Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dept Of State Hospitals - Napa D/p Snf during CMS and state inspections, most recent first.
Inaccurate MDS assessments were submitted for multiple residents when documented diagnoses, treatments, PASRR status, feeding tube use, language needs, and medication use were not reflected on the MDS. Records showed omissions for psychotic disorder, hospice, TBI, hemiplegia, anticonvulsant therapy, viral hepatitis treatment, PASRR Level II serious mental illness, peg-tube use, hip fracture, and Vietnamese language/interpreter needs, and the MDSC confirmed the data were inaccurate.
Food safety practices were not followed when multiple items in the satellite kitchen and main kitchen were found unlabeled, undated, or expired, including sherbet, ice cream, cooked rice, tofu, egg salad, and turkey breast. A refrigerator in the satellite kitchen was also measured at 48 F while breakfast food for the next day was stored inside, and a scoop was left in a bin of thickener.
Incomplete Facility Assessment: The facility’s Facility Assessment was reviewed and found to be missing key components, including a data-driven staffing plan based on resident acuity and care needs, documentation of participation by leadership, direct care staff, and resident/family representatives, staffing contingency planning for emergencies or shortages, and ongoing evaluation of competencies and resources needed for behavioral health services. The AED and SCD confirmed the missing elements, and the AED stated the assessment needed to be updated.
QAPI Program Failed to Track MDS Errors and Ongoing Legionella Detection. The facility did not identify, monitor, or correct facility-wide issues involving inaccurate MDS submissions and continued legionella pneumophila detection in the kitchen cooling tower. The MDSC was unfamiliar with PASRR and could not explain inaccurate assessments submitted for most residents reviewed, while the DON was unaware of the errors. Quality Council minutes showed no PIP, audit findings, trend review, or tracking for either the MDS issue or the ongoing legionella findings, and the DON stated these issues had not been identified or tracked in QAPI.
Infection control practices were not followed when Legionella remained detected in a kitchen cooling tower without documented remediation, PPE was not kept immediately outside the rooms of residents on EBP, and an LVN administered G-tube medications to a resident without the required gown and gloves. The resident had a feeding tube, and staff confirmed the PPE and EBP requirements were not followed.
Unsafe courtyard conditions and damaged day hall walls were observed when a pothole and a large uneven surface were found in the courtyard and multiple wall areas had deep gouges exposing drywall. The SRN confirmed the courtyard was accessible to all residents, including wheelchair users and a resident who used a walker, and the POS stated he was unaware of the damage and no work order had been submitted.
The facility failed to submit a quarterly MDS transmission within the required timeframe for a resident with dysphagia and total care needs. The MDSC acknowledged the assessment should have been sent within 14 days after the ARD, and the DON stated she was unaware of late submissions, although they should have been submitted timely.
Failure to Complete PASRR Screenings for Multiple Residents With Psychiatric Diagnoses The facility failed to submit federally mandated PASRR Level I screenings for seven residents with diagnoses including schizophrenia, schizoaffective disorder, psychotic disorder, depressive disorder, hallucinations, and neurocognitive disorder. During record review and interview, the SW confirmed the DHCS portal showed missing Level I submissions for these residents and stated she did not know why the screenings were not submitted. The PASRR overview noted that a Level I screening, Level II evaluation if needed, and a determination are required for NF admissions.
A resident with dysphagia and total care needs was observed sitting upright in bed while a PTA stood over him and fed him dinner. The PTA stated she normally fed residents this way, while the DON said staff should be at eye level for dignity and respect. The facility policy for dysphagia also directed staff to position at eye level during feeding, and the resident's care plan called for staff to assist with all meals.
Call Light Left Out of Reach: A resident with spastic quadriparesis who required total assistance for transfers and ADLs was observed in bed with an E-Z call light placed on the bedside table and out of reach. An RN confirmed it was not within reach, and the DON acknowledged the resident could have an urgent need between hourly rounds and be unable to request help promptly.
Unnecessary Use of All Four Side Rails: A PTA raised all four side rails on a resident’s bed after feeding the resident and lowering the HOB. The resident had dementia, spastic quadriplegia, and required total care. The DON stated there was no MD order for restraints and that all side rails up was considered a restraint; the facility policy also identified side rails as a form of medical restraint requiring an MD order.
