Inspection visit
Inspection
23 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 23 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to implement their policies on medication
self-administration (resident takes medication without staff assistance) for one sampled resident (Resident
157) when the facility did not determine that the resident was clinically appropriate and safe to
self-administer medications and did not remove an expired medication from the resident's bedside. These
failures had the potential for unsafe and improper administration of medications.
Residents Affected - Few
Findings:
Review of Resident 157's admission Record indicated; Resident 157 was admitted to the facility with
diagnoses including unspecified abdominal hernia with gangrene (a condition where a portion of the
abdominal organs protrudes through a weakened area in the abdominal wall, leading to tissue death),
peritoneal adhesions (fibrous bands of tissue that form between organs and tissues in the abdomen).
Review of Resident 157's Minimum Data Set (MDS - an assessment tool), dated [DATE], indicated
Resident 157's brief interview for mental status (BIMS - an assessment to test a person's cognition level)
was 9, (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is
cognitively intact] which meant Resident 157 had moderately impaired cognition.
During an observation and concurrent interview conducted on [DATE], at 2:30 p.m., it was noted that there
was a slightly open purse on top of Resident 157's bed containing an inhaler. Upon inspection, it was found
to be a Ventolin inhaler (medication to treat difficulty breathing) with an expiration date of [DATE]. Resident
157 confirmed using the inhaler and stated that staff were aware of its presence but had not checked its
expiration. Resident 157 reported experiencing difficulty breathing the previous morning and used the
expired inhaler, which was ineffective. As a result, Resident 157 was currently receiving supplemental
oxygen via concentrator, as indicated by the oxygen at bedside.
During an observation and concurrent interview with the Director of Nursing (DON) on [DATE], at 2:50 p.m.,
the DON confirmed the expiration of the Ventolin inhaler and emphasized the importance for nurses to
regularly check medications stored at bedside to ensure they are not expired. The DON informed Resident
157 that the inhaler was expired, while pointing to the date indicated on the inhaler. Resident 157 stated
she didn't see it. The DON informed Resident 157 the inhaler was not effective to use, to which Resident
157 insisted it was still usable by rinsing it with water.
During an interview and concurrent record review with the DON on [DATE], at 3:05 p.m. it was confirmed
there was no IDT (Interdisciplinary Team, a group of health care professionals who help patients to receive
the care they need) assessment indicating it was safe for the resident to self-administer medications.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 22
Event ID:
056178
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0554
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of facility's policy, revised 2/2021, Self-Administration of Medications, indicated, .the
interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether
self-administering medications is safe and clinically appropriate for the resident. The IDT considers the
following factors when determining whether self-administration of medications is safe and appropriate for
the resident: a. The medication is appropriate for self-administration; b. The resident is able to read and
understand medication labels; c. The resident can follow directions and tell time to know when to take the
medications; d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side
effects and when to report these to the staff . f. The resident is able to safely and securely store the
medication. If it is deemed safe and appropriate for a resident to self-administer medications, this is
documented in the medical record and the care plan .Self-administered medications are stored in a safe
and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's
room, medications of residents permitted to self-administer are stored on a central medication cart or in the
medication room. A licensed nurse transfers the unopened medication to the resident when the resident
requests them .The nursing staff routinely checks self-administered medications and removes expired,
discontinued, or recalled medications .
Event ID:
Facility ID:
056178
If continuation sheet
Page 2 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop a care plan (identifies residents' concerns and
outlines the care and services needed to meet their needs) to address smoking for one of three sampled
resident (Resident 255). This failure had the potential to result in the inability to identify the resident's
individualized care issues and implement a person-centered care.
Findings:
Review of Resident 255's clinical record, indicated, Resident 255 was admitted on [DATE] with diagnoses
including cellulitis of right lower limb (skin infection that causes redness, swelling and pain in the affected
area of the skin), arthritis (swelling and tenderness in one or more joints causing pain or stiffness) due to
other bacteria right knee, unspecified right hip open wound and a smoker. There was no care plan
developed to address smoking.
During an interview with Resident 255 on 4/10/24 at 10:18 a.m., Resident 255 stated he has a schedule to
smoke outside the facility at 10:30 a.m. and 1:30 p.m. for 15 minutes, accompanied by a staff.
During a concurrent interview and record review on 4/10/24 at 10:37 a.m., with the Director of Nursing
(DON), the DON verified that there was no care plan developed for smoking. The DON stated that baseline
care plan should be developed within 72 hours after smoking assessment was done. Smoking assessment
was done on 4/3/24.
During a review of the facility's policy and procedure titled Care Plans - Baseline, dated March 2022,
indicated .the comprehensive care plan is developed within 48 hours of the resident's admission and meets
the requirements of a comprehensive assessment.
During a review of the facility's policy and procedure titled Care Planning-Interdisciplinary Team, dated
March 2022, indicated Comprehensive, person-centered care plans are based on resident assessments
and developed by an interdisciplinary team (IDT).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 3 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
2a. During an observation on 4/8/24, at 10:24 a.m., Resident 2 was sitting in the wheelchair, asleep, and
receiving supplemental oxygen in her room. There was no date on the oxygen humidifier bottle.
