Watsonville Nursing Center

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interviews, the facility failed to ensure food served was palatable and attractive for three of fifty-one residents (Resident 2, Resident 17, and Resident 72). The failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored and prepared in accordance with professional standards for food safety when there was unsanitary baking equipment in the kitchen, four base plate, deformed, dented and discolored covers. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the seventy-nine residents who received food from the facility kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure infection control practices were implemented when: 1. Resident 13 were not placed on Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes.) signage posted and there was no available PPE (Personal Protective Equipment, refers to specialized gear like gloves, gowns, masks, and eye protection that creates a barrier to shield healthcare workers from infectious materials, preventing disease transmission to themselves, patients, and others by stopping contact with germs, blood, or body fluids); 2. Facility unit refrigerator had a box of chicken and mashed potatoes for resident and it was not stored in the freezer as per manufacturing label to keep frozen.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 61) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). This failure had the potential for inaccurate care and services provided to residents with mental disorder, intellectual disability, or related conditions.

Inspectors wroteBased on observation. interview, and record review, the facility failed to develop and implement comprehensive care plan for one of 28 sampled residents (Resident 35) when Resident 35's care plan did not reflect his noncompliance behavior to safety and well-being. This failure had the potential to compromise the facility's ability to implement interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that meet professional standards for two of 18 sampled residents (2 and 26) when:1. Zinc Oxide cream (used to treat and prevent diaper rash) was left on top of Resident 26's bedside drawers; and 2. Treatment nurse B (TN B) used Dermal Wound Cleanser (a liquid used to gently clean and helps remove dirt and debris from chronic and acute wounds) to cleanse Resident 2's wounds instead of normal saline (NS, a mixture of water and salt with a salt concentration of 0.9%) as ordered by the physician. These failures had the potential to negatively affect the wound healing, and the residents might access the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (19) receive care and services for the provision of dialysis (procedure to remove waste or toxins from the blood and adjust fluid and electrolyte imbalances) consistent with professional standards of quality when licensed vocational nurse C (LVN C) did not know how to check Resident 19's bruit (an audible vascular sound associated with turbulent blood flow usually heard with the stethoscope). This failure had the potential for delayed detection, reporting, and management of complications from the dialysis shunt for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 28 sampled residents (Resident 1 and Resident 35) were free from unnecessary medications when: 1. Resident 1 received Nuedexta (used to treat pseudobulbar affect [PBA, a medical condition that causes involuntary, sudden, and frequent episodes of crying]) and was not monitored for episodes of crying. This failure resulted in the effectiveness of Nuedexta being undetermined, and Resident 1 might have unnecessary adverse effects. 2. Resident 35 did not have adequate monitoring for the side effect and adverse reaction of the antibiotic medication therapy. This failure had the potential for side effects and adverse reaction of the antibiotic to go undetected or recognized for timely interventions.

Inspectors wroteBased on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans for five of five residents (Residents 19, 66, 78, 238, and 59): 1. For Resident 19, the facility did not develop care plan for activities of daily living (ADLs, a term used to describe the basic skills needed to independently care for oneself) to address hygiene and did not implement the anticoagulant therapy (sometimes called blood thinning medicines that reduces blood clots and can cause bleeding) care plan; 2. For Resident 66, the facility did not develop care plan for Urinary Tract Infection (UTI- an illness that often start when bacteria get into the tube through which urine leaves), and the physician order of Ciprofloxacin Hydrochloride (medication for bacterial infections). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions for two out of three medication rooms and two out of three medication carts when: 1. There was an outdated vial (cylindrical container) of tuberculin (liquid used to test for tuberculosis) in the medication refrigerator in med storage CC; 2. There was an open, unlabeled Ozempic (medication used to lower blood sugar) injection pen in the medication refrigerator in med storage CC; 3. There were three medications in med cart BB that were not refrigerated as ordered; 4. There were two outdated antiperspirants and one outdated biohazard spill kit (a collection of materials used to clean up blood, vomit, mucus, saliva, and other bodily fluids) in med storage CC; [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the food was prepared by methods that conserved nutritive value and appearance when eight out of 18 resident sample (Residents 51, 6, 26, 20, 17, 192, 59, and 41) stated facility food was served cold without flavor and not at the appropriate texture. These deficient practices had the potential to decrease the food intake of residents and negatively impact their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant N (CNA N) and certified nursing assistant O (CNA O) did not perform hand hygiene when serving lunch trays; 2. Resident 187's nebulizer mask (a device used to convert a drug from liquid form into a mist, inhaled through the mask) was not properly stored when not in used and undated; 3. Licensed Vocational Nurse C (LVN C) did not disinfect the blood pressure (BP) apparatus (BP apparatus, a cuff that is wrapped around the arm to measure BP) in between residents; 4. Resident 238's nebulizer tubing was outdated and left on top of the resident's bedside table; 5. Resident 50's humidifier bottle was on the floor; 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and privacy was upheld for 1 of 2 sampled Residents (Resident 12) when Resident 12's Suprapubic catheter [SP Catheter, a device inserted into your bladder (organ that collects urine) to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine] drain bag was left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent for one of two sampled residents (Resident 44), for the medication lorazepam (medication used for anxiety). This deficient practice had the potential for the resident or the representative not to be informed of the risks, benefits, and alternatives of the given treatment (medication) and may lead to the inability to exercise the rights to a preferred choice or alternative treatment.

