Other·October 22, 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 a RECERTIFICATION survey from 7/16/18 to 7/20/18. Representing the Department: Health Facilities Evaluator Nurses #37797, 31424, 38628, 39792, and Pharmacy Consultant #25447. Census on date of entry, 7/16/18, was 44 residents and there were 12 sampled residents. Three Facility Reported Incidents CA00542632, CA00546758, and CA00541468 were included in the survey and were substantiated with no deficiencies.

F578 SS=F Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 08/20/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). 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: ODJ411 Facility ID: CA010000053 If continuation sheet 1 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide 44 of 44 residents written information about advance directives (advance directives are documents in which residents state how they should be cared for in case they lose capacity to make decisions for themselves). This failure had the potential to prevent residents from creating advance directives. Findings: During an interview on 07/18/18, at 10:40 a.m., the Social Services Director (SSD) was asked if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 2 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 the facility provided written information about advance directives to residents upon their admission to the facility. The SSD stated the facility did not provide written information to residents about advance directives. The SSD stated the facility did not have written materials about advance directives for residents. The SSD stated the facility provided advanced directive forms to residents if they requested them. During an interview on 7/20/18, at 11:30 a.m., the Director of Nursing (DON) confirmed no written information about advance directive was available or provided to residents upon admission. The DON stated it was the residents' family responsibility to create advance directives for the residents if they wished to formulate them. Facility policy titled "Advance Directives", revised December 2016, indicated: "Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so."

F584 SS=E Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 08/20/2018 Facility ID: CA010000053 If continuation sheet 3 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 4 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment to two of 12 sampled residents (Residents 22 and 37) and three unsampled residents (Residents 14, 17 and 33) when: 1. The water temperature in the shower rooms did not remain at the desired temperature, which resulted in discomfort for Residents 14, 17, 33 and 37 during showers; 2. The door to Resident 22's room was kept constantly open, which resulted in discomfort for Resident 22 and infringed on his privacy; and 3. The water faucet in Resident 37's bathroom sink was leaking which upset Resident 37. These failures prevented Residents 14, 17, 22, 33 and 37 from having a comfortable and homelike environment. Findings: 1. During a resident group interview on 7/17/18, starting at 10 a.m., Residents 14, 17, 33 and 37 stated the water temperature in the shower rooms did not remain at the temperature desired during showers. The Residents stated once they got under the shower, the water temperature started to go up and down without any adjustment inputs from residents or staff. The Residents stated the water temperature variation created an uncomfortable shower experience for them. Resident 14 stated she had been a resident at the facility for 7 years and this was a recurrent problem that the facility seemed to be always working on. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 5 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 During an interview with the Director of Maintenance (DM) on 7/17/18, at 11:35 a.m, the DM stated the facility had two shower rooms: Shower Room #1 and Shower Room #2. During a concurrent observation of Shower Room #2, the DM opened the shower faucet and set the water temperature to the hottest setting. The DM measured the water temperature and the thermometer recorded 106°F (Fahrenheit). Without further inputs from the DM, the water temperature dropped to 96°F and then rose to 106°F. The shower water temperature continued to spontaneously fluctuate between 96°F and 106°F. During an observation of the Shower Room #1 with the DM on 7/17/18, at 11:45 a.m., the DM opened the shower faucet and set the water temperature to the hottest setting. The DM measured the water temperature and the thermometer recorded 108°F. The DM then turned the water faucet to a colder setting. The DM stated: "You can hear the cold water mixing in". The DM then measured the water temperature and it was 99°F. Without further inputs from the DM, the water temperature rose to 106°F and then dropped to 93°F. When asked the reason for the variation in water temperature in the shower rooms the DM stated the boiler pump needed replacement. Facility policy titled "Quality of Life - Dignity", dated 2001, indicated: "Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality." 2. During an observation on 7/17/18, at 11:24 a.m., Resident 22's room door was open. Resident 22's bed was located next to the door to the room facing a hallway used by staff, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 6 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 residents and visitors. A sign next to Resident 22's room door indicated "Please leave door open". During a concurrent interview, Resident 22 stated he would like to have the door closed but staff kept the door open. He stated the noise from the hallway bothered him and affected his sleep, resulting in discomfort. He stated he had no privacy because the door was kept constantly open. During an interview with the Director of Nursing (DON) on 7/19/18, at 2:20 p.m., the DON stated Resident 22's room door was kept open for better air circulation in the room (because the room tended to get hot) and for the safety of Resident 22, because Resident 22 was at risk for falls. The DON stated if Resident 22 fell, there would be no way for staff to know if the door was closed, but with the door open, staff walking by the hallway would see if he had fallen. The DON stated Resident 22's door was kept open day and night. Facility policy titled "Quality of Life - Dignity", dated 2001, indicated: "Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality." "Resident's private space and property shall be respected at all times." 3. During an interview on 7/16/18, at 10:25 a.m., Resident 37 stated the water faucet in his bathroom sink was dripping and had been dripping for the past two months. Resident 37 stated: "Everybody knows about it but nobody does anything about it". Resident 37 stated it bothered him because it was a waste of water. During a concurrent observation, the faucet in Resident 37's bathroom sink was set to the closed setting but water was coming out as if it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 7 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 was open. During an observation with the Assistant Director of Maintenance (ADM) on 7/16/18, at 11:15 a.m., the ADM verified the faucet in Resident 37's bathroom sink was leaking water. Facility policy titled: "Maintenance Service", dated April 2013, indicated: "Maintenance service shall be provided to all areas of the building, grounds and equipment." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 8 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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