Failure to complete a SCSA after a resident with COPD, CHF, dysphagia, and a PEG tube experienced increased behaviors, significant weight loss, and a hospitalization for lethargy, hypernatremia, dehydration, AKI, and acute metabolic encephalopathy. The MDSC acknowledged the decline and said the SCSA should have been completed, while the DON stated it was expected when a significant decline was identified.
Pressure-relieving equipment was not properly implemented for two residents at high risk for pressure ulcers. One resident with spastic quadriplegia and total care needs had a mattress setting that matched a much higher weight than his recorded weight, and another resident with dementia and inability to stand or walk had a mattress setting above her recorded weight. RN 2 stated the settings were incorrect and said she did not know how to change them or had not been trained on the mattresses, while the DON stated staff were expected to match settings to the resident’s most accurate weight.
Inaccurate and Untimely MDS Assessments: The MDSC did not demonstrate competency to accurately complete federally mandated resident assessments. Survey review found inaccurate MDS coding for multiple residents, one late quarterly assessment transmittal, and one missed significant change assessment after a decline was identified. The MDSC stated she had no prior MDS training before taking the role and only received a brief training course, while the DON said she did not review the assessments for accuracy.
Pureed Meal Served in an Unappetizing Manner: A resident with dementia, dysphagia, and total care needs was observed receiving a dinner tray with multiple pureed items. An PTA mixed three beige pureed foods together before feeding the resident and then added some of the mixture to vanilla ice cream. The PTA confirmed the action, while the DON and RD stated that mixing pureed foods together was not appetizing and the facility policy called for food to be presented in an attractive manner.
Surveyors found that staff failed to provide continuous enhanced 1:1 supervision for two residents who had MD orders for close observation due to self-injurious behavior and safety concerns. On separate occasions, PTAs assigned to 1:1 observation were seen or reported with their eyes closed, and one was described as sleeping, after working double shifts and while also orienting another PTA. These lapses occurred despite a facility policy requiring enhanced observation to promote patient and staff safety when less restrictive measures were ineffective.
A CNA did not complete required annual training on abuse, neglect, and exploitation according to facility policy, with records showing missed trainings for two consecutive years. The Standards Director confirmed the staff member's training was not current and out of compliance.
A Food Service Technician did not perform hand hygiene or change gloves between handling an ice scooper and serving ice, despite moving between clean and dirty areas. Both the Food Service Supervisor and the technician acknowledged that handwashing should have occurred to prevent cross contamination, in accordance with facility policy.
Staff failed to use required gowns and gloves while providing personal hygiene care to a resident on Enhanced Barrier Precautions due to a suprapubic catheter, and a nurse did not use sterile technique or disinfect the catheter port during irrigation for another resident with a history of neurogenic bladder and repeated UTIs. Both instances were observed and confirmed by facility staff and were not in accordance with facility policy.
The facility failed to secure a medication room, allowing unauthorized access to medications. Observations showed that the medication refrigerator was unlocked, and unlicensed staff had access to keys. Additionally, keys to medication carts were not securely stored, and staff took keys home, risking unauthorized access.
The facility failed to secure medication carts and remove expired medical supplies. A medication cart was repeatedly left unlocked in a room accessible to unlicensed staff, contrary to policy requiring secure storage. Additionally, expired medical supplies were found in stock, which should have been returned to Central Supply.
The facility failed to maintain proper food storage and labeling, with unlabeled and undated meat and tortillas found in the kitchen. Water temperatures were below required levels, affecting sanitation. A can opener was found dirty, and staff food was improperly stored with patient food, posing risks to the skilled nursing population.
