The Meadows of Napa Valley

In the surveyor’s words

From the most serious findings on record at The Meadows of Napa Valley, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 8, 2024

  Based 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. Findings: A review of Resident 196's admission record indicated he was admitted to the facility on [DATE] with medical diagnosis which included: acute on chronic combined systolic and diastolic heart failure (a sudden worsening of a pre-existing condition where the heart struggles to both effectively pump blood out and fill with… […]

• Actual harm, isolatedF689Jan 27, 2023

  Based 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. Findings: Review of Resident 188's Admission Record indicated Resident 188 admitted to the facility in May 2021 with diagnoses including heart disease and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). […]

• No harm, potential for more than minimal, widespreadF761Aug 13, 2026

  Based on observation, interview and record review, the facility did not store resident medications in a safe and sanitary manner for 31 residents, when safe temperature ranges were not established in the medication storage room, and when loose pills, dust and dried substances, expired laboratory items, damaged medication storages boxes and dirty and contaminated items were observed in the medication storage room and on the crash cart and medication cart. These failures had the potential for cross-contamination, infection, ineffective resident medication absorption and false wound and lab culture results for 31 residents. […]

• No harm, potential for more than minimal, patternF689Aug 13, 2026

  Based on interviews and record review, the facility failed to ensure the safety for five of five sampled residents (Resident 1, 16, 28, 31, and 40) when they did not assess the fall risk for Resident 31 and Resident 40 upon admission and when they did not complete post-fall evaluations for Residents 1,16, 28, 31, and 40 to prevent future falls.These failures limited the facility's ability to recognize hazards resulting in increased risk of future falls for Residents 1, 16, 28, 31, and 40.A review of Resident 1's admission record indicated she was admitted in 3/22 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and repeated falls.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool)… […]

• No harm, potential for more than minimal, patternF761Jan 27, 2023

  Based 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. […]