F623 Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/20/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 9 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 10 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide notice of discharge for one of three residents (Resident 43) to the Office of the State Long-Term Care Ombudsman. This failure prevented the Ombudsman from advocating for Resident 43. Findings: A review of Resident 43's "Admission Record" indicated she was admitted to the facility on 4/16/18 with a primary diagnosis of left knee effusion (swelling of the knee because of water accumulation around the knee joints). During an interview with the Social Services Director (SSD) on 7/20/18, at 10:35 a.m. the SSD stated Resident 43 was discharged on 4/25/18. The SSD was asked if the discharge was initiated by the facility or at the request of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 11 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 Resident 43. The SSD stated Resident 43 was discharged because she completed her physical therapy. The SSD was asked if there was any indication in Resident 43's record that Resident 43 initiated the discharge. The SSD searched the record but did not provide any evidence Resident 43 initiated the discharge. A review of Resident 43 clinical record indicated the facility issued a "Notice of Proposed Transfer/Discharge" (The Notice of Discharge) to Resident 43 on 4/25/18. The Notice indicated: "You have been notified of the decision to transfer or discharge. If it is your decision to appeal the proposed transfer or discharge, please be aware that you have the following rights regarding your appeal hearing..." During an interview with the Social Services Director (SSD) on 7/20/18, at 10:35 a.m., the SSD was asked if the facility provided a copy of Resident 43's Notice of Discharge to the Office of the State Long-Term Care Ombudsman (The Ombudsman is an advocate for the elderly). The SSD searched Resident 43's record but found no indication the facility sent a copy of Resident 43's Notice of Discharge to the Ombudsman. During an interview on 7/19/18, at noon, the Ombudsman stated the facility had not been informing her office of resident discharges, which was preventing her from advocating for discharged residents. A review of the facility's "Discharge Summary and Plan", revised December 2012, had no indication of provisions to nofity the Ombudsman of resident transfers and discharges. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 12 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/20/2018 SS=E CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 2 of 12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 13 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 sampled residents (Resident 40 and Resident 12), who had a Stage 3 pressure ulcer or deep tissue injury (DTI) respectively, received care and treatment to promote healing and prevent new ulcers from forming when the facility: 1) failed to timely notify Resident 40's physician after Resident 40 developed a pressure ulcer; 2) failed to provide an appropriate support surface (bed) to Resident 40 after Resident 40 was diagnosed with a Stage 3 pressure ulcer; and 3) failed to ensure Residents 40 and 12 received timely nutritional assessments (which assess nutritional needs and are designed to promote wound healing) after they were diagnosed with a Stage 3 pressure ulcer and deep tissue injury while living at the facility. A Stage 3 pressure ulcer (also known as pressure sore, pressure injury, and bedsore; localized damage to the skin and/or underlying tissue as a result of pressure or pressure in combination with shear and/or friction) includes full thickness skin loss where subcutaneous fat may be visible. A DTI injury is injury to tissue below the skin's surface caused by excessive pressure to an area. These failures contributed to a potential delay in treatment for Resident 40's pressure injury and Resident 12's deep tissue injury. Pressure injuries can cause pain, lead to infection, and increase risk of death (Institute for Health Improvement, 2007). Failure to aggressively treat pressure wounds may result in increased pain and potential infections. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 14 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 1) During an observation on 7/18/18, at 10:43 a.m., Resident 40 was observed lying on her back. Medical record review of a nurse skin assessment for Resident 40, dated 4/25/18, indicated Resident 40 had "shearing"on her sacrum that measured 0.8 centimeters (cm) by 1.2 cm , by 0.1 cm (deep). (The sacrum is the area located at the lower spine, just above the buttocks). Shear occurs when two surfaces move in the opposite direction (sliding down in bed when the head is elevated). Shear, which can damage the underlying tissue like fat and muscle, is one of the primary contributing factors for pressure ulcers (Mayo Clinic; https://www.mayoclinic.org/diseasesconditions/bed-sores/symptomscauses/syc-20355893). Medical record review of a nurses note for Resident 40, dated 5/31/18, indicated Resident 40 had a "pressure injury to sacrum (location where shearing was documented on 4/25/28)" that measured 1 centimeter (cm), by 1 cm, by 0.2 cm. Medical record review of a "Weekly Pressure Ulcer Record," dated 6/6/18, indicated Resident 40 had a pressure ulcer to her sacrum that now measured 1.3 cm, by 1 cm, by 0.3 cm. The document indicated the date of onset was 5/31/18. The document indicated the "Physician/Family/Dietary" were notified of the pressure ulcer on 6/6/18 (six days later). Medical record review on 07/17/18 at 10:03 a.m. indicated Resident 40's physician had ordered wound care and wound measurement for a Stage 3 pressure ulcer to the sacrum on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 15 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 6/8/18 (eight days after the notification of a pressure ulcer). 