Residents Affected - Some
During an observation on 4/9/24, at 12:37 p.m., Resident 157 was observed sitting in the wheelchair, and
receiving supplemental oxygen in her room. There was no date on the oxygen humidifier bottle.
Based on observation, interview, and record review, the facility failed to follow its Policy and Procedure as
well as professional standards of practice regarding oxygen administration for 7 of 8 sampled residents
(Resident 2, Resident 10, Resident 16, Resident 23, Resident 25, Resident 46, & Resident 157) when:
1. Resident 23 did not have an oxygen in use sign outside his room
2. Staff did not follow label and promptly replace oxygen humidifiers and/or tubing for Resident 2, Resident
10, Resident 16, Resident 25, Resident 46 & Resident 157.
Findings:
1. During an observation on 4/11/24, at 8:54 a.m., Resident 23 was receiving supplemental oxygen in his
room. Resident 23's door frame, or anywhere outside his room did not have an oxygen in use sign to alert
staff or visitors, oxygen was being used in the room.
During an interview on 4/11/24, at 9:01 a.m., with Licensed Vocational Nurse (LVN) F, LVN F stated,
Resident 23 is now receiving oxygen since he came back from the hospital.
During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, dated 2010, the
P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.The
following equipment and supplies will be necessary when performing this procedure: .4. No
Smoking/Oxygen in Use signs.
2b. During an observation on 4/8/24 at 8:23 a.m., Resident 10's oxygen humidifier bottle has no date when
it was used.
During an observation on 4/8/24 at 9:02 a.m., Resident 16's nasal cannula (a flexible tube that contains
two-prongs intended to for use inside the nostrils to deliver supplemental oxygen) was dated 3/30/24 and
the oxygen humidifier bottle was undated.
During an observation on 4/8/24 at 9:07 a.m., Resident 46's oxygen humidifier bottle was undated.
During an interview on 4/8/24 at 3:43 p.m., with Licensed Vocational Nurse (LVN) G, LVN G verified the
nasal cannula tubing was dated 3/30/24 but the humidifier bottle was undated. LVN G stated the humidifier
should have a date on when it was used or changed.
During an interview on 4/8/24 at 3:49 p.m., with the Director of Nursing (DON), the DON stated the oxygen
tubing are changed weekly and the date must be written on the tubing and the humidifier bottle.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 4 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
During a review of the facility's policy and procedure titled Oxygen Administration, dated October 2010,
indicated The purpose of this procedure is to provide guidelines for safe oxygen administration.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 5 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one of 15 residents (Resident 30)
remained free from accident hazards due to the use of bed rail (side rail) when Resident 30 had the half
bed rail raised up without bed rail assessment.
This failure had the potential to put Resident 30 at risk for entrapment and serious injury.
Findings:
Review of Resident 30's face sheet (a document that gives a patient's information at a quick glance),
indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including encounter for
palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of
a serious illness), unspecified dementia (loss of thinking, remembering, and reasoning skills) and type 2
diabetes mellitus with diabetic nephropathy (a condition with affects the way the body processes blood
sugar).
During an initial pool observation on 4/8/24 at 8:34 a.m., Resident 30 was not in the room. Half side rails
were raised up on the bed.
During a concurrent interview and record review on 4/10/24 at 3:50 p.m., with the Director of Nursing
(DON), the DON stated that the assessment for side rails was not done. The DON also stated that it should
have been done for the safety of the resident.
During an interview on 4/10/24 at 3:55 p.m., with Licensed Vocational Nurse (LVN) E, LVN E stated that
side rails was used for the safety of the resident and assessment should have been done.
During a review of the facility's policy and procedure titled Bed Safety and Bed Rails, undated, indicated
The use of bedrails is prohibited unless the criteria for use of bed rails have been met. Prior to the
installation or use of full side or bed rails, alternatives to the use of side or bed rails are attempted.
Interdisciplinary evaluation includes .b. The resident's risk associated with the use of bed rails.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 6 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interview, and record review, the facility failed to have a medication error rate of
less than 5% as evidence of 2 medication errors out of 25 opportunities, resulting in a medication error rate
of 8% for one of 5 residents (Resident 2) observed during medication administration. Resident 2's eye
medications were not administered in accordance with the facility's medication administration guidelines
and accepted professional standards of practice. These failures resulted in medications not given as per
accepted professional standards of practice, which may negatively affect the resident's health.
Residents Affected - Few
Findings:
During a medication administration observation on 4/10/24 at 04:05 p.m., at Resident 2's bedside, licensed
vocational nurse H (LVN H) administered brimonidine (for reduction of pressure in the eye) eye solution to
Resident 2, one drop in each eye. Then, LVN H administered the dorzolamide (to treat increased pressure
in the eye) eye solution to Resident 2, one drop in each eye. LVN H did not wait between administering
different eye medications.
During an interview with the director of nursing (DON) on 4/11/24, at 3:00 p.m., the DON stated the nursing
staff should wait 5 minutes between giving different eye medications.
Review of facility's policy, revised 1/2014, Instillation of Eye drops, indicated, .When administering two or
more different eyedrops allow three to five minutes between each application .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 7 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0800
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional
and special dietary needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and document reviews the facility failed to ensure overall systems in food and
nutrition services were maintained according to standards of practice and facility policy when:
1)
The Food and Nutrition Services Department staff were unable to correctly demonstrate kitchen tasks in
food safety, service, and sanitation tasks,
2)
The ice machine was not cleaned according to manufacturer's guidelines, and a 3-compartment sink
system for cleaning, rinsing, and sanitizing was not established for operation.
