Napa Post Acute

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the dignity of two of six sampled residents (Residents 2 and 3) when they were not assisted with toileting timely. This failure caused both Resident 2 and Resident 3 to be left in bedding soaked in urine for over an hour and caused Resident 2 to feel dirty and gross. During an observation and concurrent interview on 5/20/26 at 11 a.m., Resident 2 was sitting in bed with her husband seated at her bedside. Resident 2 stated she had long waits for call light response. Resident 2 stated every evening she would sit for hours in a wet bed. Resident 2's husband verified he had witnessed this. Resident 2 stated she could not say how long she had to sit in a wet bed, but it was long enough that the urine on the sheets dried and she smelled like urine. Resident 2 stated it made her feel dirty and gross. [...]

Inspectors wroteBased on interview and record review the facility failed to implement the care plan of one of six sampled residents (Resident 1) when nurses did not document pain assessments for three shifts during Resident 1's first two days of admission. This failure caused Resident 1 to feel panicked when her pain became out of control. During a phone interview on 5/20/26 at 11:03 a.m., Family Member (FM) stated Resident 1 was in quite a bit of pain during Resident 1's first day at the facility. FM stated that Resident 1 had suffered multiple fractures (broken bones) just three days prior to her admission to the facility, two in her spine and one in her pelvis. FM stated Resident 1 was on round-the-clock pain medications when she was at the hospital, taking oxycodone (a narcotic pain medication) every six hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not initiate the process to replace or reimburse missing dentures for one of three sampled residents (Resident 1) after they were lost at the facility, and instead, filed a claim with Resident 1's own dental insurance company for replacement, rather than assuming financial responsibility. This failure may have contributed to Resident 1 experiencing a weight loss of over nine pounds over the past month, as well as feelings of discomfort regarding dental status leading her to wear a mask. In addition, this had the potential to result in dental insurance fraud. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and maintain an effective infection prevention and control program and a system for preventing, identifying, reporting, investigating, and controlling infections, including establishing policies and procedures, when A. facility staff could not prevent a C-Diff (C. diff- a highly contagious bacteria that causes severe diarrhea) outbreak, B. facility did not follow water management requirements for Legionella (a type of bacteria naturally found in freshwater, that becomes a health concern when it grows in man-made water systems; people get sick (severe pneumonia) by inhaling mist that contains the bacteria), and C. and open sewage pipe was observed in a communal shower room which also stored medical equipment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 19) sampled for pain management received professional treatment when Licensed Nurse S did not assess, evaluate, treat, or reassess Resident 19's migraine pain. This failure resulted in persistent migraine pain for Resident 19 and affected her overall well-being. A review of Resident 19's admission record indicated she was admitted in 08/2024 with diagnoses of Chronic pain (persistent pain lasting longer than 3-6 months), a burn wound to her left thigh, and Migraine with Aura (severe headaches with visual disturbance such as zig-zag lines, flashing lights or blind spots). A review of Resident 19's Minimum Data Set (MDS-a resident assessment tool) dated 11/17/25 indicated no cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility Quality Assurance Performance Improvement Committee failed to identify multiple quality of care issues. This failure resulted in a systemic breakdown of the infection control and prevention program which potentially could have led to harm of vulnerable residents, and other poor outcomes for residents in the care of the facility. During an interview on 2/12/26 at 2:25 p.m., the Administrator stated the Quality Assurance Performance Improvement (QAPI) Committee met monthly. The Administrator stated the QAPI committee developed performance improvement projects based on information they got from department heads, grievances, the resident council, monthly all-staff meetings, and an anonymous suggestion box. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure Resident Rights were honored when:Dignity and respect for residents was not provided when residents complained staff were observed being disrespectful, rude and unprofessional. Access to call lights for assistance and emergencies was not available when the call lights of three resident (Resident 15, Resident 24, and Resident 110) were not within reach on multiple observations. Access to visitors was denied to one resident (Resident 16) when she requested a visit from her daughter and the facility prevented her daughter visitation. Four out of five sampled residents (Resident 39, Resident 41, Resident 42, and Resident 69) were not treated with dignity and respect when staff were overheard speaking in a foreign language throughout the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a safe, sanitary, homelike environment when: Patient care areas and laundry processing were observed to have broken and cracked floor tiles, exposed and unsealed medication cart work surfaces, unsealed cement on floors, exposed plaster, rusty and non-functioning equipment, and unsealed woodwork. These failures resulted in an environment for residents and staff that did not appear homelike, increased the risk of cross contamination and the spread of contagious disease. Cross Reference F880Findings: During an observation on 2/9/26 at 10:30 a.m. the floors and door jambs in resident rooms 56, 58, 59, 60, 61, 62 were observed to have chipped and cracked floor tiles, chipped paint on the doors and door jambs. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of five residents sampled for medication review from chemical restraint when Resident 4 had lorazepam (an anti-anxiety medication) ordered as needed without a frequency, duration, or monitoring for target symptoms. This failure had the potential to result in Resident 4 receiving an anti-anxiety medication unnecessarily, which can cause sedation, dizziness, weakness, and unsteadiness. During a record review on 2/11/26 at 8:08 a.m., review of Resident 4's face sheet revealed an admission date of 2/9/24, age over [AGE] years old, and medical diagnoses that included cerebral infarct (a blockage in a blood vessel to the brain), major depressive disorder in full remission, and dementia without behavioral disturbance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents sampled for nutrition (Resident 19) Care Plan was evaluated and revised to include new means by which to monitor her weight after Resident 19 had refused to have her weight measured using the Hoyer Lift (a mechanical device used to lift and/or transfer a person) for 7 months. This failure caused the facility to be unable to properly assess a vulnerable resident, Resident 19, for significant weight loss, under nutrition, and worsening health status. A review of Resident 19's admission record indicated she was admitted in 08/2024 with diagnoses of Chronic pain (persistent pain lasting longer than 3-6 months) and a large burn wound to her left thigh. A review of Resident 19's Minimum Data Set (MDS-a resident assessment tool) indicated she had no cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective participation and oversight of resident medical care by Physician R when,The infection Prevention and Control Program for a census of 116 was not provided oversight by Physician R for antibiotic stewardship and monitoring of infectious diseases in the facility designed to slow and prevent the spread of Clostridium Difficile (C. diff- a highly contagious bacteria that causes severe diarrhea), and prevention of water borne illness related to positive Legionella (a type of bacteria found in water that causes Legionnaires Disease a severe pneumonia) results.(Cross reference F 880). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure advanced knowledge and approval of ongoing treatment with psychotropic medications ( any medication that affects brain activity associated with mental processes and behavior) for two of five sampled residents ( Resident 10 and Resident 12) for unnecessary medications when resident representatives did not recall contact from the facility and the informed consent ( a document that confirms residents or resident representatives were informed on the risks, benefits, and alternatives of a medical intervention) forms were not signed nor was verbal consent documented. This failure prevented the resident's representative's from participating in their right to determine treatment interventions for Resident 10 and Resident 12. [...]