2) During an observation on 7/20/18 at 9:40 a.m., Resident 40 was in a wheelchair, returning from the shower room. A foam mattress was on her bed. During an interview on 7/20/18 at 11:40 a.m., the DON was asked why Resident 40 had a foam mattress on her bed when she had a Stage 3 pressure ulcer. The DON stated a resident with a Stage 3 pressure ulcer should have a "Hi/Low" mattress (a pressure relieving mattress). When asked why Resident 40 did not have a Hi/Low mattress, the DON stated it should have happened. Review of facility policy titled, "Prevention of Pressure Ulcers" subtitled, "Interventions and Preventive Measures: General" (revised 10/2010) indicated, "2.b. Determine if resident needs a special mattress." Pressure redistribution is the most important feature of a support surface. The body's tissues can withstand higher loads of pressure for short periods of time and lower loads for longer periods of time. A surface that effectively redistributes pressure across the entire body (contact) surface effectively reduces the amount of pressure and extends the time a patient can safely remain in one position (WOCN, 2016b). Review of a publication by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance, titled, "Prevention and Treatment of Pressure Ulcers: Quick Reference Guide" (dated 2014) indicated, "Consider using a high specification reactive foam mattress or nonpowered pressure redistribution support FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 16 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 surface for individuals with ...State I and II pressure ulcers..." Select a support surface that provides enhanced pressure redistribution, shear reduction, and microclimate control for individuals with ...Stage III, IV, and unstageable pressure ulcers." Review of Resident 40's mattress's product catalog (provided by the facility), titled "(Product Name) Long Term Care Pressure redistribution Mattress" (undated) indicated the mattress was layered, high density foam which provided pressure redistribution. The document did not indicate the mattress provided enhanced pressure redistribution, shear reduction or microclimate control. The National Pressure Ulcer Advisory Panel recommends an assessment of a residents support surface. The surface must be selected that will meet the patient's needs considering the patient's need for pressure redistribution based on the following factors: level of immobility and inactivity; need for microclimate control and shear reduction; size and weight of the patient; risk for development of new pressure ulcers as well as the number, severity, and location of existing pressure ulcers (NPUAP, 2014). 3a) During an observation and interview on 07/17/18 at 9:18 AM, Resident 40 was in bed and she looked thin. She stated she had lost weight. She stated she ate small amounts of food. Medical record review of a nurses note for Resident 40, dated 5/31/18, indicated Resident 40 had a "pressure injury to sacrum." Medical record review of Resident 40's weight summary, from 3/22/18 (admission) to 6/4/18 indicated Resident 40 had an approximate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 17 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 fifteen pound weight loss. Resident 40's medical record indicated a dietician saw her on 3/30/18 and again on 4/25/18. No other Registered Dietitian's (RD) notes were documented until 6/15/18 (approximately two weeks after nursing documented Resident 40 had a Stage 3 pressure ulcer). During electronic medical record review and interview on 7/20/18 at 11:40 a.m., the DON was asked to review Resident 40's medical record concerning her pressure ulcer and nutrition. The DON stated Resident 40 had been assessed for weight loss by dietary on 4/25/18 (prior to the pressure ulcer development) and she was started on fortified cereal at breakfast. The DON stated she saw no other RD notes in the electronic record until June 15, 2018 (two weeks after the pressure ulcer was identified). When asked what was her expectation for a timely RD nutritional assessment, the DON stated Resident 40 "should have been seen right away." When asked why this was important, the DON stated that Resident 40 had a new issue (Stage 3 pressure ulcer) and proper nutrition would help with wound healing. The DON stated she had had communication issues with the RD's, some information was delayed, and some recommendations were not started. During a telephone interview on 7/20/18 at 12:40 p.m., the RD was asked why Resident 40 had not been seen by dietary services until two weeks after her diagnosis with a Stage 3 pressure ulcer. The RD stated her expectation would be for Resident 40 to have been seen right away. 3b) During an observation on 7/16/18, Resident 12 was sitting in her wheelchair. She had a boot on her left foot. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 18 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 Medical record review of a nurses note for Resident 12, dated 5/10/18, indicated she had a suspected deep tissue injury (DTI) to her left heel. Medical record review revealed an RD note that documented Resident 12 had been assessed on 6/6/18 by the RD (approximately four weeks after her injury was documented). During electronic medical record review and interview on 7/20/18 at 11:40 a.m., the DON was asked to review Resident 12's medical record concerning her DTI. The DON stated Resident 12 was diagnosed with a DTI on her heel on 5/10/18. She stated she had a pressure relieving mattress on her bed and wore a special boot to relieve pressure. The DON stated Resident 12 had a dietary note and nutritional note dated 4/11/18 (prior to her DTI). She stated the next note was June 6th (almost four weeks after her DTI was diagnosed). The DON stated the RD "should have seen her within a couple of days." The DON confirmed Resident 12's July quarterly nutritional assessment was currently missing. Review of facility policy titled, "Pressure Ulcer/Skin Breakdown - Clinical Protocol," subtitled, "Treatment/Management" (revised April 2018) indicated the facility should try to, "maintain a stable weight" and provide, "approximately 1.2-1.5 gm/kg (grams per kilograms) protein daily." The document indicated, "2.c. any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status ..." Pressure ulcers usually occur over bony prominence such as the sacrum... and heel... Other factors-such as shearing, and poor nutrition...also contribute to the tissue breakdown (National Pressure Ulcer Advisory FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 19 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 Panel).

