Other·December 7, 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 represents the findings of the California Department of Public Health during a RECERTIFICATION SURVEY. Representing the California Department of Public Health: Surveyors #35842, #38322, #38335, #39517, and #40090 Health Facilities Evaluator Nurses. Census on the date of entry, 7/23/2018, was 114. There were 23 Sampled Residents. Complaints #CA00595063 and #CA00594499 were investigated during the RECERTIFICATION SURVEY. No Deficiencies were identified for #CA00595063, but one deficiency was issued for incidental findings for complaint #CA00594499: Refer to F623.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 08/31/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each 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: YDHM11 Facility ID: CA010000063 If continuation sheet 1 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain 1 of 23 sampled residents (Resident 169) dignity when Resident 169's Foley catheter bag filled with urine was not covered with a privacy bag and Resident 169's privacy curtain was not closed during wound care. These failures had the potential for Resident 169's loss of self-worth. Findings: During an observation on 7/23/18 at 12:14 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 2 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 p.m., Resident 169 was lying in bed and his Foley catheter bag filled with urine was hanging on the right side of his bed near the Foley catheter privacy bag, but not inside the privacy bag. During an observation on 7/24/18 at 2:31 p.m., Resident 169 was lying in bed and his Foley catheter bag filled with urine was not covered with the privacy bag, which was right next to the Foley catheter bag. Resident 169's roommate had company, who could see Resident 169's exposed Foley catheter bag due to Resident 169's privacy curtain was open. During an interview on 7/25/18 at 11:29 a.m., when Unlicensed Staff F was asked if a resident's Foley catheter bag should be exposed or covered with a privacy bag, she stated the resident's Foley catheter bag should always be covered with a privacy bag. During an observation on 7/27/18 at 9:49 a.m., Licensed Staff I and Licensed Staff L did not close Resident 169's front privacy curtain completely while doing wound care and dressing changes to his feet [Left foot: proximal metatarsal amputation (removal of all toes) and right foot: 1x1 inch ulcerated (sore on the skin accompanied by the disintegration of tissue) area on top of foot and 5th toe partially eroded] to prevent roommate's hired caregiver from seeing in while tending to resident. Resident 169's roommate with the assistance of his caregiver also walked by Resident's 169's bed on the way to the bathroom while Licensed Staff I and Licensed Staff L were doing wound care to Resident 169. Resident 169's front privacy curtain remained partially opened. During an interview on 7/27/18 at 10:00 a.m., when Licensed Staff L was asked if Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 3 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 169's privacy curtain should have been closed while wound care was being done, Licensed Staff L stated Resident 169's privacy curtain should have been closed and the table with the dressing supplies should have been brought inside the curtain to give Resident 169 privacy. Licensed Staff L stated she understood vulnerable residences should also be respected by receiving privacy when their dressing was being changed. The facility policy/procedure titled, "Quality of Care," revised 8/19, indicated: 1. Residents should be treated with dignity and respect at all times, 2. "Treated with dignity" means the resident will be assisted in maintaining and enhancing his or her self-esteem and selfworth, and 3. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

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

F623 08/31/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 4 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 5 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 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. §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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 6 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 Based on interview and record review, the facility failed to send a copy of "Notice of Discharge" to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate (official) is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] for one resident (Resident 77) prior to their discharge to home. This failure had the potential for Resident 77 being inappropriately discharged and not being provided an advocate who could inform them of their rights and options if they were not ready to be discharged to home. Findings: During an interview on 7/17/18 at 2:07 p.m., Ombudsman O stated the facility was not giving residences enough notice regarding their discharge and the facility was not informing