A resident with multiple pain-related diagnoses reported ineffective pain management. The facility failed to document required weekly pain assessments and left the Pain Management Flowsheet blank, despite the resident receiving routine narcotics. The Medication and Treatment Record showed no documentation of medication effectiveness, violating the facility's pain management policy.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to submit accurate MDS data for 8 of 13 sampled residents when the assessments did not reflect information documented in the residents’ treatment plans and records. During a concurrent interview and record review with the MDSC and DON, the most recent MDS assessments for Residents 1, 2, 3, 7, 15, 16, 17, and 21 were compared with their treatment plans and other supporting documents, and multiple discrepancies were identified across diagnoses, treatments, and resident characteristics. Resident 1’s treatment plan documented psychotic disorder, but the quarterly MDS did not list that diagnosis in Section I. Resident 2’s treatment plan documented hospice care, but the quarterly MDS did not indicate hospice in Section O. Resident 3’s treatment plan documented TBI and hemiplegia, but the comprehensive MDS did not show hemiplegia in Section I and instead listed a different primary reason for admission. Resident 7’s treatment plan documented valproic acid twice daily, but the quarterly MDS did not code an anticonvulsant in Section N. Resident 15’s treatment plan documented daily entecavir for viral hepatitis, but the quarterly MDS did not show an active viral hepatitis infection in Section I. Resident 16’s treatment plan documented peg-tube medication administration and the PASRR Determination Letter showed a Level II PASRR finding of serious mental illness, but the comprehensive MDS did not indicate PASRR Level II serious mental illness in Section A and did not code a peg-tube in Section K. Resident 17’s treatment plan documented valproic acid twice daily and an old left hip fracture with related functional limitations, but the quarterly MDS did not code an anticonvulsant in Section N or a hip fracture in Section I. Resident 21’s treatment plan documented Vietnamese as the primary language, need for an interpreter, and diagnoses of Alzheimer’s Disease, dementia, and depression, but the quarterly MDS listed English as the primary language, did not indicate an interpreter was needed, and did not code those diagnoses in Section I. The MDSC confirmed the assessments contained inaccurate data, stated the treatment plans were accurate, and said she made mistakes and was not comfortable in her position or sufficiently trained to complete the assessments accurately; the DON stated she was unaware of the inaccuracies and that the MDS should have reflected the residents’ status.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
Food safety and sanitation guidelines were not followed in the satellite kitchen and main kitchen when multiple food items were found unlabeled, undated, or expired. In the satellite kitchen, six cups of sherbet and six cups of ice cream were observed without labels or dates in the freezer, one cup of cooked rice dated 5/3/26 and two cups of tofu dated 5/5/26 were found in the refrigerator past the facility’s five-day limit, and six cups of egg salad were stored without labels or dates. The Food Service Technician confirmed the items should have been labeled and dated and stated the rice and tofu had expired under facility guidelines. During the same observation, the two-door refrigerator in the satellite kitchen was measured at 48 degrees Fahrenheit and remained at that temperature on repeat checks, while residents’ breakfast in hotel pans for the next day was stored inside. The Director of Dietetics stated refrigerated food must be held at 41 degrees Fahrenheit or below and that 48 degrees was not safe for storing food. In the main kitchen, one package of oven roasted turkey breast was found unlabeled and undated in the walk-in cooler, and a scoop was stored inside a food bin labeled Thickener. Supervising staff and the Assistant Director of Dietetics confirmed the turkey breast should not have been stored without proper labeling and dating, and that leaving a scoop in the thickener could result in food contamination.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to develop and maintain a comprehensive, data-driven facility assessment that accurately identified the resources necessary to care for its resident population. During a concurrent interview and record review with the Assistant Executive Director and Standards Compliance Director, the Facility Assessment dated 2026 was reviewed and found to be missing several key components, including a data-driven staffing plan based on resident acuity and care needs, documentation of participation by leadership, direct care staff, and resident/family representatives, assessment of staffing contingency plans during emergencies or staffing shortages, and ongoing evaluation of competencies and resources needed to provide behavioral health services to the facility’s specialized resident populations. The AED and SCD confirmed that multiple key components were missing, and the AED stated the Facility Assessment needed to be updated.