3)
Facility approved menus and recipes were not followed for residents with therapeutic diets.
4)
The Certified Dietary Manager (CDM) did not have the required state of California education requirements
on regulations for dietetic services.
These failures potentially exposed the facility's medically vulnerable residents to unsafe and unsanitary
practices that could lead to foodborne illness.
Cross reference F802, 803, 812 and California Health and Safety Code 1265.4
Findings:
1)
Dishmachine sanitizer testing
During the initial kitchen tour observation and interview on 4/8/24 at 8:20 A.M. and follow up kitchen
observations on 4/8/24 at 1:57 P.M. with the Dishwasher Kitchen Aides (KA B) and KA C, the [NAME] did
not demonstrate the correct process to test the sanitizer strength or verbalize the correct sanitizer strength
level when they tested the dish machine sanitizer. KA B dipped a test strip into the standing water solution
on the dish machine counter and stated it should read 100-200 ppm (parts per million). KA C dipped the
test strip in the dish machine solution tank and stated the test strip should read 100 ppm.
Review of facility policy titled Dish Washing, dated 2018, indicated The chlorine should read 50-100 on dish
surface in final rinse. The proper chlorine level is crucial in sanitizing the dishes.
Cooked food Cool down process
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 8 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0800
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 4/8/24 at 2:19 PM, [NAME] A stated for the cool down process, that the morning
cook takes the first temperature and writes it on the log. He said the final cook temperature should be 145
degrees Fahrenheit and up. [NAME] A did not verbalize any time frame for the entire cool down process.
[NAME] A stated the final temperature should be between 35-41 degrees Fahrenheit, and that the
afternoon cook takes the final temperature before leaving their shift.
Residents Affected - Many
Review of kitchen records indicated a blank cool down log sheet for April 2024.
Review of facility form titled Cool Down Log indicated time intervals to record temperatures and what the
goal temperatures should be: Cool down begins at 140 degrees Fahrenheit, at 2 hours temperature should
be 70 degrees Fahrenheit or less, and at 6 hours temperature should be 41 degrees Fahrenheit.
Review of facility in-service titled Time/Temp control .Cool down logs indicated Cool down cannot exceed 6
hours and that food must reach 70 degrees Fahrenheit within two hours, then 41 degrees Fahrenheit within
four hours.
2)
Kitchen equipment and cleaning/sanitation systems
During a kitchen observation and interview on 4/8/24 at 10:20 AM with the Maintenance Assistant (MNA),
the ice machine reservoir (collection) tray had black colored sediments (resembling sand) at the bottom of
the tray. The MNA stated he cleaned the ice machine with a bleach and water solution monthly. The MNA
further stated he noticed the black residue sediments in the tray for the last three months but did not know
what it was.
During an interview with the certified dietary manager (CDM), the Registered Dietitian (RD), MNA, and
Administrator (ADM) on 4/10/24 at 1:14 PM, the MNA stated he reviewed the ice machine manufacturer's
cleaning instructions and stated he did not follow the manufacturer's instructions for cleaning when using
the half cup of bleach and half cup of water solution monthly. The RD and ADM acknowledged the
manufacturer's guidelines for cleaning and stated it they expected the ice machine to be cleaned correctly
according to these instructions.
Review of facility policy titled Ice Machine Cleaning manufacturer's dated 2020, indicated Clean inside of
ice machine with a sanitizing agent per the manufacturer's instructions.
Review of manufacturer's instruction manual (manufacturer is Hoshizaki) indicates the recommended
cleaning solution is 8.25% sodium hydrochlorite (chlorine bleach), 0.31 oz (9.2 ml) to 1 gallon water (3.8 L).
Review of the 2022 Federal FDA Food Code section 4-602.11 indicated Equipment Food-Contact Surfaces
and Utensils. Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by
the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude
accumulation of soil or mold[ .]Ice makers and ice bins must be cleaned on a routine basis to prevent the
development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms[ .]
3)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 9 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0800
Menus and recipes not followed
Level of Harm - Minimal harm
or potential for actual harm
During multiple kitchen observations of the lunch meal preparation and service on 4/8/24 at 11:49 AM and
4/9/24 at 12:40 PM, the menu and standardized recipes were not followed by kitchens staff. On 4/8/24 at
11:49 AM, white rice was observed as the side dish and a plate served to a resident who received a Liberal
Renal diet, which was listed on the Resident's tray ticket.
Residents Affected - Many
Review of the facility menu titled Week 2 Monday-Therapeutic Spreadsheets, CYCLE 2 2024, the menu
spreadsheet indicated SF noodles were to be served at lunch as the side dish for the Liberal Renal diet.
During a concurrent observation and interview on 4/9/24 at 1:19 PM, the CDM stated he prepared the
lunch pureed vegetables, which was pureed cooked broccoli and tomatoes combined. The CDM stated he
did not follow a standardized recipe for the pureed vegetables he prepared the lunch meal.
Review of the facility document titled Week 2 Tuesday-Therapeutic Spreadsheets, CYCLE 2 2024, the
therapeutic menu spreadsheet indicated [ .]Puree/Level 4[ .]Lunch[ .]P Cooked vegetable[ .]