the Ombudsman's Office ahead of time regarding a resident being discharged from the facility. Ombudsman O stated she usually received a notice of the resident's discharge when she was at the facility, in which case the resident was being discharged the same day or the facility would fax the resident's discharge notice to the Ombudsman's office on such a day as 4th of July, whereby the Ombudsman's office was closed due to the holiday. Ombudsman O stated discharges were occurring because the residence's coverage was terminated or insurance was not covering their care. Ombudsman O stated Administrative Staff C really tried to help the residences regarding their discharge, but the two newer social workers were not; they were harsh, especially Administrative Staff D. Ombudsman O stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 7 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 discharge form given to the resident to sign indicated the resident asked to leave, which was not true in some cases. During an interview on 7/25/18 at 11:30 AM, Ombudsman O stated she had not received a notice of discharge for Resident 77 . During an interview on 7/27/18 at 4:08 p.m., Administrative Staff C stated she did not recall if she faxed over a "notice of discharge" prior to Resident 77's being discharged on 7/11/18. During an interview on 7/27/18 at 5:15 p.m., Administrative Staff D and Administrative Staff P stated they would send a "Notice of Discharge" to the Ombudsman's office when the resident signed his/her discharge papers. Administrative Staff D said, "It is not our problem if the resident signs their discharge paperwork a few hours before leaving. It is not until the resident signs their discharge paperwork that we send the Notification of Discharge to the Ombudsman." Administrative Staff D stated all residents were informed of their rights to call the Ombudsman if they have a concern about their discharge or other concerns. Administrative Staff D stated the resident is informed when they are admitted about the Ombudsman and the signs are posted throughout the facility. Administrative Staff D had an attitude and was very curt while talking. Neither Administrative Staff D nor Administrative Staff P understood the importance of notifying the Ombudsman in a timely manner about the resident's discharge, so the Ombudsman, who was the resident's advocate, could make sure the resident was ready to be discharged and had no issues or concerns regarding their discharge. Administrative Staff C, Administrative Staff D, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 8 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 and Administrative Staff P did agree residents who lived alone and had no family/friends were especially in need of an advocate like the Ombudsman. During a concurrent interview and record review on 7/27/18 at 5:30 p.m., Administrative Staff A stated the facility followed the California Department of Public Health "All Facility Letter (17-27) Summary," dated 12/27/17, based on Health and Safety Code (HSC) section 1439.6, which indicated Long Term Care (LTC) facilities were to notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representatives when a facilityinitiated transfer or discharge occurred. The facility must send a notice to the local Ombudsman for any transfer or discharge that is initiated by the facility, whether or not the resident agrees with the facility's decision.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 08/31/2018 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 9 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 activities to meet the interests of one of 23 sampled residents (Resident 82). This failure could potentially lead to depression, further cognitive decline, or failure to thrive for a vulnerable resident. Findings: During an observation on 7/23/18 at 12:10 p.m., Resident 82 was lying on her bed, awake, dressed in a shirt and pants. The curtains in her room were closed, completely obscuring any view out the window. When greeted, Resident 28 calmly stated, "Help me." When asked what she needed, Resident 82 stated, "Help me." During an observation on 7/23/18 at 3:55 p.m., Resident 82 was lying on her bed, awake, dressed, watching TV. She did not look up when greeted. During an observation on 7/24/18 at 9:04 a.m., Resident 82 was lying on her bed, awake, dressed, and staring at the ceiling. During an observation on 7/24/18 at 11 a.m., Resident 82 was lying on her bed, awake, dressed, and staring at the ceiling. During an observation on 7/25/18 at 9:26 a.m., Resident 82 was lying on her bed, awake, dressed, and staring at the ceiling. During an observation on 7/25/18 at 10:15 a.m., Resident 82 was lying on her bed, awake, dressed, the head of her bed was up and she was staring at the wall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 10 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 observation on 7/25/18 at 12:24 p.m., Resident 82 was lying on her