Watsonville Nursing Center

F-F803

Findings:

During an interview on 8/12/24 at 10:12 a.m. with Resident 51, Resident 51 stated food is not very good and had no taste.

During an interview on 8/12/24 at 10:15 a.m., with Resident 6, Resident 6 stated that food was absolutely horrible.

During an interview on 8/12/24 at 10:23 a.m. with Resident 26, Resident 26 stated food was inedible, and meat was tough.

During an interview on 8/12/24 at 10:34 a.m., with Resident 20 and Resident 17, Resident 20 stated that meatloaf was bland and had no seasoning. Resident 17 stated she was served fried egg that was hard to cut with a knife. Resident 17 also stated that on weekends, foods served were not to Resident 17's liking.

During an interview on 8/12/24 at 10:46 a.m., with Resident 192, Resident 192 stated food was horrible and was hard to chew.

During an interview on 8/12/24 at 10:47 a.m., with Resident 59, Resident 59 stated that chicken was too dry.

During an interview on 08/13/24 at 11:33 a.m. with Resident 41, Resident 41 stated, Food is bad and sometimes cold.

A test tray evaluation was conducted due to resident complaints on 8/13/24 at 1:39 p.m. with Registered Dietician (RD) and Dietary Supervisor (DS) for the regular and puree meals. The meal was tested for taste, temperature, and palatability. The chicken and vegetables for both textures tasted bland. The pureed chicken was dry. The pureed bread was bland. The food temperatures were: pureed vegetables, 114.1 Fahrenheit (F, unit of temperature measurement), pureed bread, 118 F, pureed chicken 113.9 F, pureed rice, 117.4 F, regular chicken 112.9 F, regular rice, 116.5 F, and cold milk, 50.8 F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 0804 A review of facility document titled In-Service Meeting Minutes dated 4/12/24, indicated, RD was the lecturer of the in-service with the topic Food Temperature/Danger Zone. Summary of lecture indicated, Discussed Level of Harm - Minimal harm or temperature danger zone, hot and cold temps for food safety. Food temps prior to food service and proper potential for actual harm reheating techniques. The document indicated, Cold food items need to be at 41 or below. Hot food items need to be at 135 or above. Residents Affected - Some According to the New Dining Practice Standards dated in 2011 by the [NAME] Regulatory Task Force, food and dining requirements are core components of quality of life and quality of care in nursing homes .

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49345

Residents Affected - Many Based on observation, interview and record review, the facility failed to store and prepare food under sanitary conditions in accordance with professional standards when:

1. Steel trays with black stains were found inside the kitchen freezer;

2. The ice machine had black substance build up found inside and yellow stain on the baffle;

3. Dietary staffs did not wear hairnet/beard restraints while inside the facility kitchen and;

4. Facility did not follow their policy and procedure regarding labeling of foods brought in by family or visitors for one out of two sampled residents (Resident 237).

These failures had the potential to expose residents to contaminants that could cause foodborne illness.

Findings:

1. During the initial kitchen tour on 8/12/24 at 9:44 a.m. with Dietary Supervisor (DS), two steel trays with visible black stains on the edges were found inside the facility freezer. DS took out the trays from the freezer.

A review of facility's policy and procedure titled Sanitization revised October 2008, the P& P indicated, 2. All utensils, counters, shelves and equipment shall be kept clean and maintained in good repair

2. During a concurrent observation and interview on 8/12/24 at 2:15 p.m. with Registered Dietician (RD), the facility ice machine had black substance build up inside. RD stated that housekeeping department cleans the ice machine once every month and a contracted company comes every six months to check and clean the ice machine as per manufacturer guidelines.

During a concurrent observation and interview on 8/12/24 at 2:41 p.m. with Housekeeping Manager (HKM) and Maintenance Supervisor (MS), HKM opened the top part of the ice machine and took out the baffle. HKM and MS confirmed yellow stain and black substance build up were observed along the edges of the baffle. HKM stated that housekeeping department cleans the ice machine once a month.

