Other·September 14, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey for Complaint # CA00518676. Inspection was limited to the Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #35362, Health Facilities Evaluator Nurse. One deficiency at F 309 was issued for Complaint # CA00518676.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 08/15/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 Facility ID: CA010000046 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555161 (X3) DATE SURVEY COMPLETED 05/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews, the facility failed to provide necessary care and services to maintain Resident 1's highest physical level of well-being when a treatment was not done resulting in an infection of a wound. A wound V.A.C. (Vacuum Assisted Closure) (a mechanical suctioning device (machine) used with a foam dressing for wound treatment and healing) treatment for one (Resident 1) of two residents receiving this treatment, was not changed according to physician orders. The treatment was signed by Licensed Staff A as completed. Licensed Staff A stated she had not actually completed the treatment. The failure to perform the ordered treatment resulted in an infection in Resident 1's wound. Resident 1 had to be re-admitted to the local hospital due to the infection. This failed practice has the potential for other treatments not being performed as ordered and causing other residents in the facility harm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 Facility ID: CA010000046 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555161 (X3) DATE SURVEY COMPLETED 05/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: On 01/18/17, the Department received a complaint alleging the facility had not taken care of Resident 1's wound as prescribed by the Physician. This "neglect" had resulted in an infection in Resident 1's wound. The wound had been "draining green purulent material", resulting in another hospitalization for Resident 1. Review of a document titled, "Admission-Clinical Admission Combined", dated 12/08/16, revealed Resident 1 was a 78 year old male who was admitted to the facility on 12/08/16. Resident 1 had abdominal surgery to repair a widening of the aorta (artery that carries blood to the stomach, pelvis, and legs). The surgery left Resident 1 with a wound in his right groin, which needed nursing care, and for which the wound V.A.C. treatment had been ordered. Resident 1's clinical record included a physician order in the "Treatment Administration History: 12/08/16- 01/04/17" to apply "Santly (collagenase clostridium histo.) (a medication) ointment; 250 units/gram; topical (onto the skin) once a day on Mon, Wed, Fri ", with Special instructions "white foam base, then black foam (used with the wound V.A.C.) continue to apply Santly to area of slough (whitish colored dead tissue) with dressing changes." The start date for the order was 12/28/16. The document revealed Licensed Staff A's initials on the page for 12/28/16 and 01/02/17. The document revealed a note by Licensed Staff A written on 01/02/17 at 18:33 (6:33 p.m.) "Comment: Done on time at 15:30 (3:30 p.m.)." During an interview and concurrent record review on 03/09/17 at 2:30 p.m., Licensed Staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 Facility ID: CA010000046 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555161 (X3) DATE SURVEY COMPLETED 05/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A was asked about Resident 1's wound condition on 01/02/17 when she had changed the wound V.A.C. Licensed Staff A stated she remembered Resident 1 but had never changed his wound V.A.C. Licensed Staff A confirmed the initial on the record were her initials, but she had not changed the wound V.A.C. on that day or any other day. Licensed Staff A stated she did not feel comfortable changing a wound V.A.C. Licensed Staff A stated she had initialed the record indicating the treatment and wound V.A.C. change had been done, but she had not done them. Licensed Staff A stated she had "signed it for other nurses" who told her that they were going to change it, "like (name), the treatment nurse, or support nurses." Licensed Staff A was asked who had changed the wound V.A.C. on 01/02/17 or 12/28/16, the two days she had initialed the wound V.A.C. change and treatment as being done. Licensed Staff A stated she was "not sure." Licensed Staff A stated "someone told me they would (change the wound V.A.C. and do the treatment) and I signed it. I'm not doing it any longer because I don't know if it gets done unless I put my hands on it or see it." Licensed Staff A stated she had learned her "lesson". Licensed Staff A confirmed there was no nursing progress note written on 01/02/17. During an interview on 03/09/17 at 2:35 p.m., Management Staff B stated the facility did not have a policy regarding the wound V.A.C. Management Staff B stated the facility followed physician orders and manufacture's guidelines. Management Staff B stated the company who provided the wound V.A.C. machine also provided the training. Management Staff B stated the training was now a web based training. Management Staff B was asked for the documentation and attendance sheets for the training. Management Staff B provided FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 Facility ID: CA010000046 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555161 (X3) DATE SURVEY COMPLETED 05/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documentation about training on the wound V.A.C. done in 03/17. No other training documentation about wound V.A.C. was provided. Management Staff B stated nurses would document the treatment and wound V.A.C. change on the treatment record. When asked about documentation in the nursing progress notes, Management Staff B stated nurses were expected to document in the progress notes if there was an "issue with the wound, like drainage, infection, or other issue." Management Staff B was asked to provide documentation about which licensed staff had been competent to change a wound V.A.C. in January 2017. No documentation was provided. During an interview and concurrent record review on 03/16/17 at 1:20 p.m., Management Staff C was informed that Licensed Staff A had documented on the treatment record that the treatment and wound V.A.C. had been changed per MD order, but Licensed Staff A had admitted she had not done so. Management Staff C stated she did not know what happened, and that maybe the treatment had been performed by the treatment nurse. Management Staff C confirmed that there was no progress note written regarding a wound V.A.C. change. Management Staff C stated she would "look into it". Management Staff C was informed Resident 1 had been re-admitted to a local hospital with an infection in his wound. Review of a document titled "Care Plan History" dated "Date Range:12/26/16-01/26/17" revealed no entry regarding a wound V.A.C. device. Review of a facility document titled "Wound Care Progress Note" dated 12/20/16 17:55 (5:55 p.m.) by Wound Consultant D revealed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 Facility ID: CA010000046 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555161 (X3) DATE SURVEY COMPLETED 05/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "...wound bed 80% pink granular (new healthy) tissue/20% scattered loose slough (whitish dead tissue)...small amount of serous (clear, thin) drainage in canister (< (less than) 25 ml), no odor, periwound with mild erythematous macropapular rash (red area with small bumps) with satellite lesions (injury) at inferior end of wound. Wound has improved." Review of a document titled "Cardiothoracic Surgery Office/Clinic Note" dated 12/22/16 12:18 PST (12:18 p.m.) (Pacific Standard Time) by Clinic Licensed Staff E, who assessed Resident 1 in the Clinic, revealed under "Physical Exam" "...Right groin incision clean, dry, intact." The document revealed under "Assessment/Plan: ...Wound vac intact at right groin site--still draining. Right groin clean and dry without sign of infection..." Review of the facility policy and procedure provided on 01/26/17 titled "Wound Care" dated 2001 (Revised April 2009) revealed under section "Preparation" 2. Review the resident's care plan to assess for any special needs of the resident. The document revealed under section "Documentation." The following documentation should be recorded in the resident's medical record: 1.The type of wound care given, 2. the date and time the wound care was given, 3. the position in which the resident was placed, 4. the name and title of the individual performing the wound care.5. Any changes in the resident's condition. 6. All assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. ...10. The signature and title of the person recording the data." Review of a document titled "Charting and Documentation" provided by the facility on 03/09/17 as facility Policy and Procedure, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 Facility ID: CA010000046 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555161 (X3) DATE SURVEY COMPLETED 05/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 2001 (Revised April 2008), revealed under Section "Documentation Criteria" ...6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum:... b. The name and title of the individual(s) who provided the care. Review of a local hospital document titled "History and Physical" dated 01/04/17 14:08 (2:08 p.m.) PST (Pacific Standard Time) revealed Resident 1's "Chief Complaint" "I have an infection in my right groin." The document revealed under "Review of Systems" General: "Depressed and does not want to return to that SNF (skilled nursing facility)." Neuro: A/O (alert and oriented) X4 (knows name, time, place, and situation). Extremities: ...Right groin wound vac not present, per patient not present for 2 days. Green purulent discharged (sic)." Review of a local hospital document titled: "Procedure Note" dated 01/04/17 17:26 PST revealed under "Indication for Procedure" "...The wound broke down requiring debridement and placement of wound VAC, patient was seen in the office today there was greenish drainage from the wound patient was admitted..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 Facility ID: CA010000046 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555161 (X3) DATE SURVEY COMPLETED 05/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIV511 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA010000046 (X5) COMPLETE DATE If continuation sheet 8 of 8