bed, awake, dressed, and staring at the wall. When greeted, she opened her mouth and pointed at her open mouth. During an observation on 7/25/18 at 2:59 p.m., a guitar player was singing "If Ever I Would Leave You" from the musical Camelot in the activity room which was down the hall and around the corner from Resident 82's room. Resident 82 was in bed, awake, dressed, the head of her bed was up, the TV was on, but pointed away from her with the volume all the way down. During an observation and concurrent interview on 7/26/18 at 10:30 a.m., Resident 82 was lying in bed, dressed. Resident 82's husband was sitting at her bedside. He stated Resident 82 had been at the facility for four years. When asked about Resident 82's participation in activities, her husband stated she does not participate in the activities because there were only activities for people who can walk or get up. He stated she does not tolerate being in the wheelchair for more than an hour, so she stays in bed all the time. When asked if any activities are done with her in her room, he stated no, "They don't come in here." He stated it would be nice and beneficial for her to have activities here in her room. He stated, "That is something they can improve on." He stated she loves music and singing, and she remembers the words to all the old songs. She cannot read anymore due to her mental decline and she does not enjoy TV. Throughout the interview, Resident 82 was softly telling her husband, "Stop it, just stop it." During an interview on 7/27/18 at 11:15 a.m., Activities Assistant J stated, "I do morning visits every day [with Resident 82]. I always invite FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 11 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 her to activities, but she always refuses and we can't force them to go. She likes to watch TV and get lotion on her hands for sensory, smell and touch. I spend 15 minutes with her at the most." When asked if Resident 82 liked any other activities, Activities Assistant J stated "No, just TV and the lotion." She stated she wrote down her in-room activities on a log and then gave the log to the activities director who entered them in the electronic chart. During an observation on 7/27/18 at 11:23 a.m., Resident 82 was sitting in a wheelchair in her room at the foot of her bed. Her curtains were closed obscuring her view out the window, the TV was off, and she was staring out the door into the hallway. During an interview on 7/27/18 at 11:30 a.m., Unlicensed Staff K stated she had cared for Resident 82 regularly for over four years. She stated Resident 82 never went to activities because she always refused. She has never seen her do any activities in her room. During a record review on 7/27/18 at 4:30 p.m., an activities note for Resident 82, dated 7/10/18, revealed, "Through out the quarters resident prefers self directed activity of her choice, she prefers to stay inside her room and do her own activities of interest . . . she was been [sic] provided in room visits with activity materials to pursue independent activity . . . . She likes to watch shows on tv." Documentation of self-directed/independent activities for the month of July 2018 revealed Resident 82 participated on three days: 7/22/18, 7/25/18, and 7/26/18. Resident 82's MDS (minimum data set, an assessment tool), dated 6/20/18, revealed a BIMS score of 3 (brief interview of mental status, a score of 0 to 3 indicates severe cognitive impairment). Section titled "Preferences for Routine and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 12 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 Activities" revealed Resident 82 was primary respondent to questions, and to the question "How important is it to you to do your favorite activities?" her answer was "Very important." Resident 82's activity care plan, initiated 7/10/18, revealed, "Provide resident with independent individual activities during her own leisure time and provide resident with activity supplies/materials as needed . . . ."

F684 SS=E Quality of Care CFR(s): 483.25

F684 08/31/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide services to maintain or improve Resident 169's range of motion, strength and endurance, when Resident 169, who was admitted on 7/13/18, had not been out of bed for 12 consecutive days. Resident 169 had not been screened by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 13 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 Physical Therapy (PT) until 7/23/18 and evaluated for PT until 7/25/18 per his care plan, dated 7/14/18, or offered the RNA (Restorative Nursing Assistant) program (helps with rangeof-motion exercises, walks with patient, etc. in order for resident to function at a high capacity). This failure had the potential for Resident 169 to have a decline in range of motion, strength and endurance, an increase in joint pain and depression, and an overall decrease in activities in daily living [(ADLs) bathing, showering, personal hygiene, grooming, brushing teeth, etc.]