Nursing Care Index

Napa Valley Care Center

Napa, Napa County, California · CCN 555161 · For-profit (LLC) · part of Pacs Group (274 facilities, chain average 2.9 stars)

CMS rates Napa Valley Care Center 3 of 5 overall as of August 2026. 130 certified beds, 126 residents a day on average. 64 citations on record from the current inspection cycles, 2 involving actual harm; 1 fine totalling $30,259.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★☆☆ 3 of 5
Health inspections★★☆☆☆ 2 of 5
Staffing★★★★☆ 4 of 5
Quality measures★★★★★ 5 of 5
Quality: long-stay / short-stay5 / 5 of 5

Staffing

Total nurse staffing3.81493 hours per resident per day
Registered nurses0.4771 hours per resident per day
Weekend total3.44049 hours per resident per day
Nursing staff turnover24.6% (registered nurses 14.3%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-07-02
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-29
2026-05-20
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-10
2025-07-25 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-08-21
2025-07-25 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-08-21
2025-07-25 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies · tag F0814
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Provide or get specialized rehabilitative services as required for a resident.
Quality of Life and Care Deficiencies · tag F0825
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-07-25 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-21
2025-05-12
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-15
2025-04-08
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-24
2025-02-21
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-11
2025-01-09
complaint survey
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.
Resident Rights Deficiencies · tag F0625
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-10
2024-10-08
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-11-13
2024-10-08
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-11-13
2024-10-08
complaint survey
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Rights Deficiencies · tag F0557
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-11-13
2024-10-08
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-11-13
2024-10-08
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-11-13
2024-07-24
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-20
2024-07-24
complaint survey
Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-21
2024-07-24
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-20
2024-02-16
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-04-02
2024-02-16
complaint survey
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-02
2024-02-16
complaint survey
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-02
2024-02-16
complaint survey
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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-02
2024-01-10
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-24
2023-12-19
complaint survey
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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-09
2023-10-18
complaint survey
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-11-26
2023-10-18
complaint survey
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.
Resident Rights Deficiencies · tag F0622
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-26
2023-09-21
complaint survey
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-11-05
2023-09-21
complaint survey
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-05
2023-09-13
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-10-06
2023-09-13
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-10-06
2023-09-13
complaint survey
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-10-06
2023-09-13
complaint survey
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Rights Deficiencies · tag F0557
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-06
2023-09-13
complaint survey
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Administration Deficiencies · tag F0838
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-06
2021-09-21 Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies · tag F0685
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2022-02-16
2021-09-21 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2022-02-16
2021-09-21 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies · tag F0740
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies · tag F0802
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 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.
Nutrition and Dietary Deficiencies · tag F0803
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies · tag F0806
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 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.
Nutrition and Dietary Deficiencies · tag F0808
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Administration Deficiencies · tag F0868
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-02-16
2021-09-21 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies · tag F0637
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · tag F0676
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 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.
Quality of Life and Care Deficiencies · tag F0693
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2021-09-21 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-02-16
2019-08-07 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2019-09-18
2019-08-07 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2019-09-18
2019-08-07 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.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2019-09-18

Fines and payment denials

DatePenaltyAmount
2023-09-13Fine$30,259

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Hudson River Opco LLC
Organization
5% or greater direct ownership interest100%2021-11-05
Bay Bridge Capital Partners, LLC
Organization
5% or greater indirect ownership interest100%2021-11-05
Serrano, Noel
Individual
contracted managing employee2023-05-11
Apt, Frederick
Individual
corporate officer2024-01-01
Jergensen, Joshua
Individual
corporate officer2024-01-01
Mitchell, John
Individual
corporate officer2024-01-01
Hadley, Spencer
Individual
operational/managerial control2021-11-05
Hadley, Spencer
Individual
w-2 managing employee2021-11-05

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Napa County.