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 08/20/2018 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews, the facility failed to ensure the Consultant Pharmacist reported irregularities in a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 20 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 resident's drug regimen to the attending physician, the Medical Director and the Director of Nursing for one of 12 sampled residents (Resident 24) in accordance with federal requirements and the facility's policy and procedures for the purpose of preventing administration of unnecessary medications. A physician (Physician B) prescribed Seroquel, an antipsychotic with a Boxed Warning, to the elderly resident diagnosed with "dementia with no behavioral disturbances" and no history of schizophrenia or bipolar disorder. Seroquel was routinely administered between 1/20/18 and 7/11/18. Monitoring Seroquel for effectiveness was limited to a single behavior "delusion" as evidenced by "calling her roommate as her mother." The Consultant Pharmacist reviewed the resident's drug regimen six times during that period; however, he did not identify or report irregularities (e.g. lack of documentation in the medical record of an indication and an adequate monitoring plan to evaluate the effectiveness of the medication). The facility's failure to ensure Resident 24's drug regimen was free of unnecessary medication placed Resident 24, at risk for adverse events including death. According to the manufacturer's label, Seroquel is indicated for the treatment of schizophrenia and bipolar disorder and contains the boxed warning: "WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; and SUICIDAL THOUGHTS AND BEHAVIORS. Increased Mortality in Elderly Patients with Dementia-Related Psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL is not approved for the treatment of patients with dementia-related psychosis." [Reference: www.dailymed.nlm.nih.gov] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 21 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 Definitions: Boxed Warning: The strongest warning that the Food and Drug Administration (FDA) requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. [Reference: www.fda.gov] DailyMed is a nationally-recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration. Findings: A review of Resident 24's Face Sheet dated 7/18/18 showed she was a 98 year old admitted 7/31/2017 with the following diagnosis: "Unspecified dementia without behavioral disturbance and essential hypertension." Hypertension is high blood pressure. A review of physician's orders showed at the time of admission she had not been prescribed an antipsychotic. A review of Resident 24's Physicians Orders dated 1/2/18 showed Physician B ordered "Seroquel 12.5 milligram tablet once daily for 1700 [5PM] for delusional thinking / hallucinations." A record review showed no evidence that Seroquel was used to treat a specific, diagnosed and documented condition. A record review of a Progress Note, dated 1/20/18, signed by Physician B showed, "Behavior again escalating. Trial Seroquel." A record review of a Progress Note, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 22 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 2/16/18, signed by Physician B showed, "Dementia with behavior problems, recent elopement, paranoia, aggressive towards staff. Now much better with start of Seroquel. More interactive with staff and participating in activities. Continue same dose for now and will try to taper next month if continuing to do well." A record review showed no evidence that resident-specific medication related goals and parameters were established for staff to monitor Resident 24's progress while on Seroquel. A record review of Resident 24's Medication Administration Records (MARs) for the months January 2018, February 2018, March 2018, April 2018, May 2018, June 2018, and July 2018 showed the facility administered Seroquel as ordered between the inclusive period 1/20/18 and 7/11/18. The MAR showed nursing staff monitored one behavior every shift specific to Seroquel "AEB [as evidenced by] delusion (calling her roommate as her mother)." The MARs showed the chart code for "11" corresponded to "No behavior noted." The only code entered by nursing staff between the inclusive period 1/20/18 and 7/11/18 was "11" which indicated the resident did not exhibit one instance of behavior for which the Seroquel was administered. Monitoring for effectiveness of Seroquel did not include elopement attempts, paranoia, or aggression towards staff. On 7/17/18 at 9:00 a.m. during a concurrent interview and a review of Resident 24's medical record, the Director of Nursing stated the resident was started on Seroquel because she had dementia and was angry, depressed, packing up clothes, and pushed staff against the wall once." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 23 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 On 7/16/18 at 11:11 a.m. during an interview, the Director of Nursing stated the Consultant Pharmacist submitted reports of monthly drug regimen reviews for each resident. She said, "Last done July 11, 2018." The Director of Nursing stated the Consultant Pharmacist did not report any irregularities to him regarding Seroquel on Resident 24's drug regimen. On 7/17/18 at 12:05 p.m. during concurrent interview and a review of Resident 24's medical record and DRR reports titled, Director of Nursing Report (also known as the DRR and Medication Regimen Review) with the DON and the Consultant Pharmacist, the Director of Nursing said, "We use dementia with agitation for indication for Seroquel and atypical antipsychotics." The Consultant Pharmacist said, "The indication for the drug is delusional thinking and hallucinations. That would be an appropriate indication for the use of Seroquel certainly. A