During a concurrent interview with the RD and record review on 4/10/24 at 1:27 PM of the Pureed recipe
preparation titled Cooked vegetable dated 2002-2024, the policy indicated .Puree diets: OMIT: TOUCH,
FIBROUS, COOKED VEGETABLES LIKE .BROCCOLI, CAULIFLOWER . The RD acknowledged the
residents should not have received the pureed cooked broccoli and tomato food mixture as their side
vegetable.
Review of facility policy titled Food Preparation, dated 2018, indicated The facility will use approved recipes,
standardized to meet the resident census, and [ .]2. Recipes are specific as to portion yield, method of
preparation, amounts of ingredients, and time and temperature guide.
Review of facility policy titled Menu Planning, dated 2020, indicated .3. All daily menu changes, with the
reason for the change, are to be noted on the back of the kitchen spreadsheet or a logbook .4. The menus
are planned to meet nutritional needs of residents in accordance with established national guidelines .and
.in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of
the National Research Council .
4)
Title 22 CDM requirements for Oversight of Dietetic Services
During an interview on 4/10/24 at 9:45 AM with the Certified Dietary Manager (CDM) and Registered
Dietitian (RD), the CDM stated he did not have the required hours of Title 22 education on Dietetic
Services. The CDM further stated he has been a CDM for three years and was unfamiliar with the state Title
22 regulations for dietary services. The RD stated she was unaware of this requirement for Food service
managers of nursing home healthcare facilities.
Review of California Health and Safety Code HSC § 1265.4 indicates The dietetic services supervisor
shall have completed at least one of the following education requirements [ .] (4) Is a graduate of a dietetic
services training program approved by the Dietary Managers Association and is a certified dietary manager
credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and
has received at least six hours of in-service training on the specific California dietary service requirements
contained in Title 22 of the California Code of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 10 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0800
Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 11 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0802
Level of Harm - Minimal harm
or potential for actual harm
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition
service.
Based on observation, interview and record review, the facility did not ensure staff performed their job
functions competently according to standards of practice when:
Residents Affected - Many
1) Two kitchen aides did not know how to properly test the level of dishwasher sanitizer.
2) One kitchen aide dumped trash can debris into the wash/rinse compartment of the 2-compartment sink
with dirty dishes in them.
3) One cook did not know how to properly calibrate thermometers meant to test food temperatures.
4) One cook did not properly verbalize the cooldown process.
5) One prep cook/diet aide did not know how to properly prepare cold foods such as tuna salad or chicken
salad.
6) One kitchen aide was seen washing his hands with only water after taking a bag of garbage out of the
kitchen, and then touching dishes needing to be cleaned.
These failures to adhere to standards of practice had the potential to expose vulnerable residents to food
borne illnesses.
Cross reference: F812
Findings:
1) During an initial kitchen tour observation on 4/8/24 at 8:20 AM, kitchen aide (KA) B was seen testing the
parts per million (PPM) for dishwasher sanitizer by dipping the testing strip in standing water on the counter
near the dishwashing machine. KA B stated the dishmachine sanitizer was between 100 and 200, but it
should be 200 ppm. KA B stated 200 ppm was good.
During a follow-up kitchen observation and interview on 4/8/24 at 1:57 PM, KA C was seen testing the PPM
for dishwasher sanitizer by dipping the testing strip in standing water in the dishwashing machine
compartment. KA C stated The strip says it's 200. It's supposed to be 100, referring to the acceptable level
of PPM.
Review of facility policy titled Dish Washing, dated 2018, indicated The chlorine should read 50-100 on dish
surface in final rinse. The proper chlorine level is crucial in sanitizing the dishes.
Review of document Job Description Kitchen Aide, date not listed, indicated the Kitchen Aide's duties
include Follow Federal and State long term care regulations and Dietary Department policies and
procedures, Follow defined safety codes while performing all duties, and Follow defined Infection Control
procedures.
2) During an observation and interview on 4/8/24 at 1:57 PM, KA C was seen taking a garbage can out to
the dumpster area, then returning with the garbage can to the kitchen, and then dumping debris and liquid
in the garbage can into the second compartment of a 2-compartment dishwashing sink. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 12 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
second compartment had dishes and utensils sitting at the bottom. KA C stated I usually spray the trash
can with bleach and wipe it. But today I couldn't find it so I used the sink. I didn't realize there were still
dishes in there.
Review of document Job Description Kitchen Aide, date not listed, indicated the Kitchen Aide's duties
include Follow Federal and State long term care regulations and Dietary Department policies and
procedures, Follow defined safety codes while performing all duties, and Follow defined Infection Control
procedures.
3) During an initial kitchen tour observation and interview on 4/8/24 at 9:58 AM, [NAME] A was seen
calibrating a thermometer. [NAME] A stated he does not typically calibrate the thermometer. [NAME] A
further stated he thinks the thermometer should be 30 degrees or something if its calibrated.
Review of facility in-service titled Time/Temp control, thermometer calibration, cool down logs indicated
Thermometers can lose their accuracy-need to calibrate-Boiling point method: 212 degrees F-Ice point: 32
degrees F. The sign-in sheet was dated 11/9/23.
