Napa Community Health Center

Inspectors wroteBased on observation, interview and record review, the nursing staff failed to provide care that met professional standards of nursing for two residents (Resident 3 and Resident 8) of 16 sampled residents when:1. Nurses did not assess, prevent, and identify the development of a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on Resident 3's left cheek; and,2. Nurses did not notify the physician when Resident 8 experienced significant and progressive weight loss. These failures resulted in Resident 3 obtaining a facility-acquired Stage 2 pressure injury (a partial-thickness loss of skin, presenting as a shallow open sore or wound) and Resident 8 unhappy and concerned about her weight loss. Cross Reference F684, F692.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 8) of four sampled residents received necessary care and services to prevent continued weight loss when:Resident 8's weight loss went unaddressed;Nursing staff did not notify the physician of Resident 8's weight loss; and,There was no Registered Dietician to provide oversight. These failures decreased the facility's potential to maintain Resident 8's nutritional status (the state of health determined by balance of nutrient intake, absorption, and the body's physiological needs) which placed Resident 8 at risk for worsening malnutrition, further weight loss, and a decline in overall health. [...]

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure resident rights were exercised when:1. A census of 24 residents and/or their Responsible Parties (RP) were not informed about their right to vote on June 2, 2026 for a primary election for state government elected officials; and,2. One resident (Resident 22) of three sampled residents did not have their final wishes followed when staff allowed family members to sign their Physician Order for Life Sustaining Treatment (POLST) forms when they did not have the legal authority to do so. These failures resulted in 24 residents not being informed of their right to vote by the facility, and Resident 22 being consented as Do Not Resuscitate (DNR) by people who were not authorized to make that decision.

Inspectors wroteBased on interview and record review, the facility's Administration failed to ensure the Dietary Manager (DM) had the required qualifications to manage the facility's kitchen in a skilled nursing facility in California. This failure decreased the facility's potential to ensure safe food handling and the prevention of food-borne illness in a highly susceptible population of 24 residents. Cross Reference F835Findings:In an interview on 6/4/26 at 9:45 a.m., DM stated he had been employed at the facility for six years and had been in the position of DM for approximately three months when the previous DM resigned. The DM stated he had a ServeSafe(R) Manager certificate (a nationally accredited certificate in food safety that is required by law in many states) but did not have a Certified Dietary Manager (CDM) certification. [...]

Inspectors wroteBased on observation, interview and record review, the facility's dietary staff failed to store food in a sanitary manner for a census of 24 when:Multiple boxes in the dry pantry were either misdated or not dated;Multiple food items in the food pantry were stored improperly, not dated, or expired;Multiple food items in the walk-in refrigerator were stored improperly, not dated, or expired;Multiple spices on the spice shelf were undated or expired;Food being prepared to be cooked was expired;The floor and blender were found dirty; and,The Dietary Manger (DM) did not adhere to the hair containment policy. These failures decreased the facility's potential to prevent the transmission of foodborne illnesses throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure trash was stored in a sanitary manner for a census of 24 residents when trash dumpsters were observed left open. This failure decreased the facility's potential to prevent a nuisance or breeding ground for insects and rodents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the electronic submission of the Payroll Based Journal (PBJ, a system by which skilled nursing facilities submit staffing information to the Centers for Medicare and Medicaid) data as required quarterly for a census of 24 residents when the Certification and Survey Provider Enhanced Reporting system (CASPER, an assortment of real-time reports that allows SNFs the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance) report indicated there was no information for the first quarter (Q1-1/26 through 3/26). This failure prevented regulatory agencies, residents, and residents' families from being able to verify that facilities had enough staff to provide necessary care to residents.

Inspectors wroteBased on observations, interviews, and record reviews, the laundry staff failed to prevent the development and transmission of communicable diseases and infections for a census of 24 residents when clean linens were not transported by methods that protected from dust, soil, moisture, and infectious organisms during transport within the facility. This failure decreased the facility's potential to prevent the transmission of infectious pathogens (tiny organisms that can make you sick if they get inside your body) residents in the facility.

