Dept of State Hospitals - Napa D/P SNF

In the surveyor’s words

From the most serious findings on record at Dept of State Hospitals - Napa D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF641May 15, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812May 15, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF838May 15, 2026

  Based 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.Findings:During a concurrent interview and record review on 5/14/26 at 10:47 AM with Assistant Executive Director (AED) and Standards Compliance Director (SCD), the Facility Assessment, dated 2026, was reviewed. The Facility Assessment did not include the following: 1. A data-driven staffing plan based on resident acuity and care needs. 2. […]

• No harm, potential for more than minimal, widespreadF865May 15, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880May 15, 2026

  Based 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… […]