Review of document Job Description Cook, date not listed, indicated the Cook's duties include Monitor
temperature of hot and cold foods through food preparation and service to ensure that established
temperature goals are met prior to steam table transfer and maintained throughout meal service, and
Follow defined safety codes while performing all duties.
Review of the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-204.112 titled
Temperature Measuring Devices indicates The importance of maintaining time/temperature control for
safety foods at the specified temperatures requires that temperature measuring devices be easily readable.
The inability to accurately read a thermometer could result in food being held at unsafe temperatures.
Temperature measuring devices must be appropriately scaled per Code requirements to ensure accurate
readings.
4) During an interview on 4/8/24 at 2:19 PM, [NAME] A stated for the cool down process, that the morning
cook takes the first temperature and writes it on the log. He said the final cook temperature should be 145
degrees Fahrenheit and up. [NAME] A did not verbalize any time frame for the entire cool down process.
[NAME] A stated the final temperature should be between 35-41 degrees Fahrenheit, and that the
afternoon cook takes the final temperature before leaving their shift.
Review of kitchen records indicated a blank cool down log sheet for April 2024.
Review of facility form titled Cool Down Log indicated time intervals to record temperatures and what the
goal temperatures should be: Cool down begins at 140 degrees Fahrenheit, at 2 hours temperature should
be 70 degrees Fahrenheit or less, and at 6 hours temperature should be 41 degrees Fahrenheit.
Review of the 2022 Federal FDA Food Code, section 3-501.14, titled Cooling indicates Cooked
TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 135
degrees F to 70 degrees F; and (2) Within a total of 6 hours from 135 degrees F to 41 degrees F or less .
5) During an interview with the preparatory [NAME] (Prep) on 4/9/24 at 12:34 PM, Prep stated the way he
prepares tuna salad or chicken salad is: He gets the cans from the storage room, then mixes in mayonnaise
and eggs (if available), mixes it in a container and then puts it in the refrigerator. He
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 13 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0802
did not specify time intervals or the use of cooling techniques.
Level of Harm - Minimal harm
or potential for actual harm
Review of facility in-service titled Time/Temp control, thermometer calibration, cool down logs indicated
Cool down cannot exceed 6 hours and that food must reach 70 degrees Fahrenheit within two hours, then
41 degrees Fahrenheit within four hours.
Residents Affected - Many
Review of facility in-service titled Time/Temp control, thermometer calibration, cool down logs indicated
Chicken, tuna, egg, pasta, potato salad-to be prepared and COOL-DOWN procedure must be implemented
and logged.
Review of document Job Description Dietary Aide, date not listed, indicated the Dietary Aide's duties
include Provide assistance to the cook in the preparation and service of meals and beverage carts, Follow
defined safety codes while performing all duties .
Review of the 2022 Federal FDA Food Code, Section 3-501.14 Cooling indicates Time/Temperature control
for Safety Food shall be cooled within 4 hours to 41 F or less if prepared from ingredients at ambient
temperature, such as canned tuna[ .]
Review of the 2022 Federal FDA Food Code, section 3-501.15, titled Cooling Methods indicates Cooling
shall be accomplished in accordance with the time and temperature criteria specified .by using one or more
of the following methods (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner
portions; (3 )Using rapid cooling equipment (4) stirring the food in a container placed in an ice water bath;
(5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective
methods
6) During an observation and interview on 4/9/24 at 11:23 AM, KA B was seen washing his hands only with
water after handling a garbage bag. KA B stated he was supposed to wash his hands with water and soap.
During an interview with the certified dietary manager (CDM) and registered dietitian (RD) on 4/10/24 at
1:27 PM, both the CDM and RD stated they expected the staff in the kitchen to perform their jobs correctly
to prevent cross contamination.
Review of facility policy titled Hand Washing Procedure, dated 2020, indicated hands need to be washed
after touching trash can or lid. Review of facility policy also indicated Use warm running water (100-108F)
and soap, preferably from a dispenser.
Review of the 2022 Federal FDA Food Code, section 2-301.14, titled When to Wash indicates FOOD
EMPLOYEES shall clean their hands and exposed portions of their arms as specified under section
2-301.12, immediately before engaging in FOOD preparation including working with exposed FOOD, clean
EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A)
After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B)
After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as
specified in section 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a
handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT
or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and
to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD
and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working
with FOOD; and (I) After engaging in other activities that contaminate the hands.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 14 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow standardized recipes and menus approved by the
facility's Registered Dietitian (RD), according to facility policy and standards of practice when:
1)
Rice was served instead of noodles for the liberal renal therapeutic diet,
2)
The puree diet did not receive an appropriate pureed vegetable for the lunch meal.
These failures had the potential to alter the palatability and nutritional value of the food, which could
decrease food intake and compromise the resident's nutritional status.
Findings:
Review of the literature pertaining to malnutrition indicates leading modifiable risk factors of malnutrition in
Long-term care (LTC) include poor nutrition, poor food/fluid intake, dependence on others for eating, and
impaired mobility. Additional factors that lead to poor oral intake include poor food delivery systems, timing
of menu and menu selections ([NAME], K.N.P., [NAME], S.R. & [NAME], C.W. Nutritional Vulnerability in
Older Adults: A Continuum of Concerns. [NAME] Nutr Rep 4, 176-184 (2015).
