Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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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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 | — | 4 | 0 |
| Napa Valley Care Center | 3.8 mi | — | 0 | 0 |
| Napa Post Acute | 3.9 mi | — | 29 | 1 |
| Solano Post Acute | 9.8 mi | — | 22 | 0 |
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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 August 2026) and official state health department websites.