Napa Community Health Center

In the surveyor’s words

From the most serious findings on record at Napa Community Health Center, in the surveyor’s own words.

• Actual harm, isolatedF658Jun 5, 2026

  Based 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. […]

• Actual harm, isolatedF692Jun 5, 2026

  Based 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. […]

• Actual harm, isolatedF757Mar 26, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF550Jun 5, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF801Jun 5, 2026

  Based 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. […]