1) During an observation of the lunch meal on 4/8/24 at 11:49 AM, white rice was observed on a resident's
plate who was served a Liberal Renal diet, and listed on her tray ticket.
Review of the facility document titled Week 2 Monday-Therapeutic Spreadsheets, CYCLE 2 2024, the menu
spreadsheet indicated SF noodles were to be served at lunch meal for the Liberal Renal diet.
During an interview with the CDM on 4/10/24 at 1:27 PM, CDM stated we had everything in stock this
week. When the CDM was asked about substituting the SF noodles from the menu spreadsheet with white
rice, the CDM did not provide an explanation for the food substitution.
During an interview with the RD on 4/10/24 at 1:27 PM, the RD stated SF noodles stood for sodium-free
noodles, and further stated they should have been served to the residents if it was listed on the menu for
the Liberal renal diet.
2) During a concurrent observation and interview on 4/9/24 at 1:19 PM, the CDM stated he prepared
cooked broccoli and tomatoes combined for the lunch pureed vegetables. The CDM stated he did not follow
a standardized recipe for the pureed vegetables he prepared the lunch meal.
During a review of the facility document titled Week 2 Tuesday-Therapeutic Spreadsheets, CYCLE 2 2024,
the therapeutic menu spreadsheet indicated [ .]Puree/Level 4[ .]Lunch[ .]P Cooked vegetable[ .]
During a concurrent interview with the RD and record review on 4/10/24 at 1:27 PM of the Pureed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 15 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
recipe preparation titled Cooked vegetable dated 2002-2024, the policy indicated .Puree diets: OMIT:
TOUCH, FIBROUS, COOKED VEGETABLES LIKE .BROCCOLI, CAULIFLOWER . The RD acknowledged
the residents should not have received the pureed cooked broccoli and tomato food mixture as their side
vegetable.
Review of facility policy titled Food Preparation, dated 2018, indicated The facility will use approved recipes,
standardized to meet the resident census, and [ .]2. Recipes are specific as to portion yield, method of
preparation, amounts of ingredients, and time and temperature guide.
Review of facility policy titled Menu Planning, dated 2020, indicated [ .]3. All daily menu changes, with the
reason for the change, are to be noted on the back of the kitchen spreadsheet or a logbook[ .]4. The menus
are planned to meet nutritional needs of residents in accordance with established national guidelines,
Physicians orders and[ .]in accordance with the most recent recommended dietary allowances of the Food
and Nutrition Board of the National Research Council[ .]
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 16 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility did not ensure food safety practices were
followed according to facility policy and standards of practice when:
Residents Affected - Many
1) A dirty cooking utensil was stored with clean utensils.
2) The ice machine reservoir tray had black colored debris in the tray and was not sanitized correctly.
3) Food in the walk-in refrigerator was not labeled with an opened-on date and use-by date.
4) The kitchen did not have a 3-compartment sink system for manually washing, rinsing, and sanitizing
dishes.
5) The 2-compartment sink the kitchen uses for dishwashing does not have an air gap which prevents
backflow of dirty water.
6) The Low temperature dish machine did not reach 120 degrees Fahrenheit consistently over three cycles.
These failures had the potential to expose vulnerable residents to potential contaminants that may cause
food borne illnesses.
Cross reference F800 and F802
Findings:
1) During an initial kitchen tour observation on 4/8/24 at 8:20 AM, a whisk with brown food debris on it was
seen hanging off the side of the tray line area with other cooking utensils.
During an interview with Kitchen Aide (KA) B and the Certified Dietary Manager (CDM) on 4/8/24 at 8:21
AM, KA B said the whisk was a little dirty. The CDM acknowledged the whisk was dirty and should not have
been stored with the clean utensils.
Review of facility policy titled Dish Washing, dated 2018, indicated All dishes will be properly sanitized
through the dishwasher [ .] Gross food particles shall be removed by careful scraping and pre-rinsing in
running water.
Review of the 2022 Federal Food and Drug Administration (FDA) Food Code Section 4-601.11. Equipment,
Food-Contact Surfaces[ .] and Utensils indicates (A) EQUIPMENT FOOD-CONTACT SURFACES and
UTENSILS shall be clean to sight and touch[ .]
2) During an observation on 4/8/24 at 10:20 AM, the Maintenance Assistant (MNA) opened the ice machine
in the kitchen and removed the reservoir tray. Black colored sediment residue was seen in the tray.
During an interview with the MNA on 4/8/24 at 10:20 AM, the MNA stated he cleaned the ice machine
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 17 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
every month using a bleach and water solution and changed the water filters every three months. The MNA
also stated every time he opened the ice machine to clean and sanitize it, he always saw the black
sediment in the reservoir tray.
During an interview with the certified dietary manager (CDM), the Registered Dietitian (RD), MNA, and
Administrator (ADM) on 4/10/24 at 1:14 PM, the MNA stated he reviewed the ice machine manufacturer's
cleaning instructions and stated he did not follow the manufacturer's instructions for cleaning when using
the half cup of bleach and half cup of water solution monthly. The RD and ADM acknowledged the
manufacturer's guidelines for cleaning and stated they expected the ice machine to be cleaned correctly
according to these instructions.