Inspectors wroteBased on interview and record review, one of two residents sampled for tube feeding (Resident 140), who was at risk for constipation, had no bowel movement (BM) for five days and was not given bowel care medications as indicated on the care plan. This failure contributed to Resident 140 developing a fecal impaction (a severe, solid, or hard mass of stool stuck in the rectum or colon, typically resulting from chronic, untreated constipation). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and monitoring for one out of two sampled Residents (Sampled Resident 60) when Resident 60 left the facility unnoticed by staff (eloped) on 12/27/25. This failure contributed to Resident 60 being found outside the facility by the police and had the potential to lead to injuries for Resident 60. Review of Resident 60's medical record document titled admission RECORD, indicated he was admitted [DATE], with diagnoses that included Heart Disease, Encounter for Aftercare Following Surgery on the Circulatory System, Muscle Weakness, Need for Assistance with Personal Care, and Unspecified Psychosis (A person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not.). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one resident's sampled for ostomy care( a surgical opening in the abdomen that redirects waste outside the body into a wearable pouch system) ( Resident 110), received care according to professional standards of practice when Licensed Nurse S disregarded Resident 110's verbal and non-verbal signs of pain with old appliance removal, did not follow the correct procedure for appliance change to minimize skin exposure to feces and urine, and did not notify the supervisor of any abnormal findings. This failure caused Resident 110 to have pain, discomfort, and had the potential to contribute to further skin breakdown around his stoma(a surgically created opening in the abdomen that diverts stool flow). [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to properly maintain the residents' food refrigerator for a census of 116 when food items were not properly labeled. This failure had the potential to result in residents consuming contaminated food, increasing the risk of foodborne illness and adverse health outcomes. During a concurrent observation and interview on 2/2/26 at 9:40 a.m., with the Dietary Services Manager (DSM), the freezer unit of the resident refrigerator contained one opened 16 oz container of Dean's French Onion Dip and two (8-pack) unopened packages of El Monterey Beef and Bean Chimichangas the DSM stated, he did not see any identifying labels on the french onion dip container or either of the chimichanga packages. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not securely attach the bed rails to the bedframe for one of seven residents who use bed rails, (Resident 105.) Resident 105's bed rails were loose and wobbly, easily swinging away from the bed. Resident 105 stated she did not feel safe using the bed rails for repositioning or getting in and out of bed and stated she almost fell to the floor. During an interview and concurrent observations on 02/09/2026 at 4:26 p.m., in Resident 105's room, Resident 105 reported that broken bed rails nearly caused a fall while repositioning. She stated, the rail just fell down and demonstrated how the left rail could move side to side, creating a 2 to 3-inch gap between the mattress and rail . The surveyor confirmed the rail could swing towards the middle of the room, forming a large gap which posed a fall risk. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate nursing services for 4 residents (Resident 2, Resident 3, Resident 4, and Resident 5) of 5 sampled residents to ensure residents achieved the highest level of physical and emotional well-being when the facility failed to make a sufficient number of nursing staff available to meet residents' needs. This failure had the potential to place residents at greater risk for dehydration, skin breakdown and placed their safety in jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate a baseline care plan for one resident (Resident 1) of three sampled residents when licensed nurses did not create a care plan for Resident 1's indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder and into a bag which collects the urine). This failure decreased the facility's potential to prevent urinary tract infections (UTI) among residents with urinary catheters in place.