Inspectors wroteBased on interviews, observation, and document review, the facility failed to maintain an effective pest control program when a cockroach was seen inside the facility's beauty shop. This failure decreased the facility's potential to prevent contamination of food supplies and respiratory distress among residents when cockroach droppings are inhaled.

Inspectors wroteBased on interviews, observations, and document review, the facility failed to ensure staff members were educated on residents' rights for a census of 24 residents , when the Social Services Designee (SSD), the Interim Activities Director (IAD), and the Assistant Administrator (AADM) unaware they were responsible for providing residents the ability and option to vote during an election. This failure denied eligible and willing residents who wanted to exercise their right to vote as citizens of the United States. Cross reference F550, F942Findings:During the Resident Council meeting on 6/3/26 at 11 a.m., attended by Residents 1, 3, 6, 11, 12, 14, 16, 21, 26, and 27, the interim Activities Director (IAD), the Ombudsman, and this surveyor. All residents in attendance stated they had not voted yesterday. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for one resident (Resident 3) of three sampled residents when Resident 3's Responsible Party (RP) did not have legal authorization to provide consent. This failure decreased the facility's potential to provide Resident 3 the ability to make her own medical decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Directives (AD - a legal document indicating resident preference on end-of-life treatment decisions) and Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life) were formulated for five of 16 residents (Resident 3, Resident 22, Resident 5, Resident 7, and Resident 6). This failure increased the risk for the residents to receive unwanted, aggressive and invasive life-sustaining treatment during a sudden medical crisis and exclude the resident and resident's family from crucial decision making.

Inspectors wroteBased on observations and interviews, the facility did not maintain hot water temperatures within safe regulatory limits when water temperatures in multiple resident-use restrooms were measured above 120 degrees Fahrenheit (F, a unit measurement of heat) for 16 residents out of a facility census of 24. This failure decreased the facility's potential to provide a hazard-free environment and prevent thermal injury. Cross Reference F835Findings:During a concurrent interview and observation in Resident 8's room on 6/3/26 at 8:15 a.m., Resident 8 stated she was bothered by not having any cold water in her restroom. Upon entering Resident 8's restroom and turning on the cold-water tap, the surveyor observed the water was lukewarm. When the hot water tap was turned on, the water became too hot to safely hold hands under, even briefly. [...]

Inspectors wroteBased on interview and record review, the medical and nursing staff failed to ensure one resident (Resident 5) out of four sampled residents received a gradual dose reduction (GDR) and behavioral interventions when Resident 5 was given a psychotropic (medication that alter brain chemistry to affect mood, thoughts, behavior and perception) drug. This failure decreased the facility's potential to ensure Resident 5 was not given unnecessary psychotropic medication without evaluating its effectiveness or necessity. Cross Reference F835Findings:A review of Resident 5's admission record indicated she was admitted to the facility on [DATE] with diagnoses of Polymyositiis (a rare, chronic condition that causes swelling, heat, and pain to the skeletal muscles) and major depressive disorder (a mood disorder characterized by feelings of sadness, emptiness and a loss of interest in activities). [...]

Inspectors wroteBased on interviews and record reviews, the licensed nurses failed to develop a baseline care plan within 48 hours of admission and provide written copies of the baseline care plan summaries to two residents (Resident 14 and Resident 16) of three sampled residents. These failures decreased the facility's potential to effectively communicate resident needs among facility staff to promote a continuity of care and prevent adverse events from occurring right after admission.

Inspectors wroteBased on observation, interview and record review, the nursing staff failed to assess, prevent, and identify the occurrence of pressure injury for one resident (Resident 3) of three sampled residents, when Resident 3 obtained a facility-acquired pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on her left cheek. This failure had the potential for the facility acquired Stage 2 pressure injury (a partial-thickness loss of skin, presenting as a shallow open sore or wound) to worsen and placed Resident 3 at risk of complications including infection and pain. [...]