. Findings: Review of Resident 169's "Admission Record," dated 7/13/18 and "History and Physical, dated 7/16/18, indicated Resident 169 had been admitted to the facility with a a urethral stent [a thin tube inserted into the ureter (tubes made of smooth muscle fibers that propel urine from the kidneys to the urinary bladder) to prevent or treat obstruction of the urine flow from the kidney], which was inserted at the acute care facility on 7/2/18 due to complications causing a urinary tract infection due to a kidney stone at the left ureter, and was to be readmitted to the acute care facility on 7/17/18 to have the stent removed. Other diagnosis included peripheral edema (swelling in your arms, legs, etc.), his left foot proximal metatarsal amputation (removal of all toes) and right foot 5th toe partially eroded, Type 2 Diabetes Mellitus (A long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) with other skin ulcers (A sore on the skin accompanied by the disintegration of tissue), severe obesity, etc. The "History and Physical" also indicated Resident 169 was non-compliant with medical treatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 14 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 Review of Resident 169's "Order Summary Report," order date 7/14/18, indicated Resident 169 was to have a PT evaluation and treat as indicated. Resident 169's "Baseline Care Plan," dated 7/13/18, indicated 1. Resident 169's goal was to get better, work on pain management and wound care to left leg, left and right foot, and coccyx region (tailbone), and return home, 2. Resident 169 had a diagnosis of adjustment disorder and depressed mood, 3. He was a short stay for nursing/rehabilitation services, 4. He used a wheelchair, bath chair with transfer pole in bathtub at home and grab bars in bathroom, and 5. and a goal of care was PT. Resident 169's "Care Plan," dated 7/14/18 indicated he had impaired mobility, weakness, partial amputation of left foot, and wounds on left and right foot. Interventions for Resident 169 were: 1. PT and OT (occupational therapy) evaluation and treatment per physician's orders, 2. Provide necessary equipment and adequate time for self-performance or participation with daily care tasks, 3. Grooming and personal hygiene daily, 4. Provide/assist with bath or shower 2-3 times weekly, more often as desired by resident, etc. Resident 169's "History and Physical, dated 7/16/18, indicated a plan of action was to get Resident 169 out of bed to chair daily. During a concurrent observation and interview on 7/23/18 at 12:14 p.m., Resident 169, who was in bed, stated he had fallen 3 times at home. Resident 169 stated he had been living in a senior living facility prior to his hospitalization, but was not very independent on his own. Resident 169 stated he had not started PT yet and he had not gotten up yet. Resident 169 stated he would like to start PT. During an observation on 7/24/18 at 2:41 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 15 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 169 was in bed wearing a hospital gown. He did not look well groomed, hair uncombed and dirty. During a concurrent observation and interview on 7/25/18 at 10:09 a.m., Resident 169 was in bed wearing only a hospital gown for the third day in a row. Resident 169 stated he wanted to read the "Activities" calendar, but it was taped to closet door. DON was asked to get him one. He did not know how to use his bed control in order to lower the head of his bed. During multiple observations on 7/23/18 at 12:14 p.m. through 7/25/18 at 10:42 a.m., Resident 169 was positioned on his back in bed with only a hospital gown on him. During an interview on 7/25/18 at 10:42 a.m., Resident 169 stated he would like PT and would like to go to Bingo today, but thought they would overlap. During an interview on 7/25/18 at 10:45 a.m., when Licensed Staff Q was asked if Resident 169 had ever been out of bed, Licensed Staff Q stated she personally had never seen him up. Licensed Staff Q stated she would talk to the nurse's aides caring for Resident 169 to find out if he had ever been up. During an interview and record review on 7/25/18 at 11:29 a.m., when Unlicensed Staff F was asked if Resident 169 had ever been out of bed, Unlicensed Staff F stated PT had not assessed him yet. Unlicensed Staff F said, "The two times I worked with him, when you just touched him, he yelled." Unlicensed Staff stated Resident 169's showers were scheduled for the PM shift on Wednesday and Saturday. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 16 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 169 needed a Hoyer lift (Used for transfers when a person requires 90-100% assistance to get into and out of bed) to weigh him; scale on Hoyer lift. Unlicensed Staff F stated Resident 169 had not gone to activities because he had not been assessed by PT yet. Unlicensed Staff F reviewed "Skin Assessment Shower Book" to see if Resident 169 had a shower; none was noted in book. Review of Resident 169's ADL flow sheets indicated he had a bed bath on July 13, 14, 15, 18, 19, 21, & 24, but there was no indication if it was a full bed bath or just peri care (Washing the genitals and anal area. Peri care can be done during a bath or as a separate procedure. Peri care prevents skin breakdown of perineal area, itching, burning, odor, and infections). Review of the "Skin Assessment Shower Book" on 7/27/18 at 10:00 a.m., indicated Resident 169 had been up for a shower on 7/18/18, but Resident 169's ADL computerized flowsheet dated, 7/18/18, indicated he had a bed bath. Review of the "Skin Assessment Shower Book," dated 7/21/18, indicated Resident 169 refused a shower or bed bath (both boxes marked) and Resident 169's ADL computerized flowsheet, dated 7/21/18 indicated he had a bed bath. During an interview on 7/27/18 at 6:50 p.m., Administrative Staff B stated the ADL computerized print out indicated if a resident had a shower or a bed bath, but the ADL computerized print out did not indicate if the CNA gave a full bed bath or only did peri care. The area marked bed bath may have only meant the CNA assisted the resident with peri care and not a complete bed bath. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 17 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 7/25/18 at 2:49 p.m., Physical Therapist G stated Resident 169, who was admitted on 7/13/18, did not have a screening by PT until the evening of Monday, 7/23/18. Physical Therapist G stated he worked Monday-Saturday and the other physical therapist worked Tuesday through Saturday, so he did not know why it took Resident 169 so long to have his PT screening and evaluation completed. Physical Therapist G stated Resident 169 was screened on 7/23/18 and was confused (unable to think clearly) and lethargic (drowsy); Resident 169 did not want to do anything. Physical Therapist G stated today (7/25/18) Resident 169 wanted to try to get up, but wanted his pain medication first. Physical Therapist G stated Resident 169 was not admitted with any clothes or special boots, which should have been sent with him from the acute facility. Physical Therapist G stated Resident 169 had bilateral toes amputated and needed a special boot for his left foot and right eroded toes. During an interview on 7/25/18 at 4:45 p.m., DON did not know why Resident 169 was not receiving PT unless he was admitted on "Custodial Care." During concurrent interviews and record review on 7/25/18 from 5:00 to 5:30 p.m., Administrative A stated Resident 169 was on "Custodial Care" and was admitted to the facility for 3 days. Administrative Staff A stated the acute care facility sent a "Letter of Agreement," which acknowledging Resident 169 was to be admitted to the facility on 7/13/18 for 3 days at a "Custodial Daily Rate of $300 per day and was to return to the acute care facility on 7/16/18 for a scheduled procedure. The facility would provide Resident 169 with room and board, and all other standard care services. Administrative Staff A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 18 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 stated Resident 169 was supposed to return to the acute care facility on 7/16/18 to have urethral stent removed. When Administrative Staff A was asked what "Custodial Care" meant, Administrative Staff A stated he would get the document, which would explain. When Administrative Staff A was asked did "Custodial Care" mean residents just stayed in bed, were not offered such services as RNA to help improve the resident's strength and endurance? How was Resident 169, who had now been at the facility for 12 days instead of 3 days, going to get stronger lying in bed? Administrative Staff A stated Resident 169 was on "Custodial Care" per the acute care facility's/physician's order and the facility was receiving $300 per day to care for Resident 169 until his procedure was scheduled. Review of "Nursing Progress Notes," dated 7/16/18, indicated Resident 169 was scheduled for removal of stent this morning (7/16/19), but Resident 169 ate breakfast, which conflicted with the procedure, and procedure was rescheduled for 7/26/18. During concurrent interviews on 7/25/18 at 5:15 p.m., Administrative Staff R stated Custodial Care" included activities of daily living (toileting, transfers, bath, etc.), wound care, catheter care, etc. When Administrative Staff R was informed Resident 169 was admitted to the facility with no clothes or special boots needed for support of his partial left foot amputation and ulcerated right foot, Administrative Staff R stated Resident 169 was admitted to two acute care facilities before he was admitted to their facility. Administrative Staff R stated he was admitted to their facility under "Custodial Care, which did not include PT. Administrative Staff A stated because Resident 169 still had not gone for the removal of his urethral stent, which had been scheduled for 7/16/18 and