Other·February 28, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the State of California Department of Public health during Abbreviated Standard Survey of Entity Reported Incident #CA 00484343. Inspection was limited to the specific Entity Reported Incident and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: #29640 (#2501), Health Facilities Evaluator Nurse. One Federal Deficiiency issued for ERI CA00484343 Intent to Issue a Citation was Issued to Administrator on 1/25/17

F226 SS=E DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.13(c)

F226 02/24/2017 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to develop and operationalize adequate written policies and procedures which LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BJKS11 Facility ID: CA010000760 If continuation sheet 1 of 3 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555639 (X3) DATE SURVEY COMPLETED 01/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS OF NAPA VALLEY CARE CENTER 1900 Atrium Pkwy Napa, CA 94559 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE addressed reporting allegations of resident abuse when the facility administrator failed to notify the State Agency immediately or within 24 hours when a staff reported to the Administrator on 4/4/16 allegations of abuse made by two Residents (Resident 1 and Resident 2). The Administrator did not report these allegations to the Department until 4/14/16. These failures had the potential to place residents at risk for abuse when allegations of abuse are not reported timely. Findings: During a telephone interview, on 4/14/16 at 4:35 p.m., the Administrator stated he would be submitting an abuse report due to care issues related to Certified Nurse Assistant (CNA) B. The Administrator stated on 4/04/16 he had received a report of allegations from Licensed Nurse E regarding CNA B. The Administrator stated Licensed Nurse E told him one resident [Resident 2] had reported feeling "scared to death" of CNA B and did not want to use the call light when that CNA was on duty. The Administrator stated Licensed Nurse E also reported to him at that time another Resident [Resident 1] told Licensed Nurse E that CNA B sprayed her in the face with a shower head and reportedly told the resident that if she did not stand up she would not receive a shower. The Administrator stated that same day he interviewed the residents. He stated the residents did not report concerns of abuse and their stories did not match up to Licensed Nurse E's initial report. During an interview, on 4/15/16 at 2:05 p.m., the Administrator stated he and the DON had not initially suspended CNA B when the allegations of abuse were first reported. He stated after they interviewed the affected residents on 4/4/16 and CNA B they decided it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BJKS11 Facility ID: CA010000760 If continuation sheet 2 of 3 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555639 (X3) DATE SURVEY COMPLETED 01/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS OF NAPA VALLEY CARE CENTER 1900 Atrium Pkwy Napa, CA 94559 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was not abuse. The administrator stated he had interviewed the residents (Residents 1 and 2) on 4/04/16 and had determined that no abuse had occurred. During a record review, on 4/15/16 at 4:00 p.m., the facility policy, "Abuse and Incident Reporting," dated, 08/10, revised 10/15, indicated: p 2.) "Incident Reporting: 3.) All incidents, including suspected or alleged abuse (see Abuse Regulations) will be immediately reported to the charge nurse. ... If the incident involves alleged, suspected or actual abuse, an immediate phone call will be made to the DNS or the Administrator. 6.) Incidents Requiring Reporting To The State Agency:.. any abuse or neglect." The policy did not reflect that all allegations of abuse would be reported to the Department immediately or within 24 hours and did not include specific reporting procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BJKS11 Facility ID: CA010000760 If continuation sheet 3 of 3