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 reflects the findings of the California Department of Public Health during an ABBREVIATED STANDARD SURVEY for Entity Reported Incident (ERI): CA00509070 Inspection was limited to the Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #28522 Health Facilities Evaluator Nurse. Deficienies are cited at Federal tags: F 225, F 226 and F241 Notice of Intent To Issue a Citation was issued to Administrator on 1/26/17 for F 241

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.13(c)(1)(ii)-(iii), (c)(2) - (4)

F225 02/10/2017 The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. 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: T3C111 Facility ID: CA010000760 If continuation sheet 1 of 12 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 01/26/2017 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 The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review Certified Nursing Assistant (CNA) A failed to follow facility policy by failing to report to facility staff Resident 1's allegation that CNA A continued to provide incontinent (inability to control bladder) care, after Resident 1 told CNA A to stop and stated he was raping her, on 10/31/16 at approximately 9 p.m. This failure had the potential to place the resident and other residents at risk for further abuse. Findings: During an interview on 11/2/16 at 8:30 a.m., with the Administrator and Licensed Nurse (LN) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 2 of 12 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 01/26/2017 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 B, the Administrator stated Resident 1 had reported to visiting family on 11/1/16, that Certified Nursing Assistant (CNA) A had raped her during the night. The Administrator stated CNA A had stated, during the facility's internal interview, Resident 1 said "stop you're raping me" and CNA A continued to change the incontinent brief and did not stop. LN B stated that during an interview with CNA A, CNA A stated he was just doing his job, that he had to finish changing her. Even though Resident 1 clearly told him to stop, he did not, and he did not report it to staff. Review of CNA A's documented statement, dated 10/31/16, indicated: "...I told her I need to change you or can I just check if your [sic] dry so that I don't have to change you, then while I'm doing care she said to me you are rapping [sic] me, and I told [Resident 1] I'm just helping you to get change and put pad on her bottom and I'm just doing my job. I did not report this to anybody because I was busy and their [sic] still have a patient to help get on bed so I'm rushing and I did not think about it to report." Review of the facility policy titled, "Abuse and Incident Reporting: California", dated last revised on 10/2015 indicated: "...Procedure: All alleged, suspected or actual abuse will be reported immediately to the Charge Nurse or Supervisor and the Health Care Administrator and Director of Nurses, so that it can be investigated in order to protect and better serve our residents...Incident Reporting: ...3. All Incidents, including suspected or alleged abuse (see Abuse Regulations for definition of abuse) will immediately be reported to the charge nurse, who will identify and direct immediate steps to be taken to prevent further incidents while an investigation is in progress. If the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 3 of 12 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 01/26/2017 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 incident involves alleged, suspected or actual abuse, an immediate phone call report will be made to the DNS [Director of Nursing Services] and Administrator..."