QAPI Program Failed to Track MDS Errors and Ongoing Legionella Detection
Penalty
Summary
The facility failed to ensure its QAPI program was comprehensive and data-driven when it did not identify, monitor, or correct facility-wide non-compliance involving inaccurate MDS submissions and continued detection of legionella pneumophila in the kitchen cooling tower. During a concurrent observation and interview, the list of all SNF residents in iQIES showed 16 of 22 residents as not having the mandatory PASRR level II evaluations. The MDS Coordinator stated she was not familiar with PASRR and could not explain the inaccuracies in the patient assessments she submitted, and the DON confirmed she oversaw the MDS Coordinator but was not aware that inaccurate assessments had been submitted for 16 of 22 residents. Review of the facility’s Quality Council meeting minutes for the prior three quarters showed no PIP was initiated to address inaccurate resident assessment submissions for SNF residents. There was also no evidence of MDS audit findings, tracking of error rates, or trend review by the committee. During interview, the DON stated she was responsible for identifying issues affecting SNF residents that required improvement and developing PIPs for QAPI, but her focus in the prior year had been limited to 2025 recertification survey findings related to staff annual health exams and staff performance reviews. She stated that because she was unaware inaccurate resident assessments were being transmitted, the issue had not been identified or tracked in QAPI. The facility also had ongoing legionella pneumophila detection in the kitchen cooling tower. A review of legionella test results showed the bacteria was still detected, with a recommendation that the kitchen cooling tower persisted in testing positive and that the Waste Management Program procedure dictated further remediation. Quality Council minutes for the prior three quarters showed no PIP was initiated for the ongoing detection, and there was no evidence of data tracking or remediation evaluations by Infection Prevention. The DON stated that the Infection Preventionist participated in Quality Council meetings, but the continued detection of legionella pneumophila had not been identified or tracked in QAPI.
Infection Control Failures With Legionella, EBP PPE Access, and G-Tube Care
Penalty
Summary
The facility failed to implement infection prevention and control practices when remediation was not documented after Legionella pneumophila was detected in the kitchen cooling tower. Legionella test results dated 11/5/25 showed the organism was detected in the kitchen cooling tower, with a recommendation to take the tower offline and physically clean it. A later test dated 3/5/26 still showed Legionella pneumophila in the same cooling tower, and the Chief of Plant Operations stated that remediation would have required emptying the tower, adding chemicals, and retesting, but there was no documentation that remediation had been completed after the initial positive result. The facility also did not have PPE immediately available outside the rooms of 12 residents who were on Enhanced Barrier Precautions. During observation on Unit A4, PPE was stored inside a locked supply room rather than outside the rooms of residents on EBP. The Infection Preventionist confirmed that gowns and gloves were not available immediately outside the rooms as required for EBP and acknowledged that residents on EBP are vulnerable and at increased risk for infection and serious infection-related complications. In addition, an LVN administered medications to a resident via G-tube without wearing a gown and gloves even though an EBP sign above the bed indicated that gown and gloves were required for high-contact care activities. The resident’s MDS documented a feeding tube, and the LVN acknowledged that PPE should have been worn during G-tube medication administration. The Infection Preventionists stated that EBP is intended for residents with indwelling devices or wounds and that gown and glove use is the minimum PPE required for feeding tube care.
Unsafe Courtyard and Damaged Day Hall Walls
Penalty
Summary
The facility failed to maintain the environment in a safe, comfortable, and functional condition when a pothole and a large area of uneven surface were observed in the courtyard. During a concurrent observation and interview, the Supervising Registered Nurse confirmed the courtyard condition and stated the unit census was 20 residents, including 10 residents who use wheelchairs and can self-propel and one resident who used a walker for mobility. The nurse also confirmed that all residents in the unit had access to the courtyard. Multiple walls in the day hall were also observed to have deep gouges exposing the drywall. The Plant Operations Supervisor confirmed the damaged wall areas, estimating the gouges exposed drywall for approximately 20 feet in total length, and stated he was not aware of the damage. He further confirmed that no work order had been submitted for repair. A review of the facility's Maintenance Services policy stated the facility is to provide patients, staff, and visitors with a safe and healthy environment and maintain infrastructure safely and consistently, and the Rights of LPS Patients policy stated patients have the right to decent living conditions in facilities that are physically safe, sanitary, and conducive to treatment.
Untimely Quarterly MDS Transmission
Penalty
Summary
The facility failed to ensure that a quarterly MDS transmittal was submitted within 14 days after the ARD for one sampled resident. Resident 15 was admitted with diagnoses including dysphagia and need for total care. Review of the resident’s quarterly MDS showed an ARD of 1/30/26, but the assessment was not submitted until 2/26/26. During interview and record review, the MDSC stated the assessment should have been submitted within 14 days after the ARD, and the DON stated she was unaware of any resident assessments being submitted late, but they should have been submitted timely. CMS LTCF RAI 3.0 User’s Manual states quarterly transmission is due no later than MDS completion date plus 14 calendar days.