A review of facility's policy and procedure (P&P) titled Sanitization revised October 2008, P&P indicated, Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy

3. During an observation on 8/12/24 at 2:03 p.m. with DS in the facility kitchen, DS confirmed Dietary [NAME] (DC) E, had a head cap on and hair was not fully covered, Dietary Aide (DA) J wore a head cap, long hair in loose braid without hairnet and Dietary Aide (DA) F had facial beard exposed without covering. DS stated

they should have worn a hairnet and beard must be covered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 During an interview on 8/12/24 at 2:22 p.m. with DA F, DA F stated Sometimes, I forget to cover my beard.

Level of Harm - Minimal harm or A review of facility document titled In-Service Meeting Minutes dated 4/12/24, indicated, RD was the lecturer potential for actual harm of the in-service with the topic Hair Restraint and Fingernail/Hand Hygiene. Summary of lecture indicated, Proper use of hairnets, caps, and beardguards during food prep, service and all duties within the kitchen. Residents Affected - Many Appropriate fingernail length and coatings. The document also indicated, .Hairnets or other hair restraints need to cover all hair to prevent it falling into food and other contact surfaces. Hat comes off hairnet goes on!!! .Staff who have facial hair need to wear a beard restraint. DC E, DA J and DA F were listed as attendees of the in-service.

A review of facility's policy and procedure (P&P) titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices revised October 2017, the P&P indicated, 12. Hair nets, caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

4. During a concurrent observation and interview on 8/19/24 at 10:39 a.m. with Licensed Vocational Nurse (LVN) K of a facility refrigerator which stored foods brought-in by resident's relatives, LVN K confirmed a re-sealable bag of cooked French fries had a written date of 8/17/24 and Resident 237's name. LVN K also confirmed another re-sealable bag of cooked chicken strips with written date of 8/17/24 had Resident 237's name. LVN K stated the written date on both bags was the date on when it was received. LVN K stated they usually keep brought- in foods for three days.

During a concurrent interview and record review on 8/19/24 at 2:37 p.m. with Director of Nursing (DON), DON confirmed that according to facility's policy and procedure regarding brought-in foods, brought-in foods should be labeled with the date on when it should be discarded. DON agreed they should follow the facility policy and procedure.

A review of facility's policy and procedure (P&P) title Foods Brought by Family/Visitors revised December 2021, the P&P indicated, Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the 'use by' date (maximum of 72 hours).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 44583 potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control practices Residents Affected - Some 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. Registered nurse I (RN I) did not follow manufacturer's instructions for disinfecting the glucometer (device used to check blood sugar levels); and

7. Nursing Assistant (NA) P did not do hand hygiene in between residents' assistance during lunch.

These failures had the potential to compromise resident's health and safety in the facility.

Findings:

1. During observation of lunch tray distribution on 8/12/2024 at 12:52 p.m., at the hallway, CNA N touched, and pushed the food cart then, parked it in front of Resident 42's room. CNA N touched and opened the food cart, took out Resident 42's lunch tray without performing hand hygiene. CNA N delivered the lunch tray and set it up for Resident 42. At 12:53 p.m., CNA N touched the food cart, pull it in front of Resident 189's room. CNA N took Resident 189's lunch tray without performing hand hygiene and served it to Resident 189. At 12:54 p.m., CNA N and CNA O touched, pushed the food cart, and parked in front of Resident 187's room. CNA N prepared coffee without performing hand hygiene. CNA O took Resident 187's lunch tray and served

it to Resident 187 without performing hand hygiene.

During an interview with CNA N on 8/12/2024 at 12:54 p.m., CNA N confirmed above observation and stated

she should have performed hand hygiene before she touched Resident 42 and Resident 189's lunch tray. CNA N further stated she should have performed hand hygiene before she prepared coffee because food cart could be dirty.