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

F226 02/10/2017 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 4 of 12 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 01/26/2017 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 facility failed to: 1. Ensure staff followed policy and procedure when one allegation by Resident 1 of suspected abuse was not reported to the facility staff immediately by Certified Nursing Assistant (CNA) A which had the potential to place the resident at further risk for abuse. 2. Fully develop policy and procedures to ensure the facility reports all allegations of alleged abuse or suspected abuse of a resident of the facility to the required state agencies within the required time frame. This had the potential for an inability of the facility to prevent, protect, investigate and/or report to proper authorities in a timely manner all allegations of alleged or suspected abuse in the facility. Findings: 1. During an interview, on 11/2/16 at 8:30 a.m., with the Administrator and Licensed Nurse (LN) B, the Administrator stated Resident 1 had reported to visiting family on 11/1/16, that Certified Nursing Assistant (CNA) A had raped her during the night. The Administrator stated that CNA A had stated, during the facility internal interview, Resident 1 said "stop you're raping me" and CNA A continued to change the incontinent (loss of bladder control) brief (designed for adult incontinent use) and did not stop. LN B stated, during an interview with CNA A, that CNA A indicated he was just doing his job, that he had to finish changing her, even though Resident 1 clearly told him to stop and he did not, and he did not report it to staff because he was too busy. During a record review, on 11/3/16 at 11:25 a.m., CNA A's documented statement, dated 10/31/16, indicated: "...I told her I need to change you or can I just check if your [sic] dry FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 5 of 12 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 01/26/2017 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 so that I don't have to change you, then while I'm doing care she said to me you are rapping [sic] me, and I told [Resident 1] I'm just helping you to get change and put pad on her bottom and I'm just doing my job. I did not report this to anybody because I was busy and their [sic] still have a patient to help get on bed so I'm rushing and I did not think about it to report." 2. Review of the facility policy titled, "Abuse and Incident Reporting: California", dated last revised on 10/2015 indicated: "...Procedure: All alleged, suspected or actual abuse will be reported immediately to the Charge Nurse or Supervisor and the Health Care Administrator and Director of Nurses, so that it can be investigated in order to protect and better serve our residents...Incident Reporting:...3. All Incidents, including suspected or alleged abuse (see Abuse Regulations for definition of abuse) will immediately be reported to the charge nurse, who will identify and direct immediate steps to be taken to prevent further incidents while an investigation is in progress. If the incident involves alleged, suspected or actual abuse, an immediate phone call report will be made to the DNS [Director of Nursing Services] and Administrator...5. INCIDENTS THAT DO NOT REQUIRE REPORTING TO THE STATE REPORTING AGENCY when abuse and/or neglect has been ruled out include (but, not limited to): small skin tears, small bruises not caused by staff or other residents; non-injury falls by ambulatory residents. 6. INCIDENTS REQUIRING REPORTING TO THE STATE REPORTING AGENCY: Any injury requiring treatment outside the facility (if required by your state); any injury caused by staff or another resident; unexplained weight loss; any sexual contact; illegal or improper use of resident's resources; verbal abuse; mental abuse; corporal punishment; involuntary seclusion; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 6 of 12 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 01/26/2017 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 abduction, any abuse or neglect. 7. Injuries requiring diagnosis or treatment outside the facility (if required by your state) and/or those caused by another person will be reported as soon as possible by calling the state agency..." The above policy and procedure for abuse and incident reporting did not include the facility specific reporting requirements of Health and Safety Code 1418.91 (a) and (c) and Welfare and Institution Code15610.07 (a) and (b); which requires reporting to The Department of all allegations of alleged abuse or suspected abuse of a resident of the facility immediately, or within 24 hours. During an interview on 11/9/16 at 11:15 a.m., the Administrator concurred that the facility Abuse Policy and Procedure did not include a statement that "all incidents of alleged abuse or suspected abuse will be reported to The Department immediately, or within 24 hours."