psychiatric diagnosis would justify the use of Seroquel." The Consultant Pharmacist stated he conducted a Drug Regimen Review (DRR) for Resident 24 on 7/11/18 to identify irregularities with medications. The Consultant Pharmacist said, "Yes I have done the DRR. My stamp is on Physician's Orders ... July 11, 2018 stamp is on paper." The Consultant Pharmacist stated the only irregularity he identified for Resident 24 since 1/20/18 was on the Director of Nursing Report dated 7/11/18 which indicated, "Lab results could not be found in Resident's chart please clarify and correct." The Consultant Pharmacist said," I assume I did not identify any irregularities with Seroquel." A review of the DRR monthly reports between 1/20/18 and 7/17/18 showed the Consultant Pharmacist did not identify any irregularities with Seroquel for Resident 24 or report them to the Medical Director or the DON as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 24 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 * On 2/7/18 the Consultant Pharmacist documented, "No recommendation" * On 3/14/18 the Consultant Pharmacist documented, "No recommendation" * On 4/9/18 the Consultant Pharmacist documented, "No recommendation" * On 5/10/18 the Consultant Pharmacist documented, "No recommendation" * On 6/21/18 the Consultant Pharmacist documented, "No recommendation" * On 7/11/18 the Consultant Pharmacist documented, "No recommendation" On 7/17/18 at 12:30 p.m. during an interview and concurrent medical record review, Physician B denied Resident 24 had been diagnosed with schizophrenia or bipolar disorder. Physician B said Resident 24 "had psychosis" but a record review showed no documented diagnosis of psychosis in the medical record. Physician B indicated she prescribed Seroquel for Resident 24's behaviors. She said Resident 24's behaviors were "frowning, hitting, pursed brows, pacing and went outside." Physician B indicated the Consultant Pharmacist did not report any irregularities to her regarding Seroquel on Resident 24's drug regimen. On 7/17/18 at 3:12 p.m. during an interview, the Medical Director said, "[Resident 24] we did not discuss in IDT [Interdisciplinary Team] meetings." The Medical Director indicated the Consultant Pharmacist did not report any irregularities to him regarding Seroquel on Resident 24's drug regimen. He said, "[Nurse Practitioner] A nurse practitioner recommended a psychiatric medication evaluation and [Physician B] declined." A review of the facility's policy, Medication Regimen Review and Reporting, dated 11/17 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 25 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 showed, "The consultant pharmacist reviews the medication regimen in medical chart of each resident at least monthly to appropriately monitored the medication regimen and ensure that the medications each resident receives are clinically indicated. The findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filed with other consultant pharmacist recommendations and the resident's chart."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 08/20/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 26 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews, the facility failed to ensure one of 12 sampled residents (Resident 24) drug regimen was free from the unnecessary medication Seroquel, an antipsychotic, when there was an absence of a documented indication and monitoring plan for effectiveness of the medication in the medical record. A physician (Physician B) prescribed Seroquel, an antipsychotic with a Boxed Warning, to the elderly resident diagnosed with "dementia with no behavioral disturbances" and no history of schizophrenia or bipolar disorder. Seroquel was routinely administered between 1/20/18 and 7/11/18. The facility's monitoring Seroquel for effectiveness was limited to a single behavior "delusion" as evidenced by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 27 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 "calling her roommate as her mother." The facility's failure placed the resident, an elderly woman with dementia, at risk for adverse events including death. According to the manufacturer's label, Seroquel is indicated for the treatment of schizophrenia and bipolar disorder and contains the boxed warning: "WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; and SUICIDAL THOUGHTS AND BEHAVIORS. Increased Mortality in Elderly Patients with Dementia-Related Psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL is not approved for the treatment of patients with dementia-related psychosis." [Reference: www.dailymed.nlm.nih.gov] Definitions: Boxed Warning: The strongest warning that the Food and Drug Administration (FDA) requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. [Reference: www.fda.gov] DailyMed is a nationally-recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration. Findings: A review of the resident's Face Sheet dated 7/18/18 showed she was a 98 year old admitted 7/31/2017 with the following list of diagnoses: "Unspecified dementia without behavioral disturbance and essential FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 28 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 hypertension." Hypertension is high blood pressure. A review of Physician's Orders showed at the time of admission the resident had not been prescribed an antipsychotic. A review of the resident's Physicians Orders dated 1/2/18 showed Physician B ordered "Seroquel 12.5 milligram tablet once daily for 1700 [5PM] for delusional thinking / hallucinations." A review of the resident's record showed no evidence that Seroquel was used to treat a specific, diagnosed and documented condition. A review of the resident's Progress Note, dated 1/20/18, signed by Physician B showed, "Behavior again escalating. Trial Seroquel." A review of the resident's Progress