Failure to Complete PASRR Screenings for Residents With Mental Health and Neurocognitive Diagnoses
Penalty
Summary
The facility failed to ensure completion and submission of federally mandated PASRR Level I screenings for seven sampled residents. During record review, Resident 1 was documented as having major neurocognitive disorder, personality change, psychotic disorder, and hallucinations; Resident 3 had schizophrenia and major neurocognitive disorder; Resident 4 had psychotic disorder, hallucinations, neurocognitive disorder, and pedophilic disorder; Resident 5 had schizoaffective disorder, bipolar type; Resident 8 had schizophrenia and paraphilic disorder; Resident 11 had schizoaffective disorder, bipolar type; and Resident 21 had depressive disorder and neurocognitive disorder. During a concurrent interview and record review with the Social Worker, the DHCS Application portal was reviewed and showed that five residents had PASRR screenings I and II, but Residents 1, 3, 4, 5, 8, 11, and 21 did not have PASRR Level I screenings submitted. The Social Worker stated she did not know why she did not submit a PASRR Level I Screening for Residents 1, 3, 4, 5, 8, 11, 20, and 21. The PASRR General Overview stated that all Medicaid-certified SNFs are subject to the PASRR process and that a Level I screening, a Level II evaluation if needed, and a determination must be completed for anyone being admitted to a NF.
Resident Fed While Staff Stood Over Him
Penalty
Summary
The facility failed to ensure staff maintained a resident's dignity and provided care in a respectful manner when Psychiatric Technician Assistant 1 stood over Resident 15 while feeding him dinner. Resident 15's Treatment Plan showed he was admitted with dysphagia and required total care, and his Nursing Care Plan directed nursing staff to assist with feeding at all meals. During an observation in the resident's room, Resident 15 was sitting upright in bed while PTA 1 stood at bedside and fed him dinner. When interviewed, PTA 1 stated she normally stood over residents while feeding them. The DON later stated it was not normal for staff to stand while feeding a resident and that staff should be at eye level for dignity and respect. The facility's Dysphagia/Choking Screen policy also directed staff to position at eye level when assisting with feeding, and the Rights of LPS Patients policy identified a right to dignity.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 6’s call light was within reach. Resident 6’s Treatment Plan, dated 2/24/26, indicated that the resident was admitted with spastic quadriparesis and required total assistance from staff for transfers and activities of daily living. During a concurrent observation and interview on 5/12/26 at 9:24 AM, Resident 6 was observed lying in bed with an E-Z call light placed on the bedside table and out of reach. RN 1 confirmed that the call light was out of Resident 6’s reach. During an interview on 5/13/26 at 3:08 PM, the DON confirmed that even with hourly rounding, Resident 6 could still have an urgent need for assistance between checks and that being unable to reach the call light placed the resident at risk for delayed and unmet urgent care needs. The facility’s policy titled Rights of LPS Patients, dated 5/26/25, stated that the facility is to protect and promote patients’ legal rights and identified prompt medical care and treatment as a non-deniable right.
Unnecessary Use of All Four Side Rails
Penalty
Summary
The facility failed to ensure that Resident 15 was free from unnecessary physical restraints when Psychiatric Technician Assistant (PTA) 1 raised all four side rails on the resident’s bed before leaving the room. Resident 15’s treatment plan dated 4/14/26 identified diagnoses including dementia, spastic quadriplegia, and need for total care. During a concurrent observation and interview on 5/11/26 at 5:57 PM, Resident 15 was sitting upright in bed with two upper side rails already raised. After PTA 1 finished feeding the resident dinner and lowered the head of the bed, she raised the two lower side rails as well, resulting in all four side rails being up. During an interview on 5/13/26 at 3:08 PM, the DON stated Resident 15 did not have a physician’s order for restraints and that no residents were allowed to have all side rails up because it was considered a restraint. The DON further stated residents should never be restrained in their bed. The facility policy titled Medical Restraint, dated 1/27/25, stated restraints shall be used only when less restrictive assistive devices have not been successful, shall never be used for patient discipline or staff convenience, and require a physician’s order; side rails were listed as an acceptable form of medical restraint.
