Napa Valley Care Center

In the surveyor’s words

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

• Actual harm, patternF697Sep 21, 2023

  Based on interviews and records review, the facility failed to implement a physician ' s order for pain management for two of four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a physician ' s order for Dilaudid (an opioid [class of drugs that derive from, or mimic, natural substances found in the opium poppy plant] used to relieve moderate to severe pain) 4 mg (milligram-a unit of mass) to be given three times a day for pain management; however, the facility did not administer the medication according to the physician ' s order. […]

• Actual harm, isolatedF686Jan 10, 2024

  Based on interview and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure injuries (bedsores) to one of two residents (Resident 1), when the facility did not frequently and regularly turn and reposition Resident 1, who could not turn and reposition herself independently, and was at risk for developing pressure injuries. This failure resulted in Resident 1 developing two unstageable (unable to determine the exact extent of the wounds) pressure injuries, one on her sacrum (the tailbone area) and one on her buttocks area. Findings: A review of Resident 1 ' s Facesheet indicated she was admitted to the facility on [DATE] with a primary diagnosis of hip fracture. […]

• Actual harm, isolatedF677Sep 13, 2023

  Based on observation, interview and record review, the facility failed to ensure that three of three sampled residents (Resident 1, Resident 2 & Resident 3) were provided with activities of daily living (ADLs-Activities related to personal care such as dressing, bathing and toileting) as required in their comprehensive care plans. The three residents were not provided with incontinence care (Cleaning the skin and changing the soiled undergarments and clothing of people with bowel or bladder incontinence [inability to control urination and defecation (The discharge of feces from the body)]), and two residents (Resident 1 & Resident 2) were not provided with bed repositioning as needed. […]

• Actual harm, isolatedF689Apr 18, 2023

  Based on interviews and records review, the facility failed to complete a wandering (traveling aimlessly from place to place) risk assessment and failed to provide oversight supervision to one of two sampled residents (Resident 1) when Resident 1 left the facility unsupervised on three occasions. This failure resulted to Resident being found on the ground outside of the facility twice and sustained fracture (broken bone) of the left pinkie (fifth digit) finger to which Resident 1 experienced pain. […]

• Actual harm, isolatedF685Sep 21, 2021

  Based on observation, interview and record review, the facility failed to arrange a follow-up appointment for vision care for 1 of 20 sampled residents (Resident 60) when Resident 60 verbalized she could not see well and needed new eyeglass. This failure resulted to Resident 60's inability to pursue her interest to read, stopped Resident 60 from watching T.V., feeling sad and uncomfortable because of headaches. Findings: During a clinical record review for Resident 60, the Progress Notes dated 11/17/20 indicated, the Director of Staff Development (DSD) spoke to the Nurse Practitioner (NP) about Resident 60's need for a new eyeglass. The NP stated to make an appointment for Resident 60. DSD called the Optical office but there was no available appointment. […]