Note, dated 2/16/18, signed by Physician B showed, "Dementia with behavior problems, recent elopement, paranoia, aggressive towards staff. Now much better with start of Seroquel. More interactive with staff and participating in activities. Continue same dose for now and will try to taper next month if continuing to do well." A review of the resident's record showed no evidence that resident-specific medication related goals and parameters were established for staff to monitor her progress while on Seroquel. A review of the resident's Medication Administration Records (MARs) for the months January 2018, February 2018, March 2018, April 2018, May 2018, June 2018, and July 2018 showed the facility administered Seroquel as ordered between the inclusive period 1/20/18 and 7/11/18. The MAR showed nursing staff monitored one behavior every shift specific to Seroquel "AEB [as evidenced by] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 29 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 delusion (calling her roommate as her mother)." The MARs showed the chart code for "11" corresponded to "No behavior noted." The only code entered by nursing staff between the inclusive period 1/20/18 and 7/11/18 was "11" which indicated the resident did not exhibit one instance of behavior for which the Seroquel was administered. Monitoring for effectiveness of Seroquel did not include elopement attempts, paranoia, or aggression towards staff. 7/17/18 at 9:00 a.m. during a concurrent interview and a review of the resident's medical record the Director of Nursing indicated the resident was started on Seroquel because she had dementia and was angry, depressed, packing up clothes, and pushed staff against the wall once." The Director of Nursing indicated antipsychotics were not discussed in Interdisciplinary Team Meetings (IDT). She said, "We only discuss falls." On 7/17/18 at 12:05 p.m. during concurrent interview and a review of the resident's medical record and DRR reports titled, Director of Nursing Report with the Director of Nursing and the Consultant Pharmacist (on the telephone), the Director of Nursing said, "We use dementia with agitation for indication for Seroquel and atypical antipsychotics." The Consultant Pharmacist said, "The indication for the drug is delusional thinking and hallucinations. That would be an appropriate indication for the use of Seroquel certainly. A psychiatric diagnosis would justify the use of Seroquel." The Consultant Pharmacist indicated that the facility had a consistent process to monitor the adverse effects of Seroquel. He said, "We usually have a sticker with adverse side effects." He indicated he could not recall whether or not the physician established parameters for staff to observe or tracked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 30 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 progress toward goals for evaluating the ongoing need for the medication. On 7/17/18 at 12:30 p.m. during an interview Physician B (on the telephone) indicated she prescribed Seroquel for the resident's behaviors. Physician B said the resident's behaviors were "frowning, hitting, pursed brows, pacing and went outside." Physician B denied the resident had been diagnosed with any of the following labeled indications: chronic psychiatric illness such as schizophrenia or schizoaffective disorder, bipolar disorder, depression, post-traumatic stress disorder; Huntington's disease, Tourette's syndrome (neurological illnesses) or psychotic episodes. Physician B said the resident's "had psychosis." A review of the resident's record showed no documented diagnosis of psychosis. On 7/17/18 at 3:12 p.m. during an interview, the physician and Medical Director said, "We did not discuss Seroquel [for Resident 24] in IDT meetings." He said, "The situation began acutely and continued chronically. Seroquel was used acutely and continued chronically." He indicated the resident had visual hallucinations. He said, "[Nurse Practitioner] A nurse practitioner recommended a psychiatric medication evaluation and [Physician B] declined." The Medical Director indicated that a tool had been provided to guide to prescribers how to document appropriate behavior monitors for antipsychotics. A review of the hospital's undated procedure titled, Appropriate Behavior Monitors for Antipsychotics, showed the following words in the "Can Use" section: tripping others, ramming others, pushing, slapping, head banging, selfinflicted injuries, purposeful vomiting, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 31 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 continuous crying out, continuous yelling, continuous screening, speeding, biting, kicking, scratching, fighting, hallucinations (with the notation "be specific"), extreme fear, delusions (with the notation "be specific"), pinching, and throwing objects. A review of the hospital's undated procedure titled, Appropriate Behavior Monitors for Antipsychotics, showed the following words in the "Can't Use" section: pacing, wandering, climbing out of bed, restlessness, crying out (occasional), yelling (occasional), screeming (occasional), anxiety, depression, insomnia, and sociability, fidgeting, nervous is, uncooperativeness, PRN [As needed] use, and dementia." A review of an untitled two-page fax dated 1/25/18 at 2:28 p.m., showed Resident 24's name on the first page. It showed Physician B checked a box under the ninth choice under the heading Diagnosis and Condition next to this statement, "Dementing illnesses with associated behavioral problems." She circled the second choice under the heading Criteria next to this statement, "The behavioral symptoms present a danger to the resident or others." The second page showed Seroquel was used for "delusional thinking / hallucinations." There was no description of how these behaviors presented a danger to the resident or others.

