Dept of State Hospitals - Napa D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to submit accurate Minimum Data Set (MDS- a federally mandated assessment tool used to guide resident care) data for eight of 13 sampled residents (Residents 1, 2, 3, 7, 15, 16, 17, and 21) when the MDS did not reflect the following: 1. Resident 1 had a diagnosis of psychotic disorder (mental health condition that causes a person to lose touch with reality). 2. Resident 2 received hospice care (end-of-life care). 3. Resident 3 had diagnoses of Traumatic Brain Injury (TBI- damage to the brain caused by an outside physical force), dementia (decline in brain function that affects a person's memory and thinking skills) and hemiplegia (paralysis of one vertical half of the body). 4. Resident 7 received anticonvulsant (medication used to calm the brain) daily. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when:Six cups of sherbet were undated in the freezer of the satellite kitchen. Six cups of ice cream were undated in the freezer of the satellite kitchen. One cup of cooked rice was expired in the refrigerator of the satellite kitchen. Two cups of tofu were expired in the refrigerator of the satellite kitchen. Six cups of egg salad were unlabeled and undated in the refrigerator in the satellite kitchen. One refrigerator had a holding temperature of 48 degrees Fahrenheit, above the maximum temperature, in the satellite kitchen. One package of oven roasted turkey breast was unlabeled and undated in the cooler of the main kitchen. A scoop was stored in a food bin labeled Thickener in the main kitchen. [...]

Inspectors wroteBased on interview and record review, 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. These failures had the potential to result in insufficient staffing, unmet resident care needs, delayed interventions, and inability to safely provide services consistent with resident acuity and diagnoses.

Inspectors wroteBased on interview and record review, the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program was comprehensive and data-driven when the facility failed to identify, monitor, and correct facility-wide non-compliance in two areas:1. Ongoing inaccuracies in Minimum Data Set (MDS- standardized, federally mandated assessment tool used to evaluate the health, functional abilities and care needs of every patient in a skilled nursing facility) submissions were identified.2. Continued detection of legionella pneumophila (harmful bacteria causing Legionnaires' disease- type of serious infection in the lungs) in the kitchen cooling tower was not resolved. This deficient practice resulted in a lack of system-wide tracking, data analysis, and quality oversight for issues of non-compliance that affected 22 of 22 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices that protect residents from the spread of infectious diseases when:Remediation was not completed and documented after legionella pneumophila (harmful bacteria causing Legionnaires' disease- type of serious infection in the lungs) was detected in the kitchen cooling tower.12 of 12 residents (Residents 1, 2, 3, 5, 8, 10, 11, 12, 15, 16, 21, and 22 ) were on Enhanced Barrier Precaution (EBP-infection control intervention used to protect patients from the spread of multi-drug resistant organisms (MDROs- bacteria that are resistant to most antibiotics)) and did not have Personal Protective Equipment (PPE-specialized clothing or equipment used to reduce exposure to hazards or infections) available immediately outside the residents' rooms in accordance with The Center [...]

Inspectors wroteBased on observation and interview and record review, the facility failed to maintain the environment in a safe, comfortable, and functional condition for residents when: 1. One pothole and a large area of uneven surface was observed in the courtyard. 2. Multiple walls in the day hall with deep gouges exposing the drywall were observed. These failures had the potential to affect the safety and well-being of residents, staff, and visitors. During a concurrent observation and interview on 5/13/26 at 10:45 AM, with the Supervising Registered Nurse (SRN 1), of the courtyard, a pothole and a large area of uneven surface were identified. SRN 1 confirmed the presence of a pothole measuring approximately 1 foot by 2 feet, as well as a large area of uneven surface in the courtyard. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a transmittal of a quarterly Minimum Data Set (MDS- a federally mandated assessment tool used to guide resident care) was submitted no more than 14 days after the assessment reference date (ARD-the date the resident assessment was completed) for one of 13 sampled residents (Resident 15). This failure resulted in Resident 15's Quarterly MDS being submitted untimely.