F241 SS=G DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.15(a) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 02/10/2017 Facility ID: CA010000760 If continuation sheet 7 of 12 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 01/26/2017 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 The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review facility staff failed to promote care in a manner to enhance dignity and respect for 1 of 4 residents (Resident 1), when Certified Nursing Assistant (CNA) A continued to provide incontinent (inability to control bladder) care after Resident 1 told him to stop and stated CNA A was raping her. This failure resulted in Resident 1 being exposed to continued fear and anxiety, when staff did not respond to Resident 1's cry for help. CNA A returned to Resident 1's room later that evening which frightened Resident 1and which Resident 1 stated made her feel helpless and fear for her safety. Findings: During an interview on 11/2/16 at 8:30 a.m., with the Administrator and Licensed Nurse (LN) B, the Administrator stated Resident 1 had reported to visiting family on 11/1/16, that Certified Nursing Assistant (CNA) A had raped her during the night on 10/31/16. The Administrator stated CNA A had stated, during the facility internal interview, Resident 1 said "stop, you're raping me". The Administrator stated CNA A continued to change the incontinent brief (designed for adult incontinent use) and did not stop and should have when Resident 1 said stop. LN B stated, during an interview with CNA A, CNA A indicated he was just doing his job, that he had to finish changing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 8 of 12 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 01/26/2017 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 her. LN B stated, even though Resident 1 clearly told CNA A to stop he did not, and CNA A did not report it to staff on the evening shift (3 p.m. to 11 p.m.). LN B stated upon return from the emergency room with Resident 1 the police officer and LN B asked Resident 1 if she felt safe and Resident 1 indicated she felt safe but had a bad experience. During an observation and concurrent interview on 11/2/16 at 10:05 a.m., Resident 1 was in bed with Family Member 2 at the bedside. Resident 1 stated on 10/31/16, during the night, while she was asleep, CNA A came into the room and "ripped" the blanket off her and got on top of her and held down her arms. Resident 1 sated she tried to fight him off by hitting CNA A and cried out for help, but no one responded, and stated her roommate was asleep with her hearing aides out so she could not hear and didn't respond. Resident 1 stated she felt "helpless, frightened" and that CNA A returned later that night and tried to apologize. She stated she was so frightened and just wanted him away from her. Resident 1 stated she still did not feel safe and it was a "horrible experience, felt so helpless, and it will take a very long time to recover from this." Family Member 2 stated Resident 1 had relayed the same story to her and the social service person who had just finished interviewing Resident 1. Family Member 2 stated even after staff assured Resident 1 that CNA A was not there and only female caregivers would take care of her, Resident 1 continued to state she was afraid and felt helpless. Family Member 2 stated, "its such a shame, she is on hospice" (a program of medical and emotional care for the terminally ill). Family Member 2 also stated Resident 1 kept commenting that it would take a very long time to get over this horrible experience. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 9 of 12 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 01/26/2017 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 During a record review on 11/2/16 at 9:30 a.m., the Emergency Department Report, dated 11/1/16, indicated physician's diagnosis and medical decision: "...Based on the patients presentation to the ER [emergency room] today, the general diagnostic impression is reported assault. At this time I see no obvious life-threatening injuries ... From the emergency department standpoint, the patient is safe for discharge and the rest of the evaluation will be left up to the evaluating officer..." During an interview on 11/2/16 at 11 a.m., Social Service (SS) C stated Resident 1 had been interviewed about the rape allegation earlier that morning. SS C stated Resident 1 stated CNA A came into the room in the middle of the night while she was sleeping and reported "he raped me." When SS C asked Resident 1 what happened Resident 1 stated he ripped the cover (blanket) off her and got on top of her. When asked how he got on top of her, SS C stated Resident 1 stated he just did, when asked what CNA A was doing Resident 1 told SS C that she was hitting him and he tried to penetrate her and got off her when she kept hitting him. SS C stated that Resident 1 told her that CNA A returned with a handful of Kleenex with poop on them and he changed her diaper. When SS C asked Resident 1 if she was afraid SS C stated Resident 1 stated yes, but not really now. During a record review, on 11/3/16 at 11:25 a.m., CNA A's documented statement, dated 10/31/16, indicated: "...I told her I need to change you or can I just check if your [sic] dry so that I don't have to change you, then while I'm doing care she said to me you are rapping [sic] me, and I told [Resident 1] I'm just helping you to get change and put pad on her bottom and I'm just doing my job. I did not report this to anybody because I was busy and their [sic] still FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 10 of 12 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 01/26/2017 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 have a patient to help get on bed so I'm rushing and I did not think about it to report." During an interview on 1/9/17 at 2:40 p.m., Police Officer D stated the police determined that alleged rape of Resident 1 was "unfounded", and that CNA A did not stop when Resident 1 told him to stop. Resident 1's annual History and Physical, dated 4/21/16, indicated Resident 1 was enrolled in hospice care for Stage 4 lung cancer. The annual Minimum Data Set (MDS, a resident assessment and evaluation tool), dated 9/12/16, indicated the Brief Interview of Mental Status (BIMS) score of 14 (score of 1315 indicates cognitively intact). A Care Plan entitled "Psychosocial Well-Being" dated 11/2/16, indicated the problem of psychosocial well-being is impaired related to emotional distress and included interventions of provide emotional support, only female caregivers, and Social Services to provide support if feelings of emotional distress. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T3C111 Facility ID: CA010000760 If continuation sheet 11 of 12 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 01/26/2017 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: T3C111 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA010000760 (X5) COMPLETE DATE If continuation sheet 12 of 12