During an interview with CNA O on 8/12/2024 at 12:58 p.m., CNA O confirmed above observation and stated, I should have sanitized my hands before touching [Resident 187's] lunch tray.

During an interview with infection preventionist (IP) on 8/16/2024 at 1:55 p.m., IP stated hand hygiene should be performed in between residents and after staff touched a possible dirty area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, date revised October 2023, indicated, The facility considers hand hygiene the primary means to prevent the spread of Level of Harm - Minimal harm or healthcare-associated infections .All personnel are expected to adhere to hand hygiene policies and potential for actual harm practices to help prevent the spread of infections to other personnel, residents, and visitors.

Residents Affected - Some 2. During an observation on 8/12/2024 at 9:58 a.m., inside Resident 187's room, Resident 187 was awake but observed to be confused. Resident 187's nebulizer's mask was placed on top of Resident 187's bedside drawer. There was no date labeled in the nebulizer kit (tubing, mask, nebulizing chamber.

During a concurrent observation and interview with registered nurse M (RN M) on 8/12/2024 at 11:05 a.m., inside Resident 187's room, RN M confirmed above observation. RN M stated nurses should have rinsed the nebulizer kit, airdried and stored inside a bag when not in used. RN M confirmed the nebulizer kit was undated and there was no nebulizer kit bag available in Resident 187's bed side drawer. RN M stated they should change the nebulizer kit once a week.

During an interview with IP on 8/16/2024 at 1:55 p.m., IP stated the nebulizer kit should be changed once a week. IP further stated the nebulizer kit should be stored in a black mesh bag when not in used and the black mesh bag should be changed monthly.

During an interview with director of nursing (DON) on 8/19/2024 at 2:13 p.m., DON stated the nebulizer kit should be changed once a week or as needed when visibly soiled. DON further stated the nebulizer kit should have been stored in a bag and the bag should be changed once a month.

During a review of the facility's policy and procedure titled, Cleaning and Disinfecting, date revised May 2023, indicated, .for medical devices and equipment, standard cleaning and disinfection procedures for healthcare facilities are practiced as recommended in the cleaning and disinfecting policies.

46553

3. During a medication pass observation on 8/13/24 at 10:22 a.m., with LVN C in Resident 58's room, LVN C took Resident 58's BP with a BP apparatus. LVN C did not disinfect the BP apparatus before and after using it.

During an interview with LVN C on 8/13/24 at 10:53 a.m., LVN C confirmed she did not disinfect the BP apparatus before and after using it on Resident 58. LVN C stated she was supposed to disinfect it with a disinfectant wipe before and after using it.

During an interview with the infection preventionist (IP) on 8/19/24 at 10:51 a.m., the IP stated the nurses should disinfect the BP apparatus in between residents to prevent the spread of infection.

A review of the facility's policy and procedure titled Cleaning and Disinfecting, revised 5/2023, indicated, Non-disposable medical equipment used for that resident is cleaned and disinfected according to the manufacturer's instruction and facility policies before use on another resident.

4. During an observation on 8/12/24 at 9:53 a.m., Resident 238's nebulizer mask and tubing were on the resident's bedside table. The mask and tubing were dated 7/2/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 During a concurrent observation and interview with LVN C on 8/12/24 at 1:01 p.m., LVN C verified Resident 238's nebulizer mask and tubing were outdated. LVN C stated the mask and tubing should be changed every Level of Harm - Minimal harm or week and as needed. LVN C stated these items should be stored in a plastic bag when not in use. potential for actual harm 5. During an observation on 8/12/24 at 9:29 a.m., Resident 50 was lying in bed receiving oxygen. The Residents Affected - Some humidifier bottle attached to the oxygen concentrator (a machine that supplies oxygen) was on the floor.

During a concurrent observation and interview with LVN C on 8/12/24, at 10:41 a.m., LVN C verified Resident 50's oxygen humidifier bottle was on the floor. LVN C stated the humidifier bottle should not be on

the floor.

