Napa Valley Care Center

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on July 29, 2026.

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CMS lists this as a complaint inspection.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on June 10, 2026.

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• Health citation

  CMS changed citation F0686 from severity G to D. It is from the health inspection on January 10, 2024. Severity D: potential for more than minimal harm, isolated.

• Health citation

  CMS changed citation F0697 from severity H to D. It is from the health inspection on September 21, 2023. Severity D: potential for more than minimal harm, isolated.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on August 21, 2025.

  CMS has cited this home for F0812 3 times since 2021.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 21, 2025.

  CMS has cited this home for F0880 4 times since 2021.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on August 21, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on August 21, 2025.

  CMS has cited this home for F0656 2 times since 2021.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on August 21, 2025.

  CMS has cited this home for F0684 2 times since 2019.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on August 21, 2025.

• Citation F0725. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on August 21, 2025.

  CMS has cited this home for F0725 3 times since 2024.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on August 21, 2025.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on August 21, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on August 21, 2025.

• Citation F0814. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on August 21, 2025.

• Citation F0825. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or get specialized rehabilitative services as required for a resident.

  CMS lists it as corrected on August 21, 2025.

• Citation F0921. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on August 21, 2025.

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CMS lists this as a standard inspection.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on August 11, 2025.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on August 5, 2025.

  CMS has cited this home for K0291 2 times since 2021.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on August 6, 2025.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 10, 2025.

  CMS has cited this home for K0353 2 times since 2019.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on August 5, 2025.

  CMS has cited this home for K0918 2 times since 2019.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on August 5, 2025.

  CMS has cited this home for K0363 3 times since 2019.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on August 15, 2025.

  CMS has cited this home for K0161 2 times since 2021.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on August 7, 2025.

  CMS has cited this home for K0324 2 times since 2021.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on August 10, 2025.

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CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on May 15, 2025.

  CMS has cited this home for F0609 2 times since 2024.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on April 24, 2025.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Fine

  CMS changed the fine from July 13, 2022 from $9,750 to $9,945.

• Fine

  CMS changed the fine from September 13, 2023 from $29,708 to $30,259.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 11, 2025.

  CMS has cited this home for F0689 2 times since 2024.

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CMS lists this as a complaint inspection.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  CMS lists it as corrected on February 10, 2025.

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• Fine

  CMS changed the fine from July 13, 2022 from $15,000 to $9,750.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on November 13, 2024.

  CMS has cited this home for F0658 2 times since 2024.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on November 13, 2024.

• Citation F0557. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on November 13, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on November 13, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 13, 2024.

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• Fine

  CMS changed the fine from September 13, 2023 from $45,705 to $29,708.

• Ownership

  CMS lists this home under a new chain.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on August 20, 2024.

• Citation F0881. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on August 21, 2024.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on August 20, 2024.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on April 2, 2024.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on April 2, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on April 2, 2024.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on April 2, 2024.

  CMS has cited this home for F0584 2 times since 2023.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a complaint inspection.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on January 24, 2024.

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CMS lists this as a complaint inspection.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on January 9, 2024.

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CMS lists this as a complaint inspection.

• Citation F0623. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on November 26, 2023.

• Citation F0622. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

  CMS lists it as corrected on November 26, 2023.

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CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

17 of 1,165 California homes (1%) got a citation at the actual harm level in 2021.

• Citation F0685. Severity G: actual harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on February 16, 2022.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on February 16, 2022.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 16, 2022.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on February 16, 2022.

• Citation F0657. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on February 16, 2022.

• Citation F0740. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on February 16, 2022.

• Citation F0802. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  CMS lists it as corrected on February 16, 2022.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on February 16, 2022.

• Citation F0806. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on February 16, 2022.

• Citation F0808. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

  CMS lists it as corrected on February 16, 2022.

• Citation F0868. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  CMS lists it as corrected on February 16, 2022.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on February 16, 2022.

• Citation F0637. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident when there is a significant change in condition

  CMS lists it as corrected on February 16, 2022.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on February 16, 2022.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on February 16, 2022.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on February 16, 2022.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on February 16, 2022.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on February 16, 2022.

• Citation F0865. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS lists it as corrected on February 16, 2022.

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CMS lists this as a standard inspection.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on November 2, 2021.

• Citation K0291. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on November 2, 2021.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on November 2, 2021.

• Citation K0347. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly provide smoke detection systems in areas open to corridors.

  CMS lists it as corrected on November 2, 2021.

  CMS has cited this home for K0347 2 times since 2019.

• Citation K0511. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on November 2, 2021.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on November 2, 2021.

• Citation E0015. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on November 2, 2021.

• Citation E0023. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on November 2, 2021.

• Citation E0026. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish roles under a Waiver declared by secretary.

  CMS lists it as corrected on November 2, 2021.

• Citation E0030. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on November 2, 2021.

• Citation E0032. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on November 2, 2021.

• Citation E0041. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Implement emergency and standby power systems.

  CMS lists it as corrected on November 2, 2021.

• Citation K0161. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on November 2, 2021.

• Citation K0321. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on November 2, 2021.

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CMS lists this as a standard inspection.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on September 18, 2019.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on September 18, 2019.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on September 18, 2019.

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CMS lists this as a standard inspection.

• Citation K0347. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly provide smoke detection systems in areas open to corridors.

  CMS lists it as corrected on October 9, 2019.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on October 9, 2019.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on October 9, 2019.

• Citation K0521. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on October 9, 2019.

• Citation K0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on October 9, 2019.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on October 9, 2019.

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