Veterans Home Of California - Yountville - Snf
VETERANS HOME OF CALIFORNIA - YOUNTVILLE - SNF in YOUNTVILLE, CA — inspection on March 26, 2026.
Found 6 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
During a concurrent observation and interview on 3/24/26 at 8:57 AM in Resident 15's room with Resident 15, Resident 15 was sitting on the edge of his bed with his breakfast tray on the bedside table in front of him. Resident 15 was unable to reach his coffee and attempted to lean forward with mouth open to try and reach the straw with his lips, was unsuccessful and requested assistance. Resident 15 attempted to open a napkin, to wipe his nose, and fell backwards laying horizontal across his bed. Resident 15 stated he was not receiving any therapy and I should be, but I don't.During a concurrent interview and record review on 3/26/26 at 9:58 AM with Supervising Registered Nurse (SRN) 2, Resident 15's PASRR Level II Notice of Individual Determination, dated 10/25/25 was reviewed, the document indicated, Are Specialized Add-on Services Needed: Yes.
This Individualized Determination Report is based on a review of the applicant's medical and social history, which reveals a significant medical condition with mental stressors that require nursing care.
Recommended Specialized Add-on Services.
Occupational Therapy [OT] Consultation- services to improve independence in activities of daily living. SRN 2 reviewed Resident 15's entire medical record and stated an OT consultation was not completed after the PASRR Level II recommendation was received.
During an interview on 3/26/26 at 10:21 AM with the Chief of Rehabilitation Services (CRS), the CRS stated she cancelled Resident 15's OT consultation without evaluation and was not aware of the PASRR Level II recommendation.During an interview on 3/26/26 at 2:20 PM with the Medical Director (MD), MD confirmed with Resident 15's PASRR Level II Notice of Individual Determination, dated 10/25/25, that an OT consultation was recommended and stated Resident 15 should have received the OT consultation in accordance with PASRR Level II recommendation.The facility was unable to provide a policy and procedure for PASRR.
555095 03/26/2026
Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599
regarding resident change of condition or status whether verbally communicated or placed in the
and pertinent details of incident and assessment in the interdisciplinary Progress Notes . e.
Update
(All Homes), dated 1/15/26, the P&P indicated, the baseline care plan must reflect changes to approaches or interventions, when there is/are significant changes) in condition or need(s).
555095 03/26/2026
Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599
During a concurrent interview and record review on 3/25/26 at 10:52 AM with CNA 1, Resident 40's ADL flowsheets were reviewed.
The flowsheet for Resident 40's shower/bathe self, dated 1/1/26 to 1/31/26, indicated 29 out of the 31 days for the month of January were documented as Code 09.
The flowsheet for Resident 40's shower/bathe self, dated 2/1/26 to 2/28/26, indicated 25 out of 28 days for the month of February were documented as Code 09.
And on the flowsheet for Resident 97's shower/bathe self, dated from 3/1/26 to 3/24/26, indicated 20 out of the 24 days for the month of March were documented as Code 09. CNA 1 stated we should have attempted or offered a daily bath to Resident 40. ˆ During a concurrent interview and record review on 3/25/26 at 11:05 AM with CNA 1, Resident 69's ADL flowsheets were reviewed.
The flowsheet for Resident 69's shower/bathe self, dated 1/1/26 to 1/31/26, indicated 1 out of the 31 days for the month of January was documented as Code 09.
The flowsheet for Resident 69's shower/bathe self, dated 2/1/26 to 2/28/26, indicated 16 out of the 28 days for the month of February were documented as Code 09.
And on the flowsheet for Resident 69's shower/bathe self, dated from 3/1/26 to 3/24/26, indicated 20 out of the 24 days for the month of March were documented as Code 09. CNA 1 stated daily baths should have been attempted or offered to Resident 69.
During an interview on 3/26/26 at 7:51 AM with Assistant Director of Nursing (ADON) 1, ADON 1 stated residents hygiene shower or partial baths should have been offered or attempted to provide daily.ˆ During a review of the facility's P&P titled, ADL, STANDARDS, dated 9/8/25, the P&P indicated, Staff will ensure residents are free of offensive odors by providing daily partial baths .ˆ
555095 03/26/2026
Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599
During a concurrent observation and interview on 3/23/26 at 5:14 PM with Resident 97, Resident 97 was observed sitting at the edge of his bed with his dinner tray on top of the bedside table.
Verbal consent was obtained and granted to compare the food on his tray with the meal ticket.
There was no grilled ham and cheese sandwich found on the tray. A tomato soup was found on the tray instead which was not on the meal ticket.
During a review of Resident 97's Meal Ticket for 3/23/26 Supper, the meal ticket indicated regular diet with the following food items: salt pepper sugar, pudding variety, ice cream, gel strawberry with peaches, salad Caesar, juice v-8, mighty shake chocolate, and grill ham and cheese sandwich.
During a concurrent observation, interview and record review on 3/23/26 at 5:42 PM with Registered Nurse Quality Assurance (RNQA) 1, Resident 97's meal ticket was reviewed.
The grill ham and cheese sandwich was missing, and tomato soup was served on the food tray. RNQA 1 stated the meal ticket should have matched what was on the Resident 97's food tray.
During an interview on 3/26/26 at 9:11 AM with Assistant Director of Nursing (ADON) 1, ADON 1 stated licensed nurses checked both the diet order and also the food tray for accuracy during mealtimes prior to serving the food trays to the residents.
