaces.
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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 mi | ★★★★★ | 12 | 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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