Inspectors wroteBased on observation, interview and record review, the licensed nurses failed to ensure expired and discontinued prescription medication were properly stored and disposed of when:Discontinued medications were observed overflowing from a large, uncovered cardboard box in front of shelves of prescription medications and medical supplies; and,Easily accessible undestroyed medication pills were found in a pharmaceutical waste container. These failures reduced the licensed nurses' ability to safely administer medication and decreased the facility's potential to prevent prescription drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use). [...]

Inspectors wroteBased on observation, interview and record review, the licensed nurses failed to ensure expired medication was properly stored when expired multivitamins and pain medication were not removed from one of two medication carts. This failure reduced the facility's ability to ensure administered medications are safe and effective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a safe and sanitary manner in the resident refrigerator for a census of 24 when food was found unlabeled and undated. This failure decreased the facility's potential to prevent foodborne illnesses in a vulnerable resident population.

Inspectors wroteBased on interview and record review, the facility failed to follow FDA (U.S. Food and Drug Administration) Black Box Warnings (or BBW, the most stringent safety warning required by the FDA for prescription drugs) and manufacturer specification for dosing a fentanyl transdermal patch (a powerful synthetic opioid, 50 to 100 times more potent than morphine, that is absorbed through the skin for consistent pain relief) for one of three sampled patients, Resident 1 when:1. Resident 1's fentanyl patch initiation on 11/26/25 did not follow FDA Black Box Warnings and manufacturer specification on starting dose based on history of opioid use, old age, and Chronic Obstructive Pulmonary Disease (or COPD, a long-term lung inflammation and obstruction, making it hard to breathe without medication or supplemental oxygen).2. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with kindness, respect, and dignity, when the Director of Nursing (DON) was witnessed bullying Resident 1. This failure resulted in Resident 1 crying. During an interview on 3/24/26 at 2:19 p.m., Confidential Witness (CW) stated that back in January 2026 something happened during activities that caused Resident 1 to get mad at someone. CW stated that while CW was at the nurses station that afternoon, Resident 1 was in the lobby when DON came at the nurses station very emotional and aggressive and said Resident 1 was out of control and we need to do something about her, we need to send her out. CW stated DON was very physically and verbally aggressive about the way she approached the nurses at the desk, all within earshot of Resident 1, who was only a few feet away. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the family member of one of three sampled residents (Resident 1) of changes to Resident 1's treatment plan for her behaviors and her pain. This failure resulted in Resident 1's family member (FM) finding out after the changes to the treatment plan had already been implemented, feeling that Resident 1 was being over-medicated with sedating drugs, and having to request further changes to Resident 1's medication regimen. During an interview on 3/11/26 at 1:28 p.m., Family Member (FM) stated he got a call in February 2026 that Resident 1 was in respiratory distress due to an increase in her fentanyl patch (a powerful synthetic opioid, 50 to 100 times more potent than morphine, that is absorbed through the skin for consistent pain relief) dose. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one of three sampled residents (Resident 1) from chemical restraint when Resident 1 had a physician order for an antipsychotic drug (mood altering drugs- used to treat symptoms like hallucinations, delusions, and paranoia) to be given as needed (PRN) for longer than 14 days without a re-evaluation for continued need. This failure resulted in Resident 1 having the potential to receive a dose of the antipsychotic when the drug continued to remain an active order for seven weeks. During an observation on 3/12/26 at 11:50 a.m., a musician in the common room adjacent to the lobby sang into a microphone and played an electric guitar. Resident 1 was in the lobby in her wheelchair with her eyes closed and her chin resting on her chest. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its abuse prevention policy and procedures when one of one sampled resident (Resident 1) reported an incident of alleged physical abuse by staff, but the facility had no evidence it conducted an investigation nor reported the results of the investigation to the State Department of Health (the Department) within 5 working days. This failure had the potential to delay the Department ' s independent investigation of the incident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. This failure can potentially result to food contamination and outbreak of foodborne illness among residents of the facility.