Inspectors wroteBased on interview, observation, and facility policy review, the facility failed to ensure the most recent survey results were readily accessible for all residents to review. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview, observation, and facility policy review, the facility failed to protect the rights of residents and their representatives to have the ability to file grievances anonymously. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of 3 (Residents #107, #106, and #61) of 29 sampled residents reviewed for MDS accuracy. Specifically, the MDS assessments inaccurately reflected Resident #107 was discharged to a hospital; Resident #106 was discharged to home/community, and Resident #61 did not use a wander/elopement alarm.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident's admission Pre-admission Screening and Resident Review (PASRR) accurately captured an admission diagnosis of a serious mental illness (SMI) for 1 (Resident #64) of 2 residents reviewed for PASRR. Specifically, Resident #64's admission PASRR did not capture their admission diagnosis of unspecified psychosis.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents with limited range of motion (ROM) received care and services to prevent any further decrease in ROM for 1 (Resident #28) of 2 residents reviewed for rehabilitation and restorative services. Specifically, Resident #28 had an order for staff to ask rehabilitation services to perform passive ROM, but there was no documentation that this order had been completed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was safe from eloping from the facility for 1 (Resident #61) of 2 residents reviewed for elopements. Specifically, Resident #61 eloped from the facility on 02/25/2025 and was found in a parking lot approximately one block away from the facility. At the time of the elopement Resident #61 was utilizing a WanderGuard device (departure alert system); however, the WanderGuard device was not applied in accordance with manufacturer's instructions. Additionally, the facility failed to ensure 1 of 1 supply closet observed containing medical supplies was locked and inaccessible to residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medication carts were locked when unattended by staff for 1 of 6 medication carts observed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an order to discontinue a medication was transcribed into the clinical record for 1 (Resident #84) of 28 sampled residents for whom orders were reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) for three residents (Resident 1, Resident 2 & Resident 3) of four sampled residents when Resident 1, Resident 2, and Resident 3 developed a gray-white residue inside their oral cavities and malodorous breath. This finding had the potential to result in tooth decay, gum disease, discomfort, and tooth loss among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were discarded from the only treatment cart (cart containing supplies and treatments for resident wounds) the facility had. This finding decreased the facility's potential to prevent residents from receiving outdated medications/supplies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Social Services Department resolved the resident concerns grievances for brought up by one resident (Resident 2) of three sampled residents (Resident 2) when Resident 2 reported his bed frame was broken and a staff member broke his electronic tablet (a portable computer with a touchscreen designed for easy use on the go). This resulted in Resident 2's boredom and frustration when the electronic tablet had not been replaced and the inability to sleep comfortably in bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was able to receive private telephone calls during her stay at the facility. This triggered a family member (Family Member AA) to call the police to perform a wellness check on Resident 1 since she was unable to contact Resident 1 by phone after multiple attempts. This failure had the potential to result in inability for Resident 1 and other residents of the facility to socialize and interact with the outside world, which could affect their emotional and mental health. This finding also had the potential to result in inability for friends and family members to advocate for the residents' health, request updates on their medical status, and ensure they were safe and comfortable at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received medications as ordered by the physician, when one routine medication (a prescription that is followed until another order cancels it), Chlordiazepoxide (a medication used to treat symptoms of anxiety and symptoms of alcohol withdrawal) was unavailable for five scheduled doses. This failure had the potential to cause Resident 1 to experience anxiety and symptoms of alcohol withdrawal.