Failure to Complete Significant Change Assessment After Major Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment for one of three sampled residents after the resident experienced a major decline in multiple areas of health status. The resident had diagnoses of COPD, CHF, dysphagia with a PEG tube, and the record showed increasing behavioral incidents, including one incident in January 2026, two in February 2026, and 12 incidents from 3/9/26 to 4/1/26. The resident also had a 7.3 lb weight loss in one month and was hospitalized for lethargy, hypernatremia, dehydration, acute kidney injury, and acute metabolic encephalopathy, requiring a four-day hospital stay and medical intervention. During interview and record review, the MDS Coordinator stated she was aware of the increased behaviors, weight loss, and hospitalization and said she should have completed a SCSA in April 2026. The DON stated the expectation was for the MDS Coordinator to complete a SCSA when the resident was identified to have a significant decline and submit it timely. The resident’s most current quarterly MDS, dated 3/12/26, still indicated only physical and verbal behavioral symptoms toward others 1 to 3 days and no weight loss within the past six months, despite the later documented decline.
Pressure-Reducing Mattresses Not Set to Residents’ Accurate Weights
Penalty
Summary
The facility failed to ensure pressure-relieving equipment was properly implemented for two sampled residents, Resident 15 and Resident 21, when their pressure-reducing mattresses were not set to their accurate weights in accordance with the manufacturer’s instructions. Resident 15’s treatment plan identified diagnoses including spastic quadriplegia, total care needs, and high risk for pressure ulcers. During observation, Resident 15’s mattress was set to setting 5, which corresponded to 210-244 lbs., while the resident’s most recent recorded weight was 166.2 lbs. RN 2 stated the setting was not correct because it did not reflect the resident’s actual weight and said she did not know how to change it or receive training on the mattress. Resident 21’s treatment plan identified diagnoses including dementia, high risk for pressure ulcers, and inability to stand or walk. During observation, Resident 21’s mattress was set to setting 2, which corresponded to 105-139 lbs., while the resident’s most recent recorded weight was 97.2 lbs. RN 2 stated the setting was not correct because the resident weighed less than 105 lbs. and said she did not know how to change the setting or receive training on the mattress. The DON stated staff had received training multiple times on operating the pressure-reducing mattresses and that the expectation was to match the mattress setting to the resident’s most accurate weight. The manufacturer’s quick reference card instructed staff to set the comfort pressure by selecting the number corresponding closest to the patient’s weight.
Inaccurate and Untimely MDS Assessments
Penalty
Summary
The facility failed to ensure the MDS Coordinator Nurse possessed and demonstrated competency to accurately complete federally mandated resident assessments. Based on interview and record review, eight of 13 sampled residents had inaccurate MDS coding, one resident had untimely transmittal of a quarterly resident assessment, and one resident did not have a significant change in status assessment after a decline was identified. These findings were identified during survey review of resident assessments and related records. During interview, the MDSC stated she began working in the role in 2017, had no prior MDS training before taking the position, and had only received a two-day training course that she believed was not sufficient. She also stated she was not fully comfortable or confident completing resident assessments. The DON stated she oversaw the MDSC but did not check the resident assessments for accuracy because she believed she did not need to, and she confirmed the inaccurate assessments, late transmittal, and missed significant change assessment. Record review showed the MDSC completed 14 credited hours of MDS basic training, had no other MDS training, and had not had an adverse employee evaluation. The duty statement for the MDSC position required knowledge of MDS 3.0 and completion and transmission of admission, annual, quarterly, and significant change assessments.
Pureed Meal Served in an Unappetizing Manner
Penalty
Summary
Food was not served in a palatable and appetizing manner for one resident who had dementia, dysphagia, and required total care. During an observation in the resident's room, the resident was sitting upright in bed with a dinner tray that included one plate of unknown green pureed food, three Styrofoam cups each containing a different beige pureed food item, and one vanilla ice cream. Psychiatric Technician Assistant 1 mixed all three beige pureed food items together before feeding the resident, then took three spoonfuls of the mixed beige pureed food and added it to the vanilla ice cream. PTA 1 confirmed she mixed the resident's pureed dinner together and stated she normally does not mix pureed food together. The DON stated staff should not mix all pureed foods together because it would not be appetizing, and the RD stated mixing multiple pureed food items together would be a strange decision and does not sound appetizing. The facility policy stated quality food is to be presented in an attractive manner.
