A skilled nursing facility in Napa is being sued for elder abuse and negligent hiring and supervision following the death of one of its elderly patients.

The lawsuit alleges that the staff at Napa Valley Care Center on Villa Lane did not provide necessary care to Caroline Johnson, an 82-year-old patient who was at the facility for nine days before having a stroke and falling into a coma. Her family took her off life support two days later on May 16, 2016, according to the suit.

Johnson’s daughter, Marilyn Burger Gomes of Napa, is being represented by Stephen Garcia of Garcia, Artigliere, Medby & Faulkner out of Long Beach. Garcia filed the lawsuit against the center, its managing entity and multiple employees in San Diego County Superior Court on April 27.

“It is our opinion that these horrific injuries to Caroline would not have occurred had Napa Valley Care Center adhered to applicable rules, laws and regulations, as well as the acceptable standard of practice governing the operation of a skilled nursing facility,” Garcia said in a press release. “Instead, as is so often the case where a business puts profits over people, further injury and even tragedy occurs. Caroline was left to deteriorate and she ultimately paid with her life.”

The named defendants – Petunia Holdings, LLC, and Plum Healthcare Group – have not filed responses yet, but a civil case management conference is scheduled for Dec. 15. Representatives from Napa Valley Care Center declined to comment on the case at this time.

Johnson’s medical history included problems with hypertension, coronary atherosclerosis, atrial fibrillation, hypothyroidism, and chronic obstructive pulmonary disease. Due to these conditions, Johnson had difficulty breathing and used a nebulizer every night, according to the suit. She also had a history of abnormally high blood pressure levels, spells of dizziness and minor falls and was confined to a wheelchair.

Despite these ailments, Johnson enjoyed the quality if her life and was alert, animated and energetic, according to the suit.

After experiencing difficulty breathing on May 2, 2016, Johnson was admitted to Queen of the Valley Medical Center for two or three days before being transferred to Napa Valley Care Center for rehabilitation and assistance with daily living. Staff at the center was tasked with helping Johnson with food preparation, eating, and taking medications in addition to monitoring her blood pressure levels and breathing, according to the suit.

Instead, the suit alleges that Johnson was left “grasping for air” without her nebulizer her first four or five nights at Napa Valley Care Center. And, the suit says, her blood pressure levels were never even assessed or documented.

Johnson was served cold, bland food and treated without dignity, according to the suit.

Once Johnson even challenged her daughter to try the food herself. The daughter then described the scrambled eggs as “soggy, watery and ice,” the suit alleges. When Johnson asked staff to serve her food while it was still warm, a staff member told her, “Well, they’re just going to get colder if you don’t eat them now,” according to the suit.

The suit alleges that Johnson lost more than 10 pounds during her nine-day stay at Napa Valley Care Center.

Johnson’s daughter, who visited and called often, routinely asked about her mother’s health and asked care staff to arrange for her mother to see a doctor about a large bruise that was on her foot or her abnormal blood pressure levels, which Johnson’s daughter tested herself, according to the suit. The daughter informed staff that bruising on her mother could be a sign of a blood clot, but, alleges the suit, staff ignored her requests.

“Johnson suffered significant blood clots in her leg leaving gruesome severe bruising and suffered a traumatic stroke from which she unnecessarily and avoidably fainted into permanent unconsciousness,” reads the suit. By the time Johnson was transported to the hospital on May 14, 2016, it was too late, the suit alleges. She was placed on life support.

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The attending physician told Johnson’s daughter that details regarding her mother’s stroke, including what time it had occurred, were unknown, the suit alleges. The facility, the physician said, failed to timely transfer her mother, leaving no opportunity for treatment, according to the suit.

Johnson died from acute vascular accident, chronic obstructive pulmonary disease and hypertension –“the very conditions for which she was admitted to the facility to address,” according to the suit.

The suit alleges that staff were poorly trained and overworked.

The 130-bed facility was given two out of five stars and an overall rating score of “below average” based on health inspection, staffing and quality measures, according to Medicare.gov Nursing Home Compare, the official U.S. government site for Medicare.

In its most recent standard health inspection report dated April 15, 2016, inspectors found that Napa Valley Care Center had 12 health deficiencies – slightly less than the average number of deficiencies in nursing homes across California, but more than the national average. The center was rated “above average” in staffing and “much above average” in quality measures.

Garcia’s law firm also has two pending lawsuits against a former Napa care facility, GoldenLiving Center. The center has since changed ownership and its name changed to Napa Post Acute.


Maria Sestito is the Napa Valley Register public safety reporter. She covers breaking news as well as crime and courts. Maria came to the Napa Valley Register in 2015 after working at as a reporter and photographer at The Daily News in Jacksonville, NC. S