Inspectors wroteBased on Observation, interviews and records review, the facility failed to ensure a safe environment for one of three sampled residents (Resident 1) when the facility staff were aware that Resident 1 attempted to leave the facility a few hours after his admission and did not develop and implement interventions to prevent Resident 1 from leaving the facility unsupervised. This failure resulted to Resident 1 leaving the facility unnoticed few hours after midnight and ended at the hospital with Hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature) and Traumatic (relating to or denoting physical injury) hematoma (occurs when a blood vessel ruptures and blood collects in the area) of left elbow.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 sampled resident's (Resident 1) maintained adequate hydration (fluid status in the body) and nutrition (food intake) during his approximate 3.5 week stay at the facility. Resident 1 was transferred to the facility from Hospital 1 (approximately 90 miles North of the facility) after having his right toe amputated (removed) and his plan of care included post-surgical (after surgery) rehabilitation at the facility, with an ultimate goal of returning home to his wife. Upon admission to the facility, Resident 1 required the assistance of staff for eating and drinking and nursing staff documented he was at risk for dehydration and malnutrition. Although Resident 1 was a Full Code (directs a patient's medical care regarding life-sustaining interventions; full support): [...]

Inspectors wroteBased on interview, and facility document review, the facility's Quality Assurance and Performance Improvement Committee (QAPI, a data driven and proactive approach to quality improvement; process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies and subsequently investigate and act upon the deficiencies once identified, as evidenced by: 1 of 3 sampled Residents (Resident 1) experienced a 30.8 (31) pound weight loss during his first 18 days at the facility. Facility staff did not notify Resident 1's physician or nurse practitioner (NP) of the severe weight loss; interventions to address the severe weight loss were not implemented; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laundry staff observed proper PPE (Personal Protective Equipment) use when handling used laundry. This failure increased the potential of spread of pathogens and communicable diseases among residents and staff at the facility.

Inspectors wroteBased on interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - provides a comprehensive assessment of each resident's functional capabilities) for three of three sampled residents (Resident 53, 90 and 7) were accurately assessed of their current health and functional status when: 1) Resident 53's MDS indicated he had stage four pressure ulcer (wound is very deep, reaching into muscle and bone and causing extensive damage); however, Resident 53's physician documented Resident 53 had an arterial ulcer (damage to the arteries due to lack of blood flow to tissue). 2) Resident 90's MDS indicated she had septicemia (bacteria enter the bloodstream, and cause blood poisoning which triggers sepsis [an overwhelming and life-threatening response to infection]); however, Resident 90's record did not indicate she was monitored or treated for infection. [...]