Inspectors wroteBased on interview and record review, the facility failed to ensure completion and submission of federally mandated Preadmission Screening and Resident Review (PASRR- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) were completed for seven of 13 sampled residents (Resident 1, 3, 4, 5, 8, 11, and 21). These failures resulted in seven residents not receiving federally mandated evaluations and determinations, which could result in residents with serious mental illness' not receiving a standardized plan of care consistent with their assessed needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff maintained resident's dignity and provided care in a manner that was respectful for one of 13 sampled residents (Resident 15) when Psychiatric Technician Assistant (PTA) 1 stood over Resident 15 while feeding him dinner. This failure had the potential to result in Resident 15 feeling intimidated or uncomfortable during meal assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light for one of 13 sampled residents (Resident 6) was placed within reach, preventing Resident 6 from independently requesting assistance from staff. This failure resulted in putting Resident 6 at risk for unmet needs and delayed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 15) was free from unnecessary physical restraints when Psychiatric Technician Assistant (PTA) 1 placed all four side rails in the raised position on Resident 15's bed prior to exiting the room. This failure had the potential to restrict Resident 15's freedom of movement and place the resident at risk for injury related to entrapment.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA- federally mandated comprehensive assessment required when a resident has a major decline or improvement) for one of three sampled residents (Resident 18) after Resident 18 experienced a major decline in condition for multiple areas of Resident 18's health status. This failure had the potential to result in unidentified causes of decline, ineffective or delayed interventions, continued escalation of behaviors, worsening nutritional status, and failure to provide care and services necessary to maintain Resident 18's highest practicable level of functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure-relieving equipment was properly implemented for two of 13 sampled residents (Resident 15 and Resident 21) when the pressure-reducing mattresses were not set to the resident's accurate weight in accordance with the manufacturers' instruction. These failures had the potential to decrease the effectiveness of the pressure redistribution and place Resident 15 and Resident 21 at a higher risk for skin breakdown and/or impaired healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a federally mandated assessment tool used to guide resident care) Coordinator Nurse possessed and demonstrated competency to accurately complete federally mandated resident assessments when eight of 13 sampled residents (Residents 1, 2, 3, 7, 15, 16, 17, and 21) had inaccurate coding, one of 13 sampled residents (Resident 15) had untimely transmittal of a quarterly resident assessment, and one of three sampled residents (Resident 18) did not have a significant change in status assessment (SCSA- federally mandated comprehensive assessment required when a resident has a major decline or improvement) after decline was identified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served in a palatable and appetizing manner for one of 13 sampled residents (Resident 15) when Psychiatric Technician Assistant (PTA) 1 mixed multiple pureed food items together prior to feeding Resident 15. This failure had the potential to result in negatively affecting Resident 15's meal enjoyment and food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and monitoring of residents when Psychiatric Technician Assistants (PTA 2 and PTA 3) were observed with their eyes closed while assigned to provide enhanced one-to-one (1:1) supervision for two of two sampled residents (Resident 1 and Resident 2). This failure compromised the safety and security of the residents, as continuous observation was required to prevent potential harm. The deficient practice placed residents at risk for unmet care needs, potential injury, and lack of timely intervention. During an observation on 4/1/26 at 1:40 PM, in Resident 1's room, staff member PTA 2 was observed with her eyes closed while assigned to provide 1:1 supervision for Resident 1. During an interview on 4/1/26 at 2:05 PM with PTA 2, PTA 2 stated she was assigned to 1:1 observation for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Abuse, Neglect, and Exploitation Training was completed on an annual basis based on the staff anniversary date of August (birth month). This failure had the potential to decrease the quality of care for vulnerable residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain sanitary conditions for a universe of 23 residents, when a Food Service Technician (FST 2) did not perform hand hygiene between tasks. This failure had the potential to cause food- borne illnesses in a vulnerable population.

Inspectors wroteThis REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record review, the facility failed to ensure safe infection control practices were followed when: 1. Enhanced barrier precautions (EBP - infection control strategy focused on preventing the spread of infection) were not implemented for one of 13 sampled residents (Resident 10), during personal hygiene care. 2. Sterile technique (a set of practices used to prevent contamination and reduce the risk of infection) was not used when irrigating the suprapubic catheter (SPC- a tube that drains urine from the bladder through the lower abdomen) for one of 13 sampled residents (Resident 4). This deficient practice placed Resident 4 at risk for catheter-associated urinary tract infection (UTI- infection of the bladder) and other complications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the security of one of (1) medication rooms from unauthorized staff. This failure had the potential to allow unlicensed staff access to medications. During an interview on 12/30/24 at 9:17 a.m. with the Director of Quality 1, the Director of Quality 1 stated Program 4 (Skilled Nursing Facility, Intermediate Care Facility, Acute Psychiatric Hospital) had three main keys . one key was a general access key that opened all the doors including the medication rooms, a medication cart key which was only for nursing, and a narcotic lock key that only the person giving the narcotics had access to. During an observation on 12/30/24 at 9:52 a.m. on the skilled nursing unit, in the medication room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage room practices per the facility's policy and procedure when: 1. The medication cart was left unlocked multiple times in the medication room where unlicensed staff had access. 2. Expired medical supplies were not removed from stock. These failures had the potential for drug diversion (illegal distribution or abuse of prescription drugs) by unauthorized staff with access to medications and for expired and unsafe medical supplies to be used for residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow facility policies and procedures relating to safe storage and labeling of food, domestic hot water supply, cleaning of can openers and storing staff food in patient freezer. 1. Water temperature in the main kitchen 74 - 76 degrees Fahrenheit. 2. Meat in the main kitchen freezer, unlabeled and undated. 3. Flour tortillas in the main kitchen cooler dated 12/15/23. 4. Can opener with black substance on cutting wheel in the main kitchen. 5. Staff food stored in the skilled nursing satellite kitchen. These failures had the potential to affect the skilled nursing population by food borne illness in a highly susceptible population by subjecting patients to infection control and quality issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate documented medical records for the pain management of one of 13 sampled residents (Resident 3). This failure had the potential for inaccurate and incomplete representation of Resident 3's pain management.

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to have a laboratory contract in place to obtain certain send out laboratory tests (tests sent by a primary laboratory to a reference laboratory when testing was unavailable at the primary laboratory) from approximately [DATE] to [DATE]. This failure affected seven (7) of 27 Skilled Nursing Facility (SNF) residents. This failure resulted in a lapse in a laboratory contract where numerous physicians ' orders for blood tests, that required send out testing, were not completed. This failure had the potential to affect the health and safety of residents in the event laboratory results were abnormal.

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to ensure the Medical Director's responsibilities for coordination of medical care in the facility was implemented. The facility failed to have a laboratory contract in place to obtain certain send out laboratory tests (tests sent by a primary laboratory to a reference laboratory when testing was unavailable at the primary laboratory) from approximately [DATE] to [DATE]. The facility failed to report this unusual occurrence to the California Department of Public Health (CDPH). This failure affected seven (7) of 27 Skilled Nursing Facility (SNF) residents. This failure resulted in a lapse in a laboratory contract where numerous physicians' orders for blood tests, that required send out testing, were not completed. [...]