Review of the facility's policy and procedure titled Cleaning and Disinfecting, revised 5/2023, indicated, Standard cleaning and disinfection practices in accordance with the Centers for Disease Control and Prevention, measures are implemented when areas, material or equipment have likely been contaminated.

6. During a medication pass observation on 8/13/24 at 4:42 p.m., RN I removed a glucometer from the medication cart. RN I cleaned the glucometer with an alcohol swab and checked Resident 189's blood sugar.

After checking Resident 189's blood sugar, RN I removed a wipe from a container with a lavender-colored top and wiped the glucometer. The container indicated the product was Micro Kill One Germicidal Alcohol Wipes.

During an interview with RN I on 8/13/24 at 4:54 p.m., RN I confirmed she wiped the glucometer with an alcohol swab before using it and used Micro Kill One Germicidal Alcohol Wipes to disinfect the glucometer afterwards.

During an interview with the IP on 8/19/24 at 10:54 a.m., the IP stated the glucometer should have been disinfected with an EPA-registered product, such as Clorox (a specific brand of disinfectant). The IP confirmed the facility did have Clorox wipes, which were in a container with a blue top.

The manufacturer's instructions for the facility's glucometer, dated 10/2023, indicated to obtain a commercially available EPA-registered disinfectant or germicidal wipe and clean/disinfect the glucometer by following step-by-step instructions.

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7. During dining observation on 8/12/24 at 12:35 p.m., NA P applied clothing protector to five residents without hand hygiene in between.

During dining observation at 8/12/24 at 12:46 p.m., NA P picked up something off the floor, put it on an empty tray and proceeded to clear out a table without doing hand hygiene.

During an interview on 8/12/24 at 1:02 p.m. with NA P, NA P confirmed hand hygiene was not done in between assisting residents with clothing protector, and right after picking up something off the floor. NA P stated hand hygiene should have been done in both instances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 A review of facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene revised October 2023,

the P&P indicated, .Hand hygiene is indicated: a. immediately before touching a resident; .c. after contact Level of Harm - Minimal harm or with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's potential for actual harm environment;

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44583

Residents Affected - Many Based on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident.

Findings:

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 3 beds, 77.7 square feet per resident

room [ROOM NUMBER], 2 beds, 74 square feet per resident

room [ROOM NUMBER], 3 beds, 77.7 square feet per resident

room [ROOM NUMBER], 2 beds, 76 square feet per resident

room [ROOM NUMBER], 2 beds, 77 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 3 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 70 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 71 square feet per resident

room [ROOM NUMBER], 3 beds, 74 square feet per resident

room [ROOM NUMBER], 3 beds, 74 square feet per resident

room [ROOM NUMBER], 3 beds, 74 square feet per resident

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 055240 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055240 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Watsonville Nursing Center 535 Auto Center Drive 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 0912 room [ROOM NUMBER], 2 beds, 76 square feet per resident

Level of Harm - Potential for room [ROOM NUMBER], 3 beds, 78.5 square feet per resident minimal harm room [ROOM NUMBER], 2 beds, 71 square feet per resident Residents Affected - Many room [ROOM NUMBER], 3 beds, 72 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 3 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 3 beds, 72 square feet per resident

room [ROOM NUMBER], 2 beds, 73 square feet per resident

room [ROOM NUMBER], 3 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 70.8 square feet per resident

room [ROOM NUMBER], 3 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 70.8 square feet per resident

room [ROOM NUMBER], 3 beds, 73 square feet per resident

room [ROOM NUMBER], 2 beds, 70.8 square feet per resident

room [ROOM NUMBER], 3 beds, 70.5 square feet per resident

room [ROOM NUMBER], 3 beds, 72.3 square feet per resident

During multiple observations on 8/12/2024 to 8/19/2024, none of the rooms were observed to inhibit the staff providing care. The staff and the residents moved freely in the rooms. The residents and staff stated the square footage of the rooms was not a concern.

Continuance of the room waiver is recommended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 055240