Inspectors wroteBased on observation, interview and records review, the facility failed to: 1) ensure hand hygiene was practiced by six (6) of 15 sampled residents (Resident 3, Resident 16, Resident 9, Resident 22, Resident 1, Resident 24) before meals. This failure had the potential to cause the spread of infections to other residents and worsen their already compromised health or cause an outbreak; 2) conduct ongoing analysis of infection surveillance. This failure had the potential to result in the facility missing to identify trends in infection types and occurrence and not being able to detect where an infection came from or the presence of an increasing number of infection or an outbreak; [...]

Inspectors wroteBased on interview and records review, the facility failed to consistently perform antibiotic stewardship. This failure had the potential to result to inappropriate or unnecessary antibiotic treatment, increase the risk of adverse events, development of antibiotic resistance, and worsen the already frail health condition of residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to appropriately diagnose and treat a growth on the left side of Resident 29's nose for one out of one sample residents (Resident 29). This failure had the potential to cause an infection and create discomfort for ongoing growth on Resident 29's face.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the RNA (restorative nursing assistant) program (assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) was being received per physician orders for one of 15 sample residents (Resident 33). This failure resulted in a disruption in treatment and had the potential for Resident 33 to have a decline in range of motion, strength and endurance, an increase in joint pain and depression, and an overall decrease in ADLs (Activities of Daily Living: activities related to personal care, which includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).

Inspectors wroteBased on observation and interview, the facility failed to follow a process of ensuring resident meals were served with the appropriate dietary consistency when one of two staff (Licensed Staff L) was observed reviewing the meal tray cards but not reviewing the covered food for accuracy prior to the meal being served to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety, and functional environment in the kitchen when cracks and missing tiles on the kitchen floor were not repaired. This failure can cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents.

Inspectors wroteBased on interview and record review the facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNA). These failures had the potential for unlicensed nursing staff to not have their skills assessed under the performance review and not have necessary training addressed in the performance review.

Inspectors wroteBased on interview and record review the facility failed to send in their investigative report for one of one alleged abuse incident to the department, within 5 days from the incident. This failure to not finish the investigation and sending the report, could result in missed chance to improve the care and services provided by the facility and potentially avoid other instances of abuse and neglect.

Inspectors wroteBased on Observation Interview and Record Review: 1. The facility failed to ensure a comfortable environment when the facility did not maintain comfortable room temperature (standard room temperatures are to be from 68-81 degrees Fahrenheit) in 19 out of 24 rooms (Rm): (Rm 101, 102, 105, 106, 108, 109, 110, 112, 114, 115, 116, 117, 118, 120, 121, 123, 124, 125, and 126) when temperatures measured were from 60 to 67 degrees and multiple residents (Resident 14, Resident 17, Resident 23, Resident 26, Resident 40, and Resident 244) complained of being cold inside of their rooms. 2. The facility did not maintain comfortable resident room temperatures safely by using three space heaters in the west hallway, two space heaters in the east hallway, and a space heater in resident rooms: (Rm 101, 112, 114, 115, and 123), which had the potential of causing a fire resulting in injury or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe water temperatures when the water temperatures in eight of 14 residents' bathroom sinks were too hot, one over 130 degrees Fahrenheit (° F). This failure could potentially result in vulnerable residents getting scalded or burned from hot water.

Inspectors wroteBased on observation and interview, the facility failed to install call lights that could be accessed by a resident lying on the floor in the bathroom or shower room. This could potentially result in a resident falling to the floor and unable to signal to staff that they need immediate assistance.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of Notice of Discharge or Transfer to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] for four out of six residents: Resident 13, who was transferred to an acute care facility and Resident 43, 247, and 249, who were discharged to home. This failure had the potential for Resident 43, 247, and 249 being inappropriately discharged and Resident 13, 43, 247, and 249 not being provided an advocate who could inform them of their rights and options before being discharge to home or transferred to the acute care facility.

Inspectors wroteBased on interview and record review, the facility failed to keep residents' pneumonia vaccines up to date when residents were not offered the 23-valent pneumonia vaccine, as recommended by the Centers for Disease and Prevention (CDC). This failure could potentially leave vulnerable residents unprotected from preventable lung infections that can lead to hospitalization or death.