Inspectors wroteBased on interview and record review, the facility failed to report a suspected allegation of resident abuse in a timely manner for two of two residents (Residents 196 and 24) when: 1. The alleged missing money of Resident 196 was not reported to the California Department of Public Health (CDPH, a state department responsible for public health in California), Adult Protective Services (APS) and Office of the Long Term Care Ombudsman ( LTCO, an advocate for residents of nursing homes, assisted living facilities, and other residential care communities) when it was first reported to the Social Services Director (SSD) on 11/18/2022; and 2. The alleged Resident/Patient/Client Abuse (Resident to Resident) incident on 12/31/22 was not reported to CDPH , Ombudsman , and Law Enforcement when the incident was first reported on 12/31/22 not until 1/3/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan to include instructions on care of oxygen use for one of three residents (Resident 190). This failure resulted in improper level of oxygen administration for Resident 190 and had the potential to result in oxygen toxicity such as lung damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) was provided for three of three sampled residents (Residents 190, 18 and 36) when: 1. Resident 190's physician'a order for oxygen administration was not followed and the Oxygen in Use sign was not visible to all passersby (staff, residents and visitors); 2. Resident 18's physician's order for oxygen administration was not followed; and 3. Resident 36's physician's order for oxygen administration was not followed. These failures had the potential to result in complications related to improper treatment while receiving O2 therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of the bed) for 2 of 24 sampled residents (residents who used bed or side rails), (Residents 39, and 78) when: 1. There was no physician orders obtained prior to the use of bed rails for Residents 39 and 78; 2. There was no side rail assessment completed prior to the use of side rails for residents 39 and 78; and 3. There were no side rail care plans for Residents 39 and 78. These failures had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient social services for one out of three sampled residents (Resident 44) when follow up psychological evaluation was not arranged. This failure had the potential to result in unmet psychosocial care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 46) was free from unnecessary medication when the facility failed to provide sufficient documentation to support a diagnosis of Dementia (decline in mental capacity affecting daily function) with psychotic (A mental disorder characterized by a disconnection from reality) disturbance m/b (manifested by) paranoia (An unrealistic distrust of others or a feeling of being persecuted) in one of two sampled residents for unnecessary medication (Resident 46.) This deficient practice increased the risk of Resident 46 to receive unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 5.88% when two medication errors occurred out of 34 opportunities during the medication administration for one of four residents (Residents 58). Residents 58 did not receive the medications as ordered. These failures resulted in medications not given according to the physician's orders and had the potential for Resident 58 not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure the dietary staff had the appropriate competencies and skills set to carry out the functions of the food and nutrition services when: 1. A pair of tongs with visual residues was found in the kitchen drawer; 2. Dietary cook E (DC E) was not able to state the cool down process; and 3. Dietary aide G (DA G) did not demonstrate the correct process of checking the chemical sanitation concentration of the dish machine. These failures had the potential to negatively impact the facility's ability to ensure foods were prepared in competent and efficient manners that prevent food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure recipe was followed for puree diet. This failure had the potential to not meet adequate nutritional value and nutritional requirements for the residents.