rescheduled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 19 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 for 7/26/18, the facility wanted Resident 169 to receive PT now, so that is why he was finally evaluate on 7/25/18. It was pointed out to Administrative Staff A Resident 169, who was alert and orientated, had not been out of bed for 12 days. Because a resident was on "Custodial Care, the resident did not get up for his bath, meals, or activities? Review of the document titled, "Custodial Care vs. Skilled Care, dated 2018, indicated: 1. Consists of any non-medical care that can reasonably and safely be provided by nonlicensed caregivers, 2. Can take place at home or in a nursing home, 3. Involves help with daily activities like bathing and dressing, and 4. May be covered by Medicaid/Medi-cal (insurance program/assistance program) if care is provided in a nursing home setting and not at home. Review of Resident 169's "PT Screen Form," dated 7/23/17, indicated Resident 169 had functional deficits in bed mobility and had the potential to decline without further interventions and transfers. Resident 169 needed further PT evaluation to access strength, balance, and transfer. Review of Resident 169's "PT Plan of Care," dated 7/25/18, indicated he was presented to PT due to a decline in functional abilities of transfer due to decrease strength, balance, and recent right foot toes amputation and a history of left fore foot amputation. Caregiver had noticed decrease in mobility for safe mobility, transfers and mobilization. PT was necessary for Resident 169 to improve balance and fall recovery skills in order to decrease risk of falls and develop restorative program. During an interview on 7/26/18 at 10:00 a.m., DON was asked to let Resident 169's physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 20 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 (who was in the facility making resident rounds) know surveyor would like to speak to him regarding Resident 169's care. DON stated she would let him know. During an interview on 7/26/18 at 10:30 a.m., DON stated Administrative Staff A was talking to Resident 169's physician and he was aware surveyor wanted to speak to him regarding Resident 169. During an interview on 7/26/18 at 11:00 a.m., Administrative Staff A stated Resident 169's physician had left the facility after making resident rounds. When Administrative Staff A was asked if physician was aware surveyor wanted to speak to him, Administrative Staff said, "Yes, but he had to leave." During a concurrent interview and record review on 7/26/18 at 12:00 p.m., Administrative Staff A gave faxed letter (created on 7/26/18 at 11:16 a.m. and faxed on 7/26/18 at 11:52 a.m.) from Physician T, which indicated Resident 169 was admitted under "Custodial Care" on 7/16/18. If resident admitted under "Custodial Care" PT/OT Evaluate and Treat were to be discontinued. This order does not prohibit the facility to evaluate and request (from patient or staff) for Part B coverage (Original Medicare and covers services and supplies that are medically necessary to treat your health condition) or additional RNA orders. Physician T indicated due to Resident 169 being noncompliant with medical treatment, he explicitly excluded Resident 169 from receiving PT/OT. During an interview on 7/26/18 at 12:15 p.m., Nurse Practitioner U, who would not talk without DON present, stated Resident 169 was at the acute care facility now, which he was not. Nurse Practitioner U was very hesitant to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 21 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 say anything regarding Resident 169. Nurse Practitioner U stated Resident 169 was going to have his stent removed today, 7/26/18. It was addressed to Nurse Practitioner U, Resident 169 had been admitted on 7/13/18 and his stent was to be removed on 7/16/18, but the procedure was postponed, so Resident 169 was placed on "Custodial Care" on 7/16/18, and the first time Resident 169 had gotten out of bed was on 7/25/18 with PT assistance. Nurse Practitioner U stated Resident 169 had a history of refusing care. Nurse Practitioner U stated Resident 169 could get up in a wheelchair while on Custodial Care. Nurse Practitioner U stated Resident 169 had gotten out of bed yesterday (7/25/18) and wanted back to bed soon afterward. It was addressed to Nurse Practitioner U Resident 169 was cooperative with PT, he was compliant. During an interview on 7/27/18 at 12:05 p.m., Resident 169 stated he was being transferred to the acute care facility to have his stent removed and thought he would be returning to the facility. When Resident 169 was asked if he had wanted to stay in bed for the past 12 days, he stated he was willing to get up, but had been staying in bed. No one offered to get him up. During an interview on 7/27/18 at 5:15 p.m., Administrative Staff D and Administrative Staff P stated Resident 169 was expected back to the facility; he had a bed hold for 7 days.