F801 SS=F Qualified Dietary Staff CFR(s): 483.60(a)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F801 Event ID: ODJ411 08/20/2018 Facility ID: CA010000053 If continuation sheet 32 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 33 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to employ a qualified director of food and nutrition services. This failure caused potential for inadequate supervision of the dietary department. Findings: During the initial kitchen tour on 7/16/18 at 10 a.m., Cook F was in the kitchen and she stated Cook G had been acting as the Dietary Supervisor for approximately one month (when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 34 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 the prior dietary supervisor stopped working at the facility). During an interview on 07/17/18 at 3:24 p.m., Cook G stated he had been acting as the Dietary Supervisor for approximately two months. Cook G stated he was currently in school and he anticipated completing the Dietary Supervisor program in three quarters (approximately 1 year). During an interview on 7/18/18 at 3:45 p.m., the Registered Dietician (RD) stated she had been working at the facility since 6/2018. She stated she worked one, eight-hour day per week. The RD stated Cook G was acting as the Dietary Supervisor because the prior Dietary Supervisor had stopped working at the facility at the beginning of July (2018). The RD stated Cook G was attending school for CDM (certified dietary manager). The RD was asked what type of training Cook G received in order to be able to act as the Dietary Supervisor. She stated she did not know what his actual training had been (she was not working at the facility at that time). She was unsure if the prior RD had trained him. The RD stated Cook G was an experienced cook. During an interview on 7/19/18 at 11:50 a.m., the Director of Nursing (DON) and Cook G were in the DON's office. Cook G was asked what new tasks he was performing, since the prior Dietary Supervisor had left. Cook G stated he was now doing staff scheduling, food ordering, and patient intakes (resident food preference assessment). Cook G was asked how he was trained to perform his new duties as acting Dietary Supervisor/manager. He stated he had "no formal training." During an interview on 7/19/18 at 2:30 p.m., the Administrator stated the previous Dietary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 35 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 Manager (Supervisor) had stopped working at the facility 6/28/18. During an interview on 7/20/18 at 1:30 p.m., the Administrator was asked why the facility had not increased RD coverage to full time after the previous Dietary Supervisor had stopped working at the facility. The Administrator stated the facility had increased the RD to two day per week and had increased Cook G's time. He stated the facility was recruiting a CDM (certified dietary manager). Review of facility policy titled, "Director of Food Services," subtitled, "Specific Requirements" (dated 2003) indicated the Director (Supervisor/Manager), "Must be registered as a Food Service Director in this state."

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 08/20/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 36 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when staff did not wear an apron when handling dirty dishes and did not remove a dirty apron before handling clean dishes. These failures caused potential for contamination of the clean dishes, which placed residents at risk of foodborne illness. Findings: During a kitchen tour on 7/18/18 at approximately 4:40 p.m., Dietary Aide H was washing spoons and pots. Dietary Aide H was not wearing an apron. At 4:55 p.m., Dietary Aide H put dirty pot through dishwasher. When the dishwashing cycle was completed, she removed the clean pot. During an observation and interview on 7/20/18 at 9:50 a.m., Dietary Aide E was washing dishes. Dietary Aide E used a hose with a strong water spray to rinse the dirty dishes. Some spray from the dirty dishes splashed on her apron. After rinsing the dishes, she changed her gloves, washed her hands and began to handle the clean dishes. She did not remove her dirty apron prior to touching the clean dishes. At 10:05 a.m., Dietary Aide E rinsed more dirty dishes using the hose with the strong water spray. The water splashed from the dirty dishes onto her apron. She changed her gloves, washed her hands and began handling clean dishes. She did not remove her dirty apron prior to touching the clean dishes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 37 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 During an interview on 7/20/18 at 10:15 a.m., Dietary Aide E was asked about her process for washing dishes. She stated she rinsed the dirty dishes, prewashed them if necessary and then put them into the dishwasher. She stated she changed her gloves and washed her hands before touching clean dishes. Dietary Aide E stated she did not change her apron between handling dirty dishes and touching clean dishes. She stated she put on a clean apron before she worked on tray line (handling and plating resident food). During a telephone interview on 7/20/18 at 12:40 p.m., the RD (Registered Dietitian) was asked if staff should change a dirty apron prior to handling clean dishes. The RD stated the dirty apron needed to be changed. During an interview on 7/20/18 at 1:30 p.m., the Administrator stated the facility had no policy and procedure for apron use during dishwashing.