Inspection citations
3’19
19’21
3’23
13’24
17’25
2’26
57 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 2, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 20, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Jul 25, 2025 | D · potential | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Routine |
| Jul 25, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jul 25, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jul 25, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jul 25, 2025 | D · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| Jul 25, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jul 25, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jul 25, 2025 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jul 25, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 25, 2025 | D · potential | Dispose of garbage and refuse properly. | Routine |
| Jul 25, 2025 | D · potential | Provide or get specialized rehabilitative services as required for a resident. | Routine |
| Jul 25, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 25, 2025 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| May 12, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Apr 8, 2025 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 21, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 9, 2025 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Complaint |
| Oct 8, 2024 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Oct 8, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Oct 8, 2024 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Oct 8, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 8, 2024 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Jul 24, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 24, 2024 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Jul 24, 2024 | E · potential | Implement a program that monitors antibiotic use. | Complaint |
| Feb 16, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Feb 16, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
| Feb 16, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Feb 16, 2024 | F · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jan 10, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Dec 19, 2023 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Oct 18, 2023 | D · potential | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Complaint |
| Oct 18, 2023 | E · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| Sep 21, 2021 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Sep 21, 2021 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| Sep 21, 2021 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Sep 21, 2021 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Sep 21, 2021 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Sep 21, 2021 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Sep 21, 2021 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Sep 21, 2021 | G · harm | Assist a resident in gaining access to vision and hearing services. | Routine |
| Sep 21, 2021 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Sep 21, 2021 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Sep 21, 2021 | E · potential | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Routine |
| Sep 21, 2021 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Sep 21, 2021 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Sep 21, 2021 | E · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Sep 21, 2021 | E · potential | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Routine |
| Sep 21, 2021 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Sep 21, 2021 | D · potential | Have a plan that describes the process for conducting QAPI and QAA activities. | Routine |
| Sep 21, 2021 | E · potential | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Routine |
| Sep 21, 2021 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Aug 7, 2019 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Aug 7, 2019 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Aug 7, 2019 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Napa Valley Care Center
3275 Villa Lane, Napa, CA 94558 · (707) 257-0931
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555161
- Certified beds
- 130
- Legal owner
- Petunia Holdings, LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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