Napa Post Acute

In the surveyor’s words

From the most serious findings on record at Napa Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Feb 17, 2026

  Based 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. […]

• Actual harm, patternF692Sep 14, 2023

  Based 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. […]

• Actual harm, isolatedF697Feb 17, 2026

  Based 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… […]

• Actual harm, isolatedF689Nov 20, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF865Feb 17, 2026

  Based 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. […]