Watsonville Post Acute Center

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 8, 2024

  Based on interview and record review, the facility failed to implement fall-related interventions for one of two residents (Resident 32) when staff did not document Resident 32's skid mat (non-slip material) was in place on 6/17/23, when staff did not ensure Resident 32's sensor pad alarm (device that emits an audible alarm when pressure is removed from the sensor pad to alert the caregivers; such as, when the user gets out of a bed or wheelchair) orders were transcribed in the administration records for nurses to document pad placement and functioning, and when the facility failed to provide evidence of periodic staff training on the operation of the sensor pad alarm and daily device testing of the sensor pad alarm per manufacturer's recommendations. […]

• No harm, potential for more than minimal, widespreadF880Aug 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant E (CNA E) wore gloves when providing toilet hygiene and bed bath to Resident 20 who was on enhanced barrier precautions (EBP, an infection control strategy for healthcare settings, especially nursing homes, to reduce the spread of multidrug-resistant organisms - MDROs, germs that are resistant to many antibiotics - by requiring healthcare personnel to wear gowns and gloves during all high-contact resident care activities); 2. Licensed vocation nurse B (LVN B) did not sanitize her hands when she went from Resident 58's room to Resident 31's room; 3. […]

• No harm, potential for more than minimal, widespreadF801Dec 13, 2021

  Based on observation, interview, and record review the facility failed to ensure the competency of the two of two staff, the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS), responsible for oversight of Food and Nutrition Services, when: 1. The RD did not provide consultation to the DSS regarding multiple kitchen sanitation issues (cross-reference F812); 2. The RD did not provide consultation regarding the palatability and consistency of food texture; 3. The DSS did not report multiple maintenance issues she was aware of including: a. a leaking reach-in refrigerator; and b. a reach-in freezer with significant ice build-up, 4. The DSS did not have a reliable system for ensuring staff cleaned according to the cleaning schedule; 5. […]

• No harm, potential for more than minimal, widespreadF804Dec 13, 2021

  Based on observation, interview, and record review the facility failed to ensure palatability and nutritive value of cooked foods were maintained when vegetables were cooked for an extended time. In addition, one resident (Resident 78) complained about food being overcooked. This failure had the potential to result in decreased palatability; leading to a decrease in food consumed by residents, and food cooked for extended time periods could lose nutritive value leading to a decreased nutrient intake for 90 residents who received food from the kitchen. Findings On 12/6/2021 at 9:21 a.m., during an observation and interview with Cook 1 and Dietary Services Supervisor (DSS), indicated pans in a hot oven covered with foil. […]

• No harm, potential for more than minimal, widespreadF812Dec 13, 2021

  Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, and served in a sanitary manner when: a. The wood shelving under a preparation table was dirty and in poor condition; b. Cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; c. The floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; d. Knives for food preparation had residue on the blades, the blades came into contact with dirty wire covers, and were stored directly under an insect killer machine which had a fly on the surface; e. […]