Review of facility policy titled Ice Machine Cleaning manufacturer's dated 2020, indicated Clean inside of
ice machine with a sanitizing agent per the manufacturer's instructions.
Review of manufacturer's instruction manual (manufacturer is Hoshizaki) indicates the recommended
cleaning solution is 8.25% sodium hydrochlorite (chlorine bleach), 0.31 oz (9.2 ml) to 1 gallon water (3.8 L).
Review of the 2022 Federal FDA Food Code section 4-602.11 indicated Equipment Food-Contact Surfaces
and Utensils. Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by
the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude
accumulation of soil or mold[ .]Ice makers and ice bins must be cleaned on a routine basis to prevent the
development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms[ .]
3) During the initial kitchen tour observation on 4/8/24 at 7:51 AM, two unopened plastic bags of broccoli
were found in the walk-in refrigerator with an expiration date of 4/1/24.
During the initial kitchen tour observation on 4/8/24 at 8:51 AM, a tray of fruit cups was seen in a smaller
refrigerator with no labels either on the fruit cups or on the tray.
During an interview with CDM on 4/8/24 at 8:51 AM, CDM stated that all food, including snacks in the
smaller refrigerator, must be labeled with an opened date and a use-by date.
Review of facility policy titled Labeling and Dating of Foods, dated 2020, indicated Produce is to be dated
with received date, Newly opened food items will need to be closed and labeled with an open date and
used by the date that follows guidelines, and All prepared foods need to be covered, labeled and dated.
Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal
service (i.e., salads, drinks, and other miscellaneous items for tray line)[ .]
Review of the 2022 Federal FDA Food Code section 3-501.17 (A) (B) (C) (D) indicates the day the original
container is opened in the food establishment shall be counted as Day 1[ .]The date marked shall not
exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the
food on or before the last date or day by which the food must be consumed on the premises[ .]
4) During an initial kitchen tour observation on 4/8/24 at 8:20 AM, there was a 2-compartment sink with
dirty pots and utensils in a soapy solution inside the left compartment and a few silverware in the right
compartment.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 18 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
During an interview with CDM on 4/8/24 at 8:25 AM, the CDM stated the left compartment was used for
washing dishes, and the right compartment was used for rinsing dishes. The CDM stated he did not know
about needing three compartments.
Review of the 2022 Federal FDA Food Code section 4-301.12, titled Manual Warewashing, Sink
Compartment Requirements, the code indicated, (A)[ .] a sink with at least 3 compartments shall be
provided for manually washing, rinsing, and SANITIZING EQUIPMENT and UTENSILS [ .] (E) A
2-compartment sink may not be used for WAREWASHING operations where cleaning and SANITIZING
solutions are used for a continuous or intermittent flow of KITCHENWARE or TABLEWARE in an ongoing
WAREWASHING process[ .]
Review of facility police titled 3 Compartment Procedure for Manual Dish Washing, dated 2018, indicated
Three compartment sink washing procedures are to be initiated when [ .] the dish machine registers low
water temperature and in the case of only a two-compartment sink, a third bin is necessary[ .]
5) During an initial kitchen tour observation on 4/8/24 at 8:25 AM, the 2-compartment sink, ice machine,
and vegetable washing sink did not have air gaps for the prevention of backflow.
During an interview with CDM on 4/8/24 at 8:25 AM, the CDM said he did not know anything about the
need for an air gap.
During an interview with the MNA on 4/8/24 at 10:30 AM, the MNA stated he was unaware of how the air
gap system works for the pipes underneath the sink system or other locations like an ice machine.
Review of the 2022 Federal FDA Food Code, section 5-402.11(A), the code indicates A direct connection
may not exist between the sewage system and a drain originating from equipment in which food, portable
equipment or utensils are placed[ .].
Review of facility policy titled Accident Prevention-Safety Precautions, dated 2018, indicated An air gap is
the most reliable backflow prevention device. It is the physical separation of the potable and non-potable
water supply systems by air space[ .].
During the initial kitchen tour observation and interview on 4/8/24 at 8:30 AM with the Kitchen aide (KA) B,
the KA B was seen running the dish machine, and the temperature gauge thermometer was between
110-120 degrees Fahrenheit during the first and second cycles. KA B stated the thermometer temperature
on the dish machine should be 120-150.
6) During a kitchen observation and interview on 4/8/24 at 1:57 PM, KA C was seen running the dish
machine more than two times to reach the proper wash temperature. On the third time the dish machine
cycle was run, the temperature registered at 120 degrees Fahrenheit. KA C stated the temperature of the
dish machine should be 120-200 degrees and I need to run the dishwasher again since it just hit 120 one
time.
Review of facility policy titled Dish Washing, dated 2018, indicated Low-temperature machine: If you do not
have the manufacturer's recommendations, use the machine at a range of 120 to 140F, and If you do not
achieve the proper temperature or chlorine level, resort to the MANUAL METHOD OF DISH WASHING.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 19 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
Based on observation, interview, and record review, the facility failed to submit the required Payroll Based
Journaling (PBJ) staffing information to the Centers for Medicare and Medicaid Services (CMS), for the last
quarter of 2023 (October, November, & December). This failure to submit the required data, staffing hours
and census information, can inhibit the facility's ability to determine an adequate level of staff is working at
a given time, leading to inadequate care of residents.