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 08/20/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 38 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 39 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment when a staff member did not sanitize a counter and a sink prior to washing his hands after one of three resident housecats (Cat A) was observed lounging and grooming himself on the countertop and drinking water from the faucet and what staff referred to as "his bowl" in a handwashing area of one of one nursing stations (Nursing Station A). The facility's failure placed all residents at risk for adverse outcomes such as an acquired infection as a result of performing handwashing under unsanitary conditions. Findings: On 7/17/18 at 10:02 a.m., a yellow tabby cat with green eyes (Cat A) hopped up from the floor onto a six foot long countertop of standard height in Nursing Station A outside the Medication Room. Cat A placed its paws at the sink's right edge facing the faucet. Cat A swished its tail over an 8.5 inch by 11 inch sign FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 40 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 posted on a container of paper hand towels titled, "Hand Washing." On 7/17/18 at 10:02 a.m., Cat A rubbed its velvety nose on the gooseneck faucet but quickly appeared to lose interest. On 7/17/18 at 10:07 a.m., Cat A padded around the counter finally settling at the far end of the counter relative to the sink and appeared to read documents on a clipboard. Cat A rubbed its eyes with its left front paw, groomed a little, yawned, and then stretched out. On 7/17/18 at 10:10 a.m., an unidentified staff member walked to the counter and Cat A sat up on the counter. Staff member made soothing conversation to Cat A as she performed handwashing with soap and water. On 7/17/18 at 3:10 p.m. Cat A was crouched on the same counter. Cat A jarred his bowl and a little water sloshed out onto the countertop. Cat A moseyed over to the sink and wedged itself between the wall and the sink's left facing edge beneath two gel hand sanitizers and beside a container of disposable hand cleaning cloths. Cat A remained on his haunches more or less in that position for two minutes. On 7/17/18 at 3:11 p.m. a staff member approached Cat A. The staff member gave Cat A a big smile and turned on the faucet to let him lap. The staff member introduced himself as the Medical Director and said, "I'm probably not supposed to be doing this." He turned off the water, washed his hands, opened the plastic container with a blue top labeled "hands" and thoroughly wiped down the countertop and faucet. On 7/18/18 at 12:00 p.m. during an interview, the Infection Nurse Preventionist said, "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 41 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 hand wipes with the blue top are for hands. The red tops are for cleaning equipment. The sink and counter are non-critical items. I'm real disappointed. I teach everybody." She indicated the brown bowl on the sink in the nurses station was "his [Cat A's] bowl" and that she had seen it there before. She looked at the contents and said, "It has water and cat hair in it." She indicated the placement of the water bowl could be an enticement for the cat and she removed it. She said environmental staff disinfect the sink and counter at the Nurses Station Daily. In the same interview the Administrator said, "I don't know what to do - he's a jumper! If I put a gate up he could clear that easy." A review of training inservices for environmental cleaning conducted by the Infection Nurse Preventionist showed neither Cat A's or the Medical Director's names were listed on the attendance sheets. A review of the facility's policy titled, Environmental Cleaning and Disinfection dated 7/3/18 showed, "Objects and environmental surfaces in patient/resident care areas that are touched frequently are cleaned and then disinfected when visibly contaminated or at least daily with an EPA (Environmental Protection Agency) - registered disinfectant. The policy showed examples of high touch surfaces that environmental services staff should clean but it did not mention cats countertops or sinks other than bathroom sinks. A review of the facility's policy titled, Cleaning and Disinfection of Environmental Surfaces dated 6/2009 showed, "Noncritical items are those that come in contact with intact skin but not mucous membranes. Noncritical environmental services include bedrails, some food utensils, bedside tables, furniture and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 42 of 43 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: _______________ 555207 (X3) DATE SURVEY COMPLETED 07/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINER'S NURSING HOME 1800 Pueblo Ave 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 floors [The policy did not specify that sinks or countertops were non-critical items.] Noncritical Services will be disinfected with an EPA-registered immediate or low level hospital disinfectant according to off-label safety precautions in use directions. Most EPA registered hospital disinfectants have a label contact time of 10 minutes. By law, all applicable label instructions on EPA-registered Products must be followed." A review of the facility's policy titled , Pets, Animals, and Plants dated 3/18/12, showed, "All personnel will minimize contact with animal saliva, dander, urine and feces and will use proper infection control at all times." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ODJ411 Facility ID: CA010000053 If continuation sheet 43 of 43