Failure to Provide Continuous 1:1 Supervision During Enhanced Observation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring of residents who were ordered to be on enhanced one-to-one (1:1) observation. During an observation in one resident’s room, a Psychiatric Technician Assistant (PTA 2) assigned to provide 1:1 supervision was seen with her eyes closed while on duty. In a subsequent interview, PTA 2 confirmed she was assigned to 1:1 observation for this resident, acknowledged that her eyes may have been closed at times during the observation, and stated she had worked a double shift from night to day shift and felt tired during the assignment. The resident’s clinical record showed a physician’s order placing the resident on 1:1 observation for self-injurious behavior. In a separate incident reported by another staff member (PTA 1), a different Psychiatric Technician Assistant (PTA 3) was observed sleeping while assigned to 1:1 supervision for another resident. PTA 1 stated she waved to PTA 3 but received no acknowledgment. In an interview, PTA 3 stated that on either one of two dates he had worked a double shift covering both night and day shifts and was also orienting a new PTA while performing 1:1 observation for the second resident. PTA 3 admitted that during this time he had his eyes closed, though he stated he was not asleep, and that the orientee called his name, prompting him to open his eyes. This occurred while the resident had an active physician’s order for 1:1 observation for safety of self and others. The facility’s policy on Enhanced Observation of Patients required time-limited enhanced observation to promote the safety of patients and staff when less restrictive interventions were ineffective or could not be safely or reasonably applied.
Failure to Complete Annual Abuse, Neglect, and Exploitation Training for Staff
Penalty
Summary
The facility failed to ensure that annual Abuse, Neglect, and Exploitation Training was completed for staff based on their anniversary or birth month, as required by facility policy. Review of a Certified Nursing Assistant's training record showed that mandated reporter training was not completed annually, with the last trainings documented outside of the required timeframes for two consecutive years. During an interview, the Standards Director confirmed that the staff member's abuse training was not current and had been out of compliance for the prior two years. The facility's policy requires all workforce members to complete annual training, but this was not followed in this instance.
Failure to Perform Hand Hygiene Between Food Handling Tasks
Penalty
Summary
A Food Service Technician (FST 2) failed to maintain sanitary conditions while handling food and utensils for a group of 23 residents. During an observation, FST 2 was seen pouring ice into a tray with gloved hands, then moving to the dishwasher area and placing an ice scooper through the dishwasher without changing gloves or performing hand hygiene. FST 2 then picked up the cleaned ice scooper with the same gloved hands and returned to scoop ice into a tray. Both the Food Service Supervisor and FST 2 acknowledged during interviews that handwashing should have occurred between these tasks to prevent cross contamination. Review of the facility's policy confirmed that thorough handwashing is required between handling dirty and clean dishes and utensils.
Failure to Implement Enhanced Barrier Precautions and Sterile Technique During Catheter Care
Penalty
Summary
The facility failed to follow safe infection control practices in two separate instances involving residents with indwelling urinary catheters. In the first instance, a resident with a suprapubic catheter and neurogenic bladder was placed on Enhanced Barrier Precautions (EBP), as indicated by a red marker at the room entrance and documented in the care plan. Despite this, three Psychiatric Technician Apprentices provided personal hygiene care to the resident without wearing the required gowns and gloves. Both a Nursing Instructor and a Registered Nurse confirmed that EBP was in place for this resident and that gowns and gloves should have been used during personal care, as outlined in the facility's EBP policy for residents with indwelling urinary catheters. In the second instance, a resident with a history of neurogenic bladder and repeated urinary tract infections, who had a suprapubic catheter, did not receive sterile technique during catheter irrigation. A Registered Nurse prepared irrigation solutions in non-sterile medication cups on a non-sterile surface and used non-sterile gloves and a non-sterile syringe to perform the procedure. The nurse also failed to disinfect the catheter port with an alcohol pad before irrigation. The Infection Control Nurse and facility policy confirmed that irrigation of a suprapubic catheter should be performed as a sterile procedure, following CDC guidelines, and that aseptic technique and disinfection of the port are required steps. These observed failures to implement EBP and sterile technique during high-risk care activities were confirmed through interviews, record reviews, and direct observation. The facility's own policies and procedures, as well as staff statements, supported that the required infection control measures were not followed in these cases.