During a review of the facility's policy and procedure (P&P) titled, Diet, Meals and Snacks, dated 2/4/26, the P&P indicated, Licensed nurse personnel ensure patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his/her professional licensure.
During a review of the facility's P&P titled, Meal Observations, dated 1/2/26, the P&P indicated, B.
Meal Observations . 1.
Tray Accuracy - Did the resident receive what is on the meal ticket .?
555095 03/26/2026
Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599
serve food in accordance with professional standards.
sanitation guidelines were followed when multiple expired food items were found in the dry storage
illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 162.Findings: During a concurrent observation and interview on 3/23/26 at 2:01 PM in the Main Kitchen- G07 Refrigerator with the Food Manager (FM) 1, one large tray labeled Orzo Pasta had an expiration date of 3/11/26. FM 1 stated the orzo pasta needed to be thrown away because it was only good for 7 days.During a concurrent observation and interview on 3/23/26 at 2:28 PM in the Main Kitchen- Dry Storage Room with FM 1, the following food items were found expired:One container of chorizo seasoning had an expiration date of 12/31/25Eight packages of ranch dressing/dip had expiration dates of 2/14/26.Three bottles of browning seasoning sauce had expiration dates of 8/29/25.Four bags of vanilla artificial flavor instant pudding had expiration dates of 3/17/23.Nine bags of marshmallows had expiration dates of 2/27/26.Two bags of vanilla puddings had expiration dates of 11/3/21.FM 1 confirmed all the items were expired and stated all expired foods needed to be discarded.During a concurrent observation and interview on 3/23/26 at 2:59 PM in the Satellite Kitchen- Refrigerator with FM 2, the following food items were found expired: - One box of Sweet n Sour sauce had an expiration date of 3/14/26. - Two boxes of Plant-Based baked tofu had expiration dates of 2/26/26.FM 2 confirmed the items were expired and stated they should have been thrown away.During a review of the U.S [United States] Food and Drug Administration (FDA) Food Code dated 2022, the U.S FDA Food Code indicated, . foods that exceed the use-by date . must be disposed of .
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
555095 03/26/2026
Veterans Home of California - Yountville - Snf 100 California Drive Yountville, CA 94599
During a review of Resident 171's Face Sheet (demographics), the Face Sheet indicated Resident 171 was admitted to the facility on [DATE] with diagnosis that included acute bronchitis (inflammation in respiratory system) due to rhinovirus (highly contagious cold that infects nose and throat).During a concurrent observation and interview on 3/24/26 at 4:23 PM in Resident 171's room with CNA 4, EDP signage that indicated, To prevent the spread of infections, Staff entering this room must wear: N95 Mask, Face Shield, Gown, Gloves. was posted outside of the door with a PPE cart. CNA 3 was observed walking away from Resident 171's bed and cleaning the vital signs machine while wearing gown, gloves and surgical mask. CNA 3 confirmed he was not wearing an N95 and face shield and stated he was unaware of the required PPE for EDP rooms.
During an interview on 3/25/26 at 2:36 PM with Infection Preventionist (IP) 1, IP 1 stated Resident 171 was on EDP for respiratory symptoms associated with a positive test result of rhinovirus, enterovirus (contagious virus) and Methicillin-resistant Staphylococcus Aureus (MRSA-bacteria that causes infections that are resistant to many antibiotics) of the nose. IP 1 further stated all staff were to wear gloves, gowns, face shield and an N95 when entering Resident 171's room.During a review of Resident 171's Physician Orders (PO), dated 3/20/26, the PO indicated Resident 171 had an order for Enhanced Droplet Precaution.During a review of the facility's policy and procedure (P&P) titled, Infection Control- Viral Respiratory Illnesses, dated 3/20/26, the P&P indicated, All staff must wear appropriate PPE as required.
Signs will be posted outside of resident rooms indicating appropriate infection control, prevention and precautions, including required PPE.2.
During a review of Resident 16's Face Sheet (demographics), undated, the Face Sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnosis that included neuromuscular dysfunction of bladder (lost control of bladder due to nerve damage).During a concurrent observation and interview on 3/24/26 at 9:36 AM in Resident 16's Room with CNA 4, EBP signage that indicated, Anyone participating in any of these movements must also: [NAME] [put on] gown and gloves. transferring. was posted outside of the door with a PPE cart. CNA 4 was observed assisting another CNA with transferring Resident 16 from his bed to the wheelchair with a Hoyer lift (mechanical device used by caregivers to safely transfer residents with limited mobility). CNA 4 was not wearing a gown or gloves. CNA 4 confirmed she was not wearing a gown or gloves and stated she did not have to wear the required PPE listed on the sign because Resident 16 was not exposed (unclothed/naked).
During an interview on 3/25/26 at 2:45 PM with Infection Preventionist (IP) 1, IP 1 stated Resident 16 was on EBP for an indwelling catheter (flexible tube placed into the bladder to drain urine). IP 1 further stated all staff assisting in high contact activities, including transferring, were required to wear PPE such as gown, gloves and mask.During a review of the facility's tracking log of Precautions, dated 3/26/26, the tracking log indicated Resident 16 was on EBP for indwelling catheter device.During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 12/30/25, the P&P indicated EBP was defined as Infection control interventions requiring gown and glove use during high-contact resident care activities.
The P&P further indicated the facility should implement EBP for residents with indwelling medical devices and that High-Contact Activities included . transferring.