Findings:
During a review of the PBJ Staffing Data Report for facility, dated October 1- December 31, 2023, the PBJ
report indicated, Failed to submit data for the quarter.
During an interview on 4/10/24, at 9:28 a.m., with Payroll Clerk (PC) D, PC D stated, she is in charge of
submitting the data to CMS for the PBJ. PC D stated, she was late to submit the data for the last quarter,
October 1st-Decemeber 31st, 2023 and did not submit the data before February 14th.
During a review of the facility's Policy & Procedure (P&P) titled, Reporting Direct Care Staffing Information
(Payroll-Based Journal), dated 2022, the P&P indicated, Staffing information is collected daily and reported
for each fiscal quarter no later than 45 days after the end of the reporting period. Dates are as follow: Fiscal
Quarter 1, Date Range October 1-December 31, Submission Deadline February 14.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 20 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to implement infection control
practices for 4 of 7 sampled residents (Residents 155, 37, 33, and 40) when:
Residents Affected - Some
1. Registered Nurse I (RN I) did not perform hand hygiene when handling Resident 155's peripherally
inserted central catheter (PICC, used to deliver medications and other treatments directly to the large
central veins near the heart); and
2. There were no personal protective equipment (PPE, equipment worn to minimize exposure to hazards
that cause serious workplace injuries and illnesses) carts outside residents' room (Residents 37, 33, and
40).
These failures had the potential to spread infection in the facility.
Findings:
1. During a medication observation on 4/10/24, at 1:50 p.m., in Resident 155's room, the registered nurse I
(RN I) administered the Levaquin (antibiotic medication that treats bacterial infections) 750 milligrams (mg,
unit of weight) intravenous (IV, administered into a vein) via Resident 155's PICC line, located at resident's
left upper arm. Subsequently, RN I touched the overbed table and IV pump (medical device that are used to
deliver therapeutic fluids, such as nutrients and medications, into a patient's body) in Resident 155's room.
Then, an alarm was heard from the IV pump, indicating air in the line on the IV pump. RN I then
disconnected the IV tubing from Resident 155's left upper arm PICC line without performing hand hygiene
and applying a new pair of gloves.
During a concurrent interview with RN I, she acknowledged that she should have performed hand hygiene
prior to handling and disconnecting the IV tubing from Resident 155's PICC line.
Review of facility's policy, dated 1/1/19, Hand Hygiene Policy and Procedure, indicated, .3. Handwashing
may also be used for routinely decontaminating hands in the following clinical situations: After contact with
inanimate objects (including medical equipment) in the immediate vicinity of the patient .
2a. During an observation on 4/8/24, at 9:45 a.m., a signage was posted on Resident 37's door indicating
the required PPE before entering the room. However, there was no PPE cart outside Resident 37's room.
During a concurrent interview with the infection preventionist (IP), the IP confirmed that PPE was required
when providing care to Resident 37, and there should have been a PPE cart available outside Resident
37's room.
2b. During an initial pool observation on 4/8/24 at 9:07 a.m., there was no personal protective equipment
(PPE) cart outside of Resident 40 and Resident 33's room.
During an interview on 4/8/24 at 9:32 a.m., with Licensed Vocational Nurse (LVN) E, LVN E verified that
there was no PPE cart outside the room of Residents 40 and 33.
During an interview on 4/8/24 at 9:40 a.m., with Infection Preventionist (IP), IP verified that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 21 of 22
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manresa Healthcare Center
919 Freedom Blvd
Watsonville, CA 95076
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
there was no PPE cart outside of the residents' room and that there should be one.
Level of Harm - Minimal harm
or potential for actual harm
According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective
Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs),
updated 7/12/22, indicated 1. enhanced barrier precautions (EBP) are an infection control intervention
designed to reduce transmission of resistant organisms that employs targeted gown and gloves use during
high contact resident care activities; 2. Effective implementation of EBP requires staff training on the proper
use of PPE and the availability of PPE and hand hygiene at the point of care.
Residents Affected - Some
During a review of the facility's policy and procedure titled Personal Protective Equipment-Using Gowns,
dated September 2010, indicated When use of a gown is indicated, all personnel must put on the gown
before treating or touching the resident.
During a review of the facility's policy and procedure titled Personal Protective Equipment-Using Gloves,
dated September 2010, indicated When gloves are indicated, use disposable single-use gloves.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056178
If continuation sheet
Page 22 of 22
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
23 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0031GeneralS&S Dpotential for harm
Provide emergency officials' contact information.
- 0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
- 0341GeneralS&S Epotential for harm
Install a fire alarm system that can be heard throughout the facility.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
- 0007GeneralS&S Dpotential for harm
Address patient/client population and determine types of services needed.
- 0015GeneralS&S Dpotential for harm
Address subsistence needs for staff and patients.
- 0023GeneralS&S Epotential for harm
Establish policies and procedures for medical documentation.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0541GeneralS&S Dpotential for harm
Install properly constructed and protected linen or trash chutes.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the April 12, 2024 survey of MANRESA HEALTHCARE CENTER?
This was a inspection survey of MANRESA HEALTHCARE CENTER on April 12, 2024. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MANRESA HEALTHCARE CENTER on April 12, 2024?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide emergency officials' contact information."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.