Watsonville Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 22, 2023

  Based on interview and record review, the facility failed to ensure staff followed the Policy and Procedure (P&P) titled Lifting machine, using a mechanical when transferring residents from the bed to a chair for two out of three residents (Residents 1 and 2). A mechanical lift is a metal assistive device with a U-shaped base, an overhead bar and a sling that work together to lift, reposition, and lower a resident into a chair or a bed. On 6/23/2023, Resident 1 was being transferred with a mechanical lift from her bed to a shower chair by one staff member (Certified Nursing Assistant (CNA) A). During the transfer, one of the straps from the sling became disconnected, which resulted in Resident 1 falling out of the sling onto the floor. […]

• Actual harm, isolatedF755Mar 20, 2023

  Based on interview and record review, the facility failed to provide routine medications to meet the needs of residents for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 did not receive his Keppra (generic name: levetiracetam, a medication to treat seizure disorder [a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness]) for 48 hours due to the medication not being available. The nursing staff did not notify the physician when the medication was not available to give, nor did they follow up with the pharmacy to receive the medication timely. […]

• No harm, potential for more than minimal, widespreadF812Aug 19, 2024

  Based on observation, interview and record review, the facility failed to store and prepare food under sanitary conditions in accordance with professional standards when: 1. Steel trays with black stains were found inside the kitchen freezer; 2. The ice machine had black substance build up found inside and yellow stain on the baffle; 3. Dietary staffs did not wear hairnet/beard restraints while inside the facility kitchen and; 4. Facility did not follow their policy and procedure regarding labeling of foods brought in by family or visitors for one out of two sampled residents (Resident 237). These failures had the potential to expose residents to contaminants that could cause foodborne illness. Findings: 1. During the initial kitchen tour on 8/12/24 at 9:44 a.m. […]

• No harm, potential for more than minimal, widespreadF812May 6, 2022

  Based on observation, interview, and record review the facility failed to store, prepare, and distribute food safely when: 1. Ground beef was not submerged in water during the thawing process; 2. Cooked potatoes (a potentially hazardous food capable of supporting bacterial growth associated with foodborne illness) were not logged for proper cool down; 3. Resident refrigerator contained multiple food items beyond the discard date; and 4. Cups and mugs used to serve resident drinks were stored stacked and wet; These failures had the potential to cause food Borne illness to a highly susceptible population of 76 residents who received food from the kitchen. The facility census was 80. Findings: 1. During concurrent observation and interview on 5/2/22 at 12:36 p.m. […]

• No harm, potential for more than minimal, patternF697Jan 9, 2026

  Based on interview and record review, the facility failed to manage pain for four of 18 residents (4, 6, 46, and 47) when license nurses did not administer pain medication according to the pain level ordered by the physician. This failure had the potential for the residents to experience avoidable pain and could negatively affect their quality of life.Findings:1. Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE] with pain in right hip diagnosis.Review of Resident 6's physician order, dated 7/5/23, indicated she had an order for acetaminophen (a drug that reduces pain and fever) 325 milligrams (mg, a metric unit of mass) 2 tablets every 4 hours as needed for mild pain level 1-3.Review of Resident 6's Medication Administration Record (MAR), from… […]