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 08/31/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 22 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to notify the Pharmacy (within the 72 hour time frame) that a 10 ml vial of NPH insulin was removed from the refrigerated emergency kit (E-kit). Failure to report the opened E-kit could have resulted in possible insufficient supply of emergency medication to meet the needs of each resident and diversion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 23 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St Napa, CA 94558 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings During an observation and concurrent interview with the ADON on 7/25/18 at 11:48 a.m., in medication storage room one, a small refrigerator unlocked by the ADON contained resident medications and two seperate E-kits. The temperature of the refrigerator was 40 degrees fahrenheit. One of the E-kits was a clear plastic container secured with a red zip tie. On one side of the box was an inventory listing of lorazepam (a medication used to treat anxiety), NPH insulin and Regular insulin (medications used to lower blood sugar) as the medications supplied in that kit. Further inspection of the kit revealed one medication, the NPH insulin, was not in the container. When asked what the red zip tie signified, the ADON indicated a red zip tie was used after the E-kit had been opened. The ADON also stated that emergency kits are delivered from the pharmacy secured with a green zip tie. When asked about the specifics of when the medication was used, the ADON reviewed a white binder labeled emergency medication administration log. Inside the binder were yellow carbon copies of the Emergency Drug Kit Usage Report forms. The ADON confirmed that these forms were located inside the E-kits and used to document when a medication was removed and as a method of requesting a replacement emergency kit from the pharmacy. Review of the log showed the most recent Emergency Drug Kit Usage Report forms dated 6/5/18 and 6/18/18 indicated normal saline as the medication removed for use. At the time of observation and concurrent interview the ADON was unable to identify when the NPH insulin was removed from the E-kit. During a follow up interview and concurrent record review with the ADON on 7/25/18 at 12:30 p.m., in medication storage room one, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 24 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 ADON stated that the Emergency Drug Kit Usage Report form was sealed inside the emergency kit. Both the original white and yellow carbon copy were present. The E-kit was re-opened for further inspection, review of the form revealed the NPH was removed on 7/16/18, 9 days prior. There was no record that the pharmacy had been notified. The ADON was unable to provide any evidence that the use had been accounted for prior to the surveyor's observation. A copy of the Emergency Drug Kit Usage Report form was requested and provided by the ADON at 12:58 p.m., on 7/25/18. During an additional observation and interview of medication storage room with the DON on 7/25/18 at 3:00 p.m., confirmed that the E-kit located in the medication refrigerator was previously opened on 7/16/18. The pharmacy form was completed and put back into the E-kit and re-sealed with red locks, and a nurse failed to notify the pharmacist and document the medication administration log that the E-kit had been opened. A vial of NPH insulin 10 ml was not in the container. During an interview with the DON on 7/25/18 at 3:30 p.m. about the process for removing a medication from an E-kit, the DON stated, a copy of the "Emergency Drug Kit Usage Report Form", should have been submit to the Pharmacy right away and documented in the emergency medication administration log. The DON confirmed that the emergency drug kit usage report form was completed and resealed in the E-kit without submitting a copy of the report to the Pharmacy and documenting on the medication administration log. Review of the facility policy and procedure titled "Emergency Medications", version 1.1., items 8 and 9 indicate, "Any medication that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 25 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 removed from the emergency medication kit must be documented on the emergency medication administration log", and "Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order". During a follow-up observation of the medication storage refrigerator on 7/25/18 at 4:00 p.m., the E-kit was replaced by the pharmacy dated 7/25/18 and a copy of the pick-up/delivery invoice was provided.

F804 SS=E Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 08/31/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 26 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide palatable food for five unsampled residents. This had the potential to lead to decreased intake and weight loss in a vulnerable population. Findings: During the initial screening on 7/23/18 from 11:06 a.m. to 12:31 p.m., four residents stated they were not happy with the food they were being served. Resident 165 said, "Food not good." Resident 166 said "Food not good." Resident 59 stated she was on a pureed diet and said, "All taste the same." Resident 81 said, "Food is horrible. All taste the same and same color." During an observation and concurrent interview on 7/23/18 at 12:54 p.m., Unsampled Resident 18 stated she was done eating. She had eaten approximately 50% of the food on her tray. She stated she does not like the food here, and, "If I don't like it, I don't eat it." During an observation and concurrent interview on 7/26/18 at 1:37 p.m., test trays of the regular and pureed diets contained teriyaki chicken, calico rice, and mixed vegetables. On the regular diet tray, the chicken was dry and hard to chew, the rice had a sticky texture, and the mixed vegetables were bland and mushy. On the pureed diet tray, the rice had a thick, glue-like texture that was difficult to swallow. The Dietary Manager confirmed the rice was sticky and the vegetables were bland on the regular diet tray, and the rice was thick and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 27 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 sticky on the pureed diet tray. Review of facility policy titled "Food and Nutrition Services," dated October 2017, revealed, "Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. . . ."

