Manzanita Healthcare Center

In the surveyor’s words

From the most serious findings on record at Manzanita Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 13, 2025

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) did not develop a pressure injury or pressure sore (PI, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) when they failed to follow and implement preventative interventions that included to turn and re-position frequently, monitor and assess for signs of skin breakdown, and, to use pressure relieving devices(s) for her chair and bed as outlined in their Care Plan Report (CP), titled Skin integrity care plan and Skin assessment and prevention of pressure injuries policy and procedures (P&P). […]

• Actual harm, isolatedF686Nov 12, 2025

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) did not develop a pressure injury or pressure sore (PI, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) when they failed to follow and implement preventative interventions that included to turn and re-position frequently, monitor and assess for signs of skin breakdown, and, to use pressure relieving devices(s) for her chair and bed as outlined in their Care Plan Report (CP), titled Skin integrity care plan and Skin assessment and prevention of pressure injuries policy and procedures (P&P). […]

• Actual harm, isolatedF689Apr 17, 2023

  Based on interview and record review, the facility failed to establish a safe environment for one of four sampled residents (Resident 1) at risk for falls when Resident 1 experienced two consecutive falls and hospitalization s; the first on [DATE], and second on [DATE]. This failure resulted in Resident 1 falling on the bedroom floor on [DATE] and sustaining two broken ribs, an eyebrow laceration (cut), bleeding in the functional part of the brain, and subsequent death on [DATE] due to the irreparable brain bleeding. […]

• No harm, potential for more than minimal, widespreadF801Dec 7, 2023

  Based on observation, interview and record review, the facility failed to ensure that the Food/Nutrition Director had the qualifications needed to oversee the dietary department. This had had the potential of unsafe food practices and food borne illness for the 94 residents eating facility prepared foods. Findings: During an interview with the Food/Nutrition Director (FND) on 12/5/23 at 9:28 a.m. a certificate of education completion was not observed in his office. When asked about his path to becoming the Food/Nutrition Director, he stated he had experience running a kitchen under the direction of a Registered Dietitian (RD) but had no formal education. […]

• No harm, potential for more than minimal, widespreadF812Dec 7, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 94 residents eating facility prepared meals as evidenced by: 1) Food preparation items were found dirty; 2) Food preparation and service equipment were found substandard; 3) Food service items were found stacked wet; 4) Opened containers were found in dry storage; 5) Multiple food items not correctly dated; 6) Fruit/vegetable sink lacked an air gap; and 7) Expired food produce. These failures had the potential to cause foodborne illness (illness that results from ingestion of contaminated food) to residents receiving food prepared in the facility kitchen. Findings: 1. […]