Inspectors wroteBased on interviews and records review, the facility failed to develop and implement person-centered Care Plan for three of 24 sampled residents (Resident 27, 80 and 7) when, 1. Facility staff were aware of Resident 27's repeated refusal of showers, however, no care plan interventions were put in place to ensure Resident 27's personal hygiene needs were maintained. (Reference F677) 2. Facility did not develop a communication care plan and activity care plan for Resident 80 to ensure Resident 80's needs were met. 3. Facility did not develop communication care plan and activity care plan for Resident 7 to ensure Resident 7's needs were met. These failures had the potential for facility staff to provide inadequate care to vulnerable residents when their individual needs and interests were not addressed appropriately.

Inspectors wroteBased upon observation, interview and record the facility failed to provide scheduled showers to three (Resident 27, 80 and 35) out of five sampled residents. This failure resulted in residents verbalizing feelings of not feeling clean or good about themselves.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to provide activities to meet the needs and preferences for three of 24 sampled residents (Residents 27, 80, and 7) when: 1. Resident 7 was not provided with activity that he could understand. Resident 7 spoke Chinese and used hand gestures to communicate with facility staff. 2. Resident 27 and 80 were left in their rooms without activities. This failure had the potential for self-isolation and decreased stimulation resulting in a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders, and provide adequate care after dialysis (A procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) for two of three sampled residents (Resident 29 and Resident 60) when the pressure dressings to prevent bleeding, applied at the dialysis clinic right after dialysis treatments were not removed timely, and the Arteriovenous (AV) Shunts (An arteriovenous fistula or shunt is an abnormal connection or passageway between an artery and a vein surgically created to remove and return blood during dialysis) were not assessed for bruit and thrill (Normal vibrations and sounds that indicate the fistula is working. Any changes may indicate problems with the fistula). [...]

Inspectors wroteBased on observation, interviews and records review, the facility failed to ensure sufficient nursing staff to provide care to three of sampled residents (Resident 27, 80 and 35) and two unsampled residents (Residents 320 and 325) when: 1. Scheduled showers for Resident 27, 80 and 35 were not provided. This failure to maintain Residents' personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial and fungal infections. 2. Call lights for Resident 27, 320 and 325 were not answered timely. This failure kept the residents needs uncommunicated to the staff, potentially placing them at risk for neglect and harm.

Inspectors wroteBased on interviews and records review, the facility failed to ensure staffing requirements where met when the facility's daily occupancy was more than 110 and did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week to oversee the care provided to the residents. This failure had the potential risk to endanger the health and safety for all the residents.

Inspectors wroteBased on observation and interview, the facility did not store food items under sanitary conditions when foods was kept past the use-by dates and frozen items were found with ice crystals clinging to them. This had to the potential to cause food-borne illness in a vulnerable population.

Inspectors wroteBased on interview and record the facility failed to have the appropriate compliment of Quality Assessment and Assurance (QAA) committee members when the Medical Director attended one out of three quarters sampled for 2022. This failure had the potential to result in the medical director not providing oversight and input into the overall clinical facility management as provided in the QAA meetings.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement effective policies and procedures to ensure COVID-19 vaccinations were offered accordingly for three of five sampled residents (Residents 102, 108 and 109) who were clinically eligible. This failure increased the susceptibility of these clinically eligible individuals to contract and transmit the COVID-19 virus among the residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment for one of three sampled residents (Resident 76) when an annual assessment for Resident 76 was not completed for more than 92 days. This failure had the potential to cause inadequate care based on delayed assessments and care planning.

Inspectors wroteBased on interview and record review the facility failed to keep one resident (Resident 35) out of two sampled residents safe while smoking. This failure resulted in Resident 35 suffering burns on his fingers from smoking.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 29) was kept safe, when medications were left by Resident 29's bedside, unattended, when she did not have an order for self-administration of medications. This failure could have resulted in omission and/or overdoses of medications, and deterioration of medications by leaving them unattended and exposed for a prolonged period of time, which ultimately could have caused serious harm to Resident 29 and other residents if they had ingested them.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of COVID-19 vaccination exemption for one of eight sampled staff with granted exemptions. This failure had the potential for decreased assurance of adherence to the facility's established COVID-19 mitigation policies and procedures by staff rendered more susceptible to the COVID-19 virus, which could lead to an increased transmission risk of COVID-19 among the residents and staff.