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

F812 08/31/2018 §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 serve food in accordance with professional standards for food service safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 28 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 ensure food was prepared in a sanitary manner consistent with professional standards when a kitchen staff member was not able to demonstrate calibration of thermometers. This failure increased the risk of residents' exposure to food borne illness. Findings: During an observation and concurrent interview on 7/25/18 at 10:15 a.m., Cook N demonstrated how she calibrated thermometers used to take food temperatures. She placed three thermometers in ice water. After two minutes, two of the thermometers read 32 degrees Fahrenheit and one thermometer read 28 degrees Fahrenheit. When asked what temperature she was looking for, Cook N stated 32. When asked to demonstrate how she would calibrate the thermometer that read 28, she put the calibration wrench on the stem of the thermometer, placed it back in the ice water, and turned the thermometer around in the water. When asked again to demonstrate how to use the calibration wrench to adjust the thermometer to read 32, Cook N did not. Review of facility document titled "Food Thermometer Guidelines," dated 2002, revealed, "To recalibrate a thermometer using the ice point method, submerge the sensor area of thermometer into a 50/50 ice and water slush. For a bi-metallic stemmed thermometer, wait until the needle stops, then use a small wrench or needle-nose pliers to turn the calibration nut until the dial reads 32 [degrees Fahrenheit]. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 29 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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

F842 Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/31/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 30 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and resident record review the facility failed to ensure 1 of 23 Sampled Residents (Resident 65's) medical records were accurate when the provider's "Verification FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 31 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 of Informed Consent of Anti-Psychotic Medications" for Seroquel (An antipsychotic used to treat schizophrenia and bipolar disorder, also known as manic-depression) had the wrong dose [30 mg (milligrams) instead of 300 mg] per physician's order. This failure had the potential for the resident to receive the incorrect dose and/or the resident or resident's representative the incorrect information on the anti-psychotic medication, Seroquel. Findings: During a review of the clinical record for Resident 69, the "Order Summer Report," for active orders as of July 2018, indicated the physician had ordered Seroquel 300 mg on 6/13/18 to be given at bedtime, but the "Verification of Informed Consent of AntiPsychotic Medications," dated 6/14/18, indicated the Seroquel dose explained to Resident 69 was 30 mg. During a concurrent interview and record review on 7/26/18 at 3:59 p.m., when DON was asked who was responsible for the "Verification of Informed Consent of Anti-Psychotic Medications," DON stated the doctor talked to the resident regarding the antipsychotic medication and the side effects and the nurse verified with the resident the doctor had talked to the resident. DON stated both the doctor and the nurse signed the consent. When DON was shown Resident 69's Seroquel order for 300 mg to be given at bedtime, DON stated the order was for 300 mg to given. When DON was shown the "Verification of Informed Consent of Anti-Psychotic Medications" for Resident 69's Seroquel, she stated it read 30 mg. DON stated Resident 69's consent for Seroquel should have read 300 mg not 30 mg. The facility policy/procedure titled, "A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 32 of 33 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: _______________ 056153 (X3) DATE SURVEY COMPLETED 07/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA POST ACUTE 705 Trancas St 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 ntipsychotic Medication Use," revised 12/16, indicated: 1. The disclosure of the material information and obtaining informed consent shall be the responsibility of the licensed healthcare practitioner who, acting within the scope of his or her professional licensure, performs or orders the procedure or treatment for which informed consent is required, 2. Whenever an order obtained for psychotropic medication(s), the licensed nurse verifies that informed consent has been obtained, and 3. Before initiating the administration of psychotherapeutic drugs facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YDHM11 Facility ID: CA010000063 If continuation sheet 33 of 33