Medication Room Security Breach
Penalty
Summary
The facility failed to maintain the security of a medication room, allowing unauthorized access to medications. During an observation, it was noted that the medication refrigerator containing various medications, including Trulicity, Ozempic, insulin, and vaccines, was not locked, making it readily accessible. Interviews revealed that unlicensed staff, such as a custodian, had keys that allowed access to the medication room, which contradicts the facility's policy that only licensed staff should have such access. Further investigation showed that keys to medication carts were not securely stored, with a key to a lockbox being hung on a push pin on a bulletin board. Additionally, the practice of staff taking keys home at the end of their shifts was confirmed to jeopardize key security, as unauthorized individuals could potentially access them. The facility's policy clearly states that keys should be held personally by licensed nursing personnel and not left unsecured or given to unauthorized individuals.
Medication Storage and Expired Supplies Deficiency
Penalty
Summary
The facility failed to ensure safe medication storage practices as per their policy and procedure. During multiple observations, a medication cart was found unlocked in the medication room, which was accessible to unlicensed staff. The Psychiatric Technician admitted to leaving the cart unlocked, and it was noted that unlicensed staff had access to the medication room, although only licensed staff had keys to the medication carts. Despite replacing the medication cart, it was again found unlocked by a Licensed Vocational Nurse, who acknowledged the oversight. The facility's policies clearly stated that medication carts should be securely locked, especially for controlled drugs, which should be behind two locks. Additionally, the facility did not remove expired medical supplies from stock, as observed during an inspection. Twelve expired Epump ENPlus Spike Sets were found in the medication room, with expiration dates that had already passed. The Psychiatric Technician confirmed that these expired supplies should have been returned to Central Supply. The Supervising Registered Nurse also stated that expired supplies should be removed and replaced according to the facility's policy, which mandates monitoring expiration dates and returning expired items to Central Supply.
Deficiencies in Food Storage, Equipment Cleaning, and Water Temperature
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the safe storage and labeling of food, maintenance of domestic hot water supply, cleaning of kitchen equipment, and separation of staff and patient food storage. Observations revealed that the water temperature in the main kitchen was consistently below the required range, with temperatures recorded at 74 and 76 degrees Fahrenheit, which is insufficient for proper cleaning and sanitation. Additionally, cooked meat was found in the main kitchen freezer unlabeled and undated, stored improperly in a grocery bag, and flour tortillas in the cooler were also unlabeled, indicating a lapse in food storage protocols. Further deficiencies were noted with the cleanliness of kitchen equipment, as a can opener was found with a black substance on its cutting wheel, contrary to the policy that requires cleaning after each use. Staff food was improperly stored in the patient freezer in the skilled nursing satellite kitchen, despite the availability of a separate staff fridge/freezer, which was reportedly not functioning adequately. These issues collectively posed a risk of foodborne illness and infection control problems for the vulnerable skilled nursing population.
Incomplete Pain Management Documentation for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for the pain management of a resident, identified as Resident 3. The resident had multiple diagnoses, including cervical myelopathy, polyneuropathy, degenerative joint disease, a history of patellectomy, and a left knee contracture, all of which contributed to their experience of pain. During an interview, the resident expressed that the pain medications provided were not effective. A review of the resident's clinical records revealed that the required weekly pain assessments were not documented after 4/4/24, despite the resident receiving routine narcotics. The facility's policy mandated weekly assessments for residents on scheduled narcotics, but no evidence of such assessments was found. Further investigation showed that the Pain Management Flowsheet, which should have documented the resident's pain assessments and the effectiveness of interventions, was left blank. The Psychiatric Technician confirmed that no charting was done on the flowsheet for scheduled pain medications. Additionally, the Medication and Treatment Record indicated that the resident was routinely administered acetaminophen, gabapentin, and tramadol, but there was no documentation of the effectiveness of these medications. The facility's policy required documentation of pain management within one hour of intervention, but this was not adhered to, leading to incomplete records of the resident's pain management.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 602 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Napa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Meadows Of Napa Valley | 1.7 mi | ★★★★★ | 0 | 0 |
| Piners Nursing Home | 3.5 mi | ★★★★★ | 40 | 0 |
| Napa Valley Care Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Napa Post Acute | 3.9 mi | ★★★★★ | 29 | 1 |
| Solano Post Acute | 9.8 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.