Piners Nursing Home
PINERS NURSING HOME in NAPA, CA — inspection on March 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
(Resident 1) with kindness, respect, and dignity, when the Director of Nursing (DON) was witnessed
p.m., Confidential Witness (CW) stated that back in January 2026 something happened during activities that caused Resident 1 to get mad at someone. CW stated that while CW was at the nurses station that afternoon, Resident 1 was in the lobby when DON came at the nurses station very emotional and aggressive and said Resident 1 was out of control and we need to do something about her, we need to send her out. CW stated DON was very physically and verbally aggressive about the way she approached the nurses at the desk, all within earshot of Resident 1, who was only a few feet away. CW stated that when Resident 1 heard DON talking about her in this way, she began sobbing.
CW stated it felt immediately like DON was bullying Resident 1. CW stated Resident 1 was sent later that day to the emergency department (ED).Review of Resident 1's progress note, dated 1/9/26 at 3:34 p.m. indicated, During Bingo today [Resident 1] got upset at [staff named] because she saw that [another resident] had not covered one of the numbers that had previously been called.
When I approached [Resident 1] I asked her if she had an issue with [another resident] and she againstated that if someone doesn't know how to play they shouldn't be playing. I let her know that we help everyone that needs it, even her and as I was removing her from the table she threatened to slap [another resident] in the face so, I took [Resident 1] down the hall towards her room and as I did so she threw 2 bingo chips, that she had in her hand, against the wall.
She then started yelling which caused our Administrator and DON to come around the corner to see what was going on. I explained the situation to them and then let them handle it from there.Review of Resident 1's progress note, dated 1/9/26 at 5:20 p.m. indicated, Resident noted with redness to face and starting shaking. [Shortness of breath] noted. No change in [level of consciousness] noted.
Resident was under emotional distress and crying.
Notified [doctor] and ordered resident to go to ED for further evaluation. [Responsible party] notified.
Ambulance arrived to facility @ [5:15] pm and resident was taken via gurney to [local acute care hospital] ED for further evaluation.Review of facility policy Resident Rights, last reviewed 3/31/26 indicated, Employees shall treat all residents with kindness, respect, and dignity.
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555207 03/26/2026
Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558
fentanyl patch to 50 mcg/hr at the end of January 2026.
During an interview and concurrent record
order.
Licensed Nurse B verified if the dose was increased and a PRN dose added while at the
the physician documented in the residents' records the residents' capacity to make decisions.During a phone interview on 3/30/26 at 11:36 a.m., Medical Director verified that when he was interviewed by the Department in October 2025 about Resident 1, he told the surveyor that Resident 1 did not have the capacity to make healthcare decisions.
Medical Director stated that had not changed, Resident 1 still did not have capacity to make decisions and no county conservator had been arranged.
Medical Director verified residents' family had the right to participate in the resident's plan of care.During a phone interview on 3/30/26 at 3:44 p.m., Medical Director stated he expected the facility nursing staff to have informed FM of the fentanyl patch dose increase.Review of facility policy Resident Rights, last reviewed 3/31/26, indicated, 1.
Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the resident's right to: . c.
Choose a physician and treatment and participate in decisions and care planning . 2.
Residents are entitled to exercise their rights and privileges to the fullest extent possible.Review of facility policy Psychotropic Medication Use, last revised 2/2025, indicated, Informed Consent or Refusal: 1.
Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings) and; d. the resident's/representative's right to accept or decline the treatment.Review of facility policy Care Plans, Comprehensive Person-Centered, last revised 8/2024, 1.
The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record.
555207 03/26/2026
Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558
Review of the February 2026 MAR indicated Resident 1 had been administered one tablet of Seroquel 25 mg PRN for agitation on 2/11/26, 2/14/26, and 2/22/26.
During an interview and concurrent record review of Resident 1's medical record on 3/26/26 at 3:29 p.m.at the nurses' station, when queried, Licensed Nurse B stated the physician re-evaluated orders for PRN antipsychotic medications during the quarterly gradual dose reduction process and then monthly when he signed the orders recapitulation.
Licensed Nurse B found Resident 1's most recent orders recapitulation, which included the Seroquel PRN order, and pointed to Medical Director's signature at the bottom.
Licensed Nurse B stated she did not know of anywhere in the record that Medical Director might have documented a re-evaluation of Resident 1's continued need for the Seroquel PRN order or his rationale for continuing the order.
Licensed Nurse B acknowledged the PRN Seroquel has been in place from 2/3/26 to 3/26/26 without the doctor or mental health doctors' assessments.
During a phone interview on 3/30/26 at 11:36 a.m., when queried, Medical Director stated he could not recall if he documented a re-evaluation of Resident 1's continued need for Seroquel PRN, but I'm sure I did.
Medical Director stated, They have it at the nurses' station somewhere, they can find it.
When informed of facility policy verbiage regarding PRN antipsychotics, Medical Director stated, So I have to document every 14 days if I want the PRN order to continue?During a phone interview on 4/1/26 9:12 a.m., Pharmacist C stated she did Resident 1's medication regimen review a couple of weeks ago and she noted the Seroquel PRN order.
Pharmacist C stated she included in her report that she was recommending to discontinue the Seroquel PRN order.Review of facility policy Psychotropic Medication Use, last revised 2/2025, indicated, PRN Medication: 1.
Psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 3. PRN orders for psychotropic medications are limited to 14 days. b.
For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.
555207 03/26/2026
Piners Nursing Home 1800 Pueblo Ave Napa, CA 94558
Review of Resident 1's ED physician's note dated 2/1/26 at 2:32 p.m., indicated Resident 1's arterial blood gas (measures the levels of oxygen, carbon dioxide, and the acid-base balance (pH) in blood taken from an artery) results indicated some hypoxia (low oxygen level), chest x-ray showed no aspiration (when something other than air gets into the airways), and this appears to be an iatrogenic event (adverse effect of treatment) that requires her pain management strategy to be re-evaluated.
Review of Resident 1's ED diagnoses indicated accidental or unintentional opiate overdose and hypoxia.Review of facility policy, titled Pain - Clinical Protocol, last revised 10/2025, the policy under Treatment/Management section indicated 2a.
Pain medications should be selected based on pertinent treatment guidelines.
Generally, and to the extent possible, an analgesic [pain medication] regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches. 4. If the physician determines that opioid medication is an appropriate option for managing acute (or in some cases chronic) pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects. 5.
Combining opioids and benzodiazepines is avoided. If prescribed concomitantly, the resident will be carefully monitored for respiratory depression .A review of the fentanyl patch drug information using DailyMed (U.S. government database providing up-to-date, FDA-approved manufacturer drug labeling information), last accessed on 4/6/26 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2a2238e9-4b5d-c56d-8663-dd354ff9ae0c, the record under Dose Titration [the process of adjusting a medication's dosage over time to find the lowest effective amount that provides maximum benefit with minimal side effects] indicated Appropriate dosage increments should be based on the daily dose of supplementary opioids, using the ratio of 45 mg/24 hours of oral morphine to a 12.5 mcg/hr increase in fentanyl transdermal system dose.
The document under Important Dosage and Administration Instructions indicated Respiratory depression can occur at any time during opioid therapy, especially when initiating and following dosage increases with fentanyl transdermal system.
Consider this risk when selecting an initial dose and when making dose adjustments.