The Vineyards Healthcare Center

Inspectors wroteBased on interviews and record reviews, the facility failed to provide care for Resident 1 that met professional standards of practice when:1. Resident's NPO status before PEG placement procedure was not verified with the physician (NPO is a medical abbreviation for the Latin phrase nil per os, which means nothing by mouth. It is a strict instruction from a doctor to not consume any food, liquids, or sometimes oral medications for a specific period, usually before surgery, PEG stands for Percutaneous Endoscopic Gastronomy. This is commonly referred to as a feeding tube that is placed directly into the stomach through the skin of the abdomen). 2. [...]

Inspectors wroteBased on interview and record review, the facility did not provide an ongoing activity program to Resident 1 to ensure that she maintained her highest physical, mental and psychosocial well-being. This deficient practice placed Resident 1 at risk of sensory deprivation and social isolation. During an interview on 1/27/26, at 2:27 p.m., with Family Member (FM) 1, FM 1 stated she did not observe Resident 1 having any activities while the resident was still residing in the facility. Review of Resident 1's admission Record dated 1/29/26, indicated that the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (memory loss and impaired decision-making capacity). [...]

Inspectors wroteBased on observation, interview, and the facility policy review, the facility failed to ensure food items were not stored on the floor in the dry storage room. This deficient practice affected all residents who received food from the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a licensed nurse, who was not certified to perform cardiopulmonary resuscitation (CPR), did not perform CPR on a resident who had a do not resuscitate (DNR) code status. This deficient practice affected 1 (Resident #236) of 6 sampled residents reviewed for advance directives.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions for 1 (Resident #14) of 2 sampled residents reviewed for urinary catheters. The facility further failed to ensure staff implemented contact precautions for 1 (Resident #26) of 3 sampled residents reviewed for transmission based precautions.

Inspectors wroteBased on observation, interview, document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 18 (Rooms 100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, 126, 128, 130, 134, 136, and 138) of 30 resident rooms in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for administering medications timely for one of three sampled residents (Resident 1), when Resident 1 ' s oral antibiotic medication (medication used to treat bacterial infections) was administered nine hours and sixteen minutes after it was ordered. This failure had the potential for exacerbating Resident 1 ' s health condition and compromising their overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to give appropriate care to Resident 1 ' s indwelling catheter tubing (a tube secured inside the bladder to drain urine into a bag outside the body). This failure resulted in Resident 1 having a urinary tract infection (UTI, an infection in any part of the urinary tract - kidneys, bladder, or urethra).

Inspectors wroteBased on interview and record review, the facility failed to ensure CNA 1 had the appropriate competencies and skills sets for providing proper care of the indwelling catheter (a tube secured inside the bladder to drain urine into a bag outside the body). This failure did not ensure Resident 1 received indwelling catheter care per physician's order and contributed to acquiring a urinary tract infection. (UTI), an infection in any part of the urinary tract - kidneys, bladder, or urethra.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. The following food items were not labeled with a delivery date or a use-by date: a. 5 containers of breadcrumbs b. 5 containers of grits c. 4 -1 pound (lb) bags of tortilla chips d. 3- 12 X 12 inch packs of rice crispy treats e. 2- 6 lb cans of pizza sauce f. 7- 11.5 ounce (oz) bottles of Real Mayonnaise g. 7 -12 oz bottles of yellow mustard h. Single use packets of mustard, tartar sauce, ketchup, [NAME] Mayo were in undated, transparent plastic containers. i. Assorted sugar-free single use jelly packs were in an undated box. 2. There was no air gap (amount of space that separates a water line from an ice machine drain to a sewer) for the ice machine to prevent potential backflow (water from flowing back up a water line). [...]

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 58), the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to direct care) admission Assessment for Resident 58's oxygen use was coded accurately. This failure resulted in the MDS containing inaccurate information regarding Resident 58's respiratory status and oxygen use.

Inspectors wroteBased on observation, interview, and record review, for two of three sampled residents (Resident 48 and Resident 58), the facility failed to post a safety sign indicating, Oxygen in Use outside the shared room of Residents 48 and 58. Both residents used oxygen concentrators (a portable medical device used to deliver oxygen to those who have a condition that caused or resulted in low levels of oxygen in their blood). This failure resulted in no cautionary sign warning others that oxygen (accelerates combustion in the presence of a flammable substance or smoking) was in use and refrain from certain activity or products to avoid a potential fire hazard.

Inspectors wroteBased on observation and interview, the facility failed to provide 55 of 55 residents in the following multiple occupancy resident rooms (100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, 126, 128, 130, 134, 136, 138, and 140 with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and for the lack of sufficient space for residents to have personal belongings at the bedside.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat four of four sampled residents (Residents 41, 45, 33, and 3) with respect and dignity when: 1. Resident 41 and Resident 45's urinary drainage bags were exposed, uncovered and hung on the side of their beds. 2. Staff stood over Resident 33 while assisting her with breakfast. 3. Resident 3 had his lunch tray uncovered in front of him and was not assisted with his meal for 20 minutes while staff assisted his tablemate resulting in Resident 3 feeling anxious and ignored. These failures had the potential for Residents 3, 41, 45, and 33 to feel humiliated and disrespected while receiving care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, serve and prepare food under sanitary conditions when the resident refrigerator contained expired food and food with no open and use-by-dates, the dry storage room contained food with no open and use-by-dates, scoops and measuring cups were stored dirty, and expired nutritional powder was stored in the utility room. These deficient practices had the potential to place residents at risk for foodborne illnesses and possibly result in unmet nutritional needs.

Inspectors wroteBased on observation, interview and record review the facility failed to perform proper handwashing while providing care to three (Residents 56, 41, and 2) of six sampled residents. Thess failures had the potential to result in the spread of infectious organisms not only to Residents 41, 56, and 2, but to other residents, staff and visitors at the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete quarterly assessments for one (Residents 49) of one sampled residents. This failure had the potential to cause residents not to have their medical and/or psychosocial needs met.

Inspectors wroteBased on record review and interview, the facility failed to send a discharge assessment for one (Resident 1) of one residents to the Centers for Medicare/Medicaid Services (CMS) within fourteen days after being discharged from the facility. This failure resulted in CMS not receiving discharge data for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the fall history of one (Resident 49) of one resident when the number of falls that caused injury to Resident 49 was not recorded accurately in the Minimum Data Set (MDS - an assessment tool used to assist in the directing of health care needs). This failure resulted in the MDS containing inaccurate information regarding Resident 49's history of falls with injuries and had the potential of not providing interventions that met the needs of Resident 49.

Inspectors wroteBased on interview and record review the facility failed to update one (Resident 49) of one sampled resident's care plans every quarter and/or as needed. This failure had the potential to result in Resident 49 not having his health care needs fully provided for.

Inspectors wroteBased on observation, interview and record review, for one (Resident 61) of four sampled residents, the facility failed to provide medications to meet the needs of the resident when the facility did not order medications in a timely manner. This failure resulted in Resident 61 not getting her medications as ordered by her physician for her health care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was below five percent. There were three errors out of 29 opportunities during medication administration. These failures resulted in a medication error rate of 10.34 percent and had the potential for placing residents at risk for undesired health care outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure multiple resident rooms (100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, 126, 128, 130, 134, 136, 138, 140) had at least 80 square feet (sq ft) per resident. This failure had the potential to compromise the provision of care residents receive.