The Meadows of Napa Valley

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the shower room in hallway 400 of the facility was kept in good working condition when the water in one of the showers did not drain properly and broken tile with sharp edges was found in the shower room floor. These failures increased the potential for residents to experience falls when water pooled and abrasions on their feet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of twelve sampled residents (Resident 19) wore her hearing aids daily to be able to communicate effectively with staff. This finding had the potential for Resident 19 to experience difficulty communicating with others and have feelings of isolation and loss of control.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision needed to prevent accidents for one resident (Resident 196) of three sampled residents when Resident 196 was left on the toilet and the staff member left Resident 196's room. This failure resulted in Resident 196 sustaining a spinal cord compression (when pressure is applied to the spinal cord causing swelling and restricted blood flow to the nerves and spinal cord) and death.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure safe storage and disposal of medications when loose units of unidentified pills and an expired bubble pack of narcotics were found in one medication cart. This failure put residents at risk of receiving expired medications that were potentially ineffective and unsafe for use and prevented prompt identification of possible loss and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used and understood the need for appropriate Personal Protective Equipment (PPE) for one resident (Resident 5) of five sampled residents for infection control, who had a medical status that required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). This failure had the potential to increase the risk of spread of MDROs and other infections among vulnerable residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 188) from an air mattress that deflated, when the facility was aware that these air mattress types had a risk of deflating. This failure resulted in Resident 188 falling out of bed, and sustaining a right thigh bone fracture. Resident 188 was transferred to the hospital and passed away nine days later.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure outdated drugs and biologicals were disposed of properly, when: 1. Two bottles of expired house stock medications (Over-the-counter medications) were found in the facility's medication room stored with other active house stock medications. This had the potential to result in inadvertently administering expired medications to the residents of the facility, which could have caused them harm, or lack of medication therapy. 2. Three controlled medications (Substances regulated by Federal law) were found in the facility's medication carts for two residents that had been discharged more than one week prior to the observation (Resident 139 & Resident 26), stored with other controlled drugs. This had the potential to result in drug diversion among facility staff. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an abuse allegation for one of six sampled residents (Resident 14) was reported to the required authorities within the appropriate timeframes established by the Federal regulations. This failure had the potential to result in financial abuse, frustration and emotional harm for Resident 14.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the required daily staffing information timely per the Federal regulations for Skilled Nursing Facilities. This had the potential to result in the inability for residents and visitors to determine if the facility was having staffing shortages, for advocacy purposes.

Inspectors wroteBased on observation, interview and record review, eight of eight residents stated they did not know how to file a grievance. This failure had the potential to cause residents to feel their needs were not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain residents' level of mobility for four of 19 sampled residents (Resident 3, Resident 16, Resident 27, and Resident 49). Which had the potential to result in: Functional decline, reduced likelihood of discharge, and increased risk for depression.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing services, to one of 16 sampled residents (Resident 27), when the facility did not in-service (train) its Certified Nursing Assistants (CNAs) on resident transfer techniques and did not ensure five of six CNAs were competent to assist Resident 27, who was wheelchair-bound, to transfer from the wheelchair to the toilet. This failure resulted in injury and pain to Resident 27, when in two separate instances CNAs transferred Resident 27 from his wheelchair to the toilet using an improper transfer technique. During one transfer, Resident 27 was placed on the edge of the toilet and pushed back against the toilet seat suffering a skin injury on his buttock, causing him pain and discomfort. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a nourishing and well-balanced diet that met nutritional needs and took into account resident preferences, to two of 16 sampled residents (Residents 3 and 42) when: 1) Resident 3 was not served a vegetable side and a salad side for lunch on 6/24/19; and, 2) Resident 42 was not offered an alternate meal for lunch on 6/24/19. These failures had the potential for Residents 3 and 42's nutritional needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to maintain an infection prevention and control program, that included: Surveillance of infections; a system for recording identified incidents; development and implementation of corrective actions; monitoring corrective actions taken; and antibiotic stewardship. This failure resulted in an increased risk for development and transmission of communicable diseases and infections, in a population of elderly residents with complex medical conditions.

Inspectors wroteBased on interview, and record review, the facility failed to implement an antibiotic stewardship program. This failure resulted in an increased risk for: Adverse drug events; ineffective treatment from inappropriate antibiotic use; and development of antibiotic-resistant organisms, in a population of elderly residents with complex medical conditions.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to ensure one of 16 sampled residents (Resident 20) was treated with dignity and respect, by maintaining and enhancing her self- esteem and self-worth, by involving her preferences and choices of Activities of Daily Living (ADL's), such as showers. The facility failed to consider Resident 20's life style and personal choices disregarding her needs and preferences. Staff failed to implement the established shower scheduled for Resident 20. Staff failed to treat resident 20, equally, when compared to other residents who received showers twice or more in a week. These failures negatively impacted Resident 20's psychosocial well-being, quality of life and quality of care.

Inspectors wroteBased on interview and record review, the facility failed to timely revise and update the comprehensive care plans of two of 16 sampled residents (Residents 25 and 42) when: 1) Resident 25 had an accidental fall on 6/1/19, and her comprehensive fall care plan was not revised and updated to include additional fall prevention interventions. This failure placed Resident 25 at risk of additional falls. 2) Resident 42 acquired a Urinary Tract Infection (UTI) on 6/18/19, and her comprehensive care plan was not revised and updated to include UTI interventions, until 6/26/19. This failure placed Resident 42 at risk of not receiving timely nursing interventions for her UTI.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 25) received treatment and care, in accordance with professional standards of practice, when the facility administered Carvedilol (a blood pressure medication) to Resident 25, without food, on an empty stomach. The Food and Drug Administration (FDA) recommends administering Carvedilol with food to slow the rate of absorption and prevent sudden loss of blood pressure, which can result in dizziness, loss of consciousness and falls. Approximately 30 minutes after being given Carvedilol on an empty stomach, Resident 25 fainted and fell, injuring her knee and face.

Inspectors wroteBased on observation, interview and record review, the facility filed to provide preventative measures, consistent with professional standards of practice, to one of 16 residents (Resident 1). The facility failed to provide treatment consistent with professional standards of practice to an existing surgical wound to the right hip and right knee. The facility failed to ensure Resident 1 did not develop avoidable skin injuries, failed to identify Resident 1 was at risk for skin injuries and failed to provide interventions to prevent further skin injuries. These failures resulted in Resident 1 acquiring five skin injuries to his left leg, nine days after admission.

Inspectors wroteBased on observation, interview and record review, the facility failed to label drugs according to professional principles, when the facility labeled one bottle of lorazepam (an anxiolytic medication) with an opened date which was unclear and did not label another bottle of lorazepam with the date it had been opened. The bottles of lorazepam indicated on their label they expired 90 days after being opened. The facility's failure to properly date the lorazepam bottles with the date they were opened, had the potential for residents to receive expired lorazepam.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy on food brought into the facility by family and visitors, for one un-sampled resident (Resident 52), when Resident 52 had fruit in her room, not provided by the facility, which was not labeled with Resident 52's name, room number and date it was brought in. This failure had the potential for Resident 52 to consume unsafe food.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate medical records for one of 16 sampled residents (Resident 42), when the facility documented Resident 42 ate 90% of her lunch on 6/24/19, when in fact, Resident 42 ate less than 25% of her lunch. This failure resulted in Resident 42's medical record not properly representing the health conditions of Resident 42.