Inspectors wroteBased on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper communication with the dialysis (a treatment that does some of the things done by healthy kidneys) Center for two of seven residents (Residents 46 and 41) who get dialysis treatments, when the dialysis communication forms were not completely filled out. This failure had the potential to result in a lack of knowledge of the residents' health status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the planned menu was followed when: 1. Seven of seven residents (Residents 19, 20, 30, 46, 54, 56, and 63) on a renal diet (renal diet is one that is low in sodium, phosphorous, and protein, limit potassium and calcium) did not receive rice and one received potatoes; 2. One of one resident (Resident 72) on a vegan diet did not receive planned menu items and received foods that were not on the menu including foods with milk and chicken, 3. [NAME] beans were served instead of seasoned beans as indicated on the menu during the lunch meal on 5/2/22, and, 4. Portion size was not followed for seasoned greens during the lunch meal on 5/2/22. Theses failures had the potential to result in the facility not meeting the nutritional needs of the residents and compromising their nutritional status. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition when: 1. The produce refrigerator was not maintaining temperatures below 41 Fahrenheit (F); the oven temperature dial did not contain numbers or markings for the temperature setting; and the plate warmer handle was detached from the lid on one side. These failures had the potential to cause equipment to not be functionally safe and impact the ability of the equipment to operate as intended or cause contamination of food, leading to foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policies on medication self-administration (resident takes medication without staff assistance) and bedside medication storage for one of 18 sampled residents (Resident 15) when: 1. The facility did not determine that the resident was clinically appropriate and safe to self-administer medications; 2. The facility did not ensure self-administered medications were stored in a safe and secure place; 3. The facility did not remove an expired medication from the resident's bedside; 4. The facility did not obtain a physician's order to store medications at bedside; and 5. The facility did not develop care plans to address self-administration of medications or bedside storage of medications. These failures had the potential to result in unsafe medication self-administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 18 sampled residents (Residents 227, 20 and 226) received necessary and proper care and services when: 1. For Resident 227, licensed vocational nurse D (LVN D) did not give the medication per physician's order; 2. For Resident 20, LVN did not wear gloves during administration of insulin (used to treat high blood sugar) by subcutaneous (SC, under the skin) injection; and 3. For Resident 226, the facility failed to develop a care plan (a document which communicates and directs the care and services, including goals and interventions, required to meet residents' needs and recognizes potential needs or risks) related to resident's pain and change of condition on 1/14/2022. These failures could affect the residents' health and individualized care and services provided while in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to arrange podiatry (medical specialty concerned with the care and treatment of the foot) services for two of 18 sampled residents (Residents 43 and 64). This had the potential to affect the residents' physical and psychosocial health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate services for two of 18 sampled residents (Residents 29 and 72) who had a gastrostomy tube (GT, tube surgically placed through the abdomen and into the stomach to administer nutrition, hydration and medications) when: 1. For Resident 29, licensed vocational nurse J (LVN J) did not check the GT placement and did not raise the head of the bed during feeding, and 2. For Resident 72, staff did not label and date the GT feeding formula bag.

Inspectors wrote2. Review of Resident 62's Order Summary Report indicated, Oxygen at 3 LPM via NC continuously. During an observation on 5/2/2022 at 9:10 a.m., Resident 62 was lying in bed and was receiving oxygen at 3 LPM via NC connected to an oxygen concentrator machine (a type of medical device used for delivering oxygen to individuals with breathing-related disorders). There was no Oxygen in Use sign posted at the door or in the resident's room. Review of the facility's policy titled Oxygen Administration, revised 10/2010 indicated, Place an 'Oxygen in Use' sign on the outside of the room entrance door. Based on observation, interview and record review, the facility failed to follow their oxygen administration policy for one of 18 sampled residents (Resident 54) and one non-sampled resident (Resident 62) when staff did not place an Oxygen in Use sign outside the entrance to the residents' rooms. [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon consultant pharmacist reports for two of 18 sampled residents (Residents 39 and 27). This failure had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored safely and properly when: 1. Two of two medication room refrigerators in Stations A and B were not kept locked; 2. Two of two Xalatan (Latanoprost, to treat high pressure inside the eye due to glaucoma) eye drops for Resident 23, and Resident 69 did not have an open date; and 3. One opened Humalog insulin (fast acting insulin) vial for Resident 228 did not have an open date.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to provide food in a form that meets the needs of two residents (Residents 31 and 45) on either mechanical soft (texture modified diet for people with difficulty chewing or swallowing) or ground meat diets when: a. Residents 31 and 45 received whole pork chops, and b. Resident 45 received two whole bean burritos. This failure had the potential to place residents on a mechanical soft or ground meat diet at an increased risk for choking.

Inspectors wroteBased on interview and record review, the facility failed to implement their antibiotic stewardship program (program intended to prevent the overuse of antibiotics) for one of 18 sample residents (Resident 54). Resident 54 received a course of antibiotics for pneumonia (a lung infection), but did not meet all the criteria that needed to be present for antibiotic use. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility.

Inspectors wroteBased on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident.