Vineyard Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, homelike environment for four of six sampled residents (Residents 1, 2, 3, and 4) when the shared bathroom between the two rooms was in disrepair. This failure violated Resident 1, 2, 3 and 4's right to a comfortable and homelike environment that would respect the residents' dignity and well-being and placed Resident 1, 2, 3 and 4 at risk for injury. During a concurrent observation and interview on 7/31/26 at 1 pm, with Resident 1, Resident 1 demonstrated the disrepair of her bathroom. Resident 1 stated she had originally complained about her bathroom [ROOM NUMBER] days earlier and had complained many times since. When she pushed the toilet, it moved to the side. The caulking at the base was cracked and missing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP-a resident representative who assists with care decisions) was notified of a change in condition for one of four sampled residents (Resident 1) when Resident 1 had bleeding from his mouth on 12/26/25 and the nurse did not notify the RP of the residents change in condition. This failure resulted in Resident 1's rights being violated when his RP was not notified of the resident's change in condition on 12/26/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses (LN) administered medications in accordance with professional standards of practice for one of four sampled residents (Resident 2), when Resident 2's morning medications were left at the bedside unattended by nursing staff and not administered timely as prescribed by the physician on 4/1/26. This failure resulted in Resident 2 not receiving the medications as prescribed by the physician and placed other residents at risk for ingesting medications not prescribed to them. During a concurrent observation and interview on 4/1/26 at 11:10 a.m. with Resident 2, Resident 2 was lying in bed with his eyes closed, but responded when spoken to. Resident 2's breakfast tray was on his overbed table, next to the tray was a small medicine cup with eight pills in it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1. The housekeeping closet on Wing B was found to have brown/gray and white residue on the floor, 2. The walls were missing plastic baseboards exposing multiple layered hole near the base of the left wall. 3. A metal drain was found to have rust colored debris and uneven untiled surface, the front of the sink piping had peeling paint and brown colored staining. These failures had the potential to result in cross contamination (the spread of harmful bacteria, viruses, or parasites from one person, object or place to another) between staff, residents and visitors which could lead to illness, sepsis (a life-threatening condition and occurs when the body's immune system overreacts to an infection) or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with current accepted professional principles when: 1.15 of 383 sampled medication blister packs (a form of tamper-proof packaging where an individual pushes individually sealed tablets through the foil to take the medication) were without a visible expiration date. 2. A liquid narcotic medication was found expired in medication cart one for one (Resident 16) of 56 sampled residents. These failures had the potential for medications without a visible expiration date to be administered to residents which can lead to medication errors and placed residents' safety at risk. 3. An unlocked medication cart was found on the back patio which contained 10 unidentified loose pills. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Dietary [NAME] (DC) 1, DC 2 and Maintenance Director (MAIND) had the appropriate competencies to carry out the functions of the food and nutrition services safely and effectively for 50 of 51 residents when: 1. MAIND did not demonstrate or verbalize proper cleaning procedure for the ice machine according to the manufacturer's guideline. This failure had the potential for contaminated ice to be served to residents and placed residents at risk of foodborne illness and infection. 2. DC 1 did not demonstrate or verbalize the proper use of a test strip (paper that measure the concentration of quaternary ammonium compounds [chemicals that kills germs on surfaces]) for the sanitizing bucket (a container used to store and mix a chemical solution that reduces germs on surfaces). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menus for proper portion control were followed for Resident 54 when the roast turkey was not weighed in accordance with the dietary spreadsheet (a spreadsheet that tracks food intake and other dietary information). This failure had the potential for Resident 54 to receive an incorrect amount of food portion which could lead to an unplanned weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for 50 of 51 residents who received food in the kitchen when: 1. A open box of green tea was not labeled with an open and received date. 2. An expired ground rosemary seasoning was found on the shelf with other seasonings. 3. Black particles were found on top of a red wine vinegar bottle. 4. Spider cobwebs and brown and black particles were found behind the ice machine. 5. Maintenance Director (MAIND) did not wear a beard net when cleaning the ice-machine. 6. Black substances were found inside the ice compartment during cleaning. These failures placed residents at risk for foodborne illness (a condition where a person becomes sick after consuming contaminated food or beverages. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an unwitnessed fall with injury to the California Department of Public Health within the required time frame for one of three sampled residents (Resident 13) when Resident 13 fell from her wheelchair on 1/8/25, hit her head and was unconscious which led Resident 13 being transferred to the General Acute Care Hospital for further evaluation. This failure resulted in Resident 13's fall not investigated timely within the required time frame and had the potential to result in Resident 13's safety needs not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 10 sampled residents (Resident 25) when Resident 25 did not have a care plan for behavior monitoring while receiving an anti-psychotic (a medication used to treat a collection of symptoms that affect your ability to tell what's real and what is not ) medication. This failure had the potential to result in Resident 25's prescribed anti-psychotic medication not having measurable objectives in place to meet Resident 25's mental and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for one of eight sampled residents (Resident 3) when Resident 3 was receiving oxygen at 2.5 Liters Per Minute (L/min - a unit of measurement for oxygen flow rate) instead of the physician prescribed 3 L/min. This failure placed Resident 3's respiratory needs to go unmet and increased her risk to experience episodes of shortness of breath, fatigue and respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective discharge planning process for one of four sample residents (Resident 60) when Representative (RP) 2 was not involved and notified of Resident 60 ' s discharge from the facility on 12/22/24. This failure resulted in Resident 60 being discharged without RP 2 ' s knowledge or consent and placed Resident 2 ' s safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of three sampled residents (Resident 21) when Resident 21 had an order of prn (as needed) oxygen and received oxygen continuously due to episodes of increasing shortness of breath and Licensed Nurses (LNs) did not notify his Attending Physician (AP) of the change of condition. This failure placed Resident 21's respiratory needs to go unmet and increased his risk to experience frequent episodes of shortness of breath.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain management was provided consistent with professional standards of practice and comprehensive person-centered care plan for one of 10 sampled residents (Resident 3) when Licensed Nurses did not address Resident 3's frequent complaints of pain to her right knee. This failure resulted in Resident 3's frequent complaints of pain going unrelieved and limited her ability to participate in physical therapy on multiple occasions meant to support her physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared in a form designated to meet individual needs for one of 10 sampled residents (Resident 311) on a mechanical soft (chopped, ground and pureed food designed for people who have trouble chewing and swallowing) diet was served with a regular diet. This failure placed residents with difficulty chewing or swallowing and, on a physician prescribed mechanical soft diet at risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for one of eight sampled residents when: 1. Registered Nurse (RN) 1 did not change her gloves after cleansing a wound, and before applying medication and a clean dressing to Resident 41 during a dressing change. RN 1 did not perform hand hygiene after removing her gown and exiting Resident 41's room after performing the dressing change on Resident 41 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for one of three sampled residents (Resident 1) when Resident 1 was bedbound for eight months and did not have an activity care plan. This failure resulted to Resident 1 spending her waking hours picking on her skin and resulted to excoriations to her various body parts, including her abdomen, left hip and right hip.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance) when seven (14 A, 14 B, 14 C, 13 A, 18 B, 19 B and 20 A) of 56 resident call lights were not functioning properly. This failure had the potential for resident needs to go unmet and placed resident's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was palatable and served at an acceptable temperature to the residents in accordance with the facility policy and procedure. This failure had the potential to affect meal and food intake which could impair the nutrition status for 45 of 45 residents who are served food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Resident 17 and Resident 47) when: 1. Resident 17's activity care plan did not have individualized interventions. 2. Resident 47 did not have an activity [NAME] plan. These failures had the potential to prevent the residents from receiving appropriate, and individualized care and services consistent with their needs.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual performance review of licensed nurses (LN) for two of nine sampled licensed nurses (Registered Nurse [RN] 1 and Infection Preventionist [IP]) when RN 1 and IP did not have annual performance evaluations and skills competencies review from 2022 to 2023. This failure had the potential to result in RN 1 and IP to not develop or maintain competencies to provide residents with needed and appropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of a nurse aide for three of 12 sampled Certified Nursing Assistants (CNA 1, CNA 2 and CNA 3) when CNA 1, CNA 2 and CNA 3 did not have annual performance evaluations and skills competencies review within the last 12 months. This failure had the potential to result in CNA 1, CNA 2 and CNA 3 to not develop or maintain competencies to provide residents with needed and appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation tools and food storage methods, according to standards of practice and facility policy when: 1. Two cutting boards were found visibly worn with multiple tears and discolorations. 2. A case of molded onions was found on a shelf underneath the Cook's prep counter. 3. A case of Corn tortillas and a bag of Parsley did not have use by dates. These failures had the potential to expose residents to contaminants that could cause foodborne illness. The facility census was 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 12 sampled residents (Resident 31) when the contracted pharmacy for the facility did not deliver Resident 31's prescribed Clonazepam (a medication used to treat severe anxiety, panic disorders, and seizures) between 12/8/23 and 12/12/23. This failure resulted in Resident 31 to experience increased anxiety and restlessness which caused disturbance to other facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary medications in their treatment plan for one of 12 sampled residents (Resident 18) when Resident 18 had no appropriate indication and monitoring for the use of Atorvastatin (a medication used to lower cholesterol levels in the blood). This failure placed Resident 18 to be at risk of being administered Atorvastatin unnecessarily which could potentially lead to constipation, muscle pain and liver damage.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the menu was followed for the grilled cheese offered as an alternate menu item. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status. The facility census was 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow CDC guidance and facility policy and procedure for the prevention of infections when the Director of Nursing (DON) did not provide evidence of vaccination and did not wear a surgical mask in accordance with written standards. This failure resulted in the increased risk of the spread of infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, when: 1. The facility failed to ensure a Registered Dietitian (RD) evaluated or reassessed Resident 31's nutritional status timely, in order to recommend nutritional interventions, after an unplanned severe and continuous weight loss of 23.9% (percent) over eight months. The facility failed to intervene timely when Resident 31's weight loss began despite documented meetings acknowledging weight loss. There was no evidence demonstrating recommended interventions were implemented from 2/21 to 7/21. The was no plan of care to address the weight loss and prevent further weight loss. During the weight loss, Resident 31 also acquired a pressure ulcer to the coccyx. 2. [...]

Inspectors wroteBased on food services observations, staff interview and departmental document review the facility failed to ensure a Registered Dietitian and Dietetic Services Supervisor comprehensively evaluated the effectiveness of food service operations as evidenced by lapses in the delivery of services associated with meal distribution accuracy and nutritional value of menus (Cross Reference F803, F805, and F808 ), and food safety (Cross Reference F812). Failure to ensure food and nutrition services systems are accurately and effectively delivered may result in compromising the nutritional status of residents through the potential transmission of foodborne illness and incorrect plating of physician ordered therapeutic diets for the 52 residents at the facility.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. Time/Temperature Control for Safety (TCS) foods (food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were not properly monitored for cool down; 2. TCS foods were not properly labeled and expired items were in the refrigerator; 3. Cups for resident drinks were stored wet and stacked or wet with lids on; 4. A utensil storage drawer, cabinets, and walls were not clean; and 5. Air gaps were not present in the ice machine and food preparation sink. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and other information) program failed to implement their action plans which include monitoring and sustaining the appropriate plan of actions to correct the identified quality deficiencies in accordance with their plan of correction from the last re-certification survey completed on 1/30/2020 when: 1. Quality care issues were not identified with an appropriate action plans developed to correct the identified deficient practices (cross reference F656, F801, F808, F812, F880); and 2. When four of ten interviewed facility staff were unable to identify the purpose of QAPI and current QAPI projects. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to maintain an essential equipment in a safe operating condition when one of two laundry washer (washer 1) had unreadable water temperature control to detect and measure recommended water temperature for laundry process of soiled resident's linens and clothes. This failure had the potential for residents to be exposed to unclean linens and microorganisms (bacteria, viruses, and fungi).

Inspectors wroteBased on observation, and staff interviews, the facility failed to provide a safe, sanitary, comfortable working environment for residents, staff, and the public when: 1. the kitchen's temperature readings exceeded 83 degrees F (Fahrenheit [temperature measure). This failure resulted in an unsuitable working environment for kitchen staff. 2. a rubber strip across doorway of a resident room came loose when it was walked on. This failure had the potential to cause tripping and injury to a resident, staff, or the public. 3. the paint from the walls of the laundry room, inlcuding above the laundry sink was peeling. The laundry sink, faucet, faucet handles, and surfaces of the sink were stained with grime (dirt ingrained on the surface).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs of the residents for three of five sampled residents (Resident 2, Resident 28 and Resident 31) when: 1. Resident 28 and 31 did not have a resident-centered care plan intervention for safe handling, humidification (process to provide moisture content to the air), and cleaning of oxygen (O2 - supplemental oxygen to supply oxygen to the lungs) therapy use; and 2. Resident 2 did not have the use of fall prevention signs implement in her room as one of the interventions to prevent falls. These failures had the potential to result in Resident 2, 28, and 31's identified care needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Controlled (drugs with high abuse potential subject to special handling, storage, disposal, and record keeping) drug accountability, when Resident 197's medication, a controlled medication was only accessible to authorized personnel 2. Provider's orders were carried out for Resident 46 These failures increased potential for drug diversion by allowing unauthorized access to Resident 197's controlled medication, and delayed the administration of medication for Resident 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when: a. Medication room and fridge temperature not monitored consistently; b. For Resident 1, an eye drop that required to be dated when opened, did not have an expiration date/date open sticker; c. For Resident 37, a morphine (pain medication) solution was incorrectly labeled with another resident's identifier These failures had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications, medications for Residents 1, and 37.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for: 1) a. 14 out of 14 residents (Residents # 6, 8, 12, 15, 16, 17, 19, 26, 38, 39, 41, 42, 45, 97) on Regular Controlled Carbohydrate diets, b. One out of one residents (Resident #1) on Small Controlled Carbohydrate diet; and 2) Three out of three residents (Residents #15, 20, 33) on Pureed diets did not receive the correct portion sizes of foods. This failure had the potential to result in not meeting the nutritional needs further compromising the medical status of the residents.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure food was served in the proper size for five of five residents (Resident #19, 30, 38, 47, 297) on chopped meat diet when they received chicken cut in approximately 1 inch squares during the lunch meal service on 7/13/21. This failure had the potential to place residents on a chopped meat diet at an increased risk for choking.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure residents are receiving therapeutic diets as prescribed by the physician when: 1. Two residents (Resident # 2 and 40) did not receive carbohydrate controlled diets (a therapeutic diet designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), and 2. Six resident's (Resident # 3, 9, 45, 197, 297, 298) tray tickets did not match their physician prescribed diets. This failure could result in further compromising resident medical status or unnecessarily restricting a resident's diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an infection control procedures when: 1. Licensed Vocational Nurse (LVN) 2 failed to observe infection control measures by failing to properly disinfect resident's glucometer for one randomly selected resident (Resident 41) according to manufacturer's specifications 2. two (Resident 28 and Resident 31) of four sampled residents' nasal cannula and humidifier container of oxygen therapy (also called supplemetal oxygen) were not changed and not labeled with date changed in accordance to facility's policies and procedures. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a sampled resident (Resident 17) was free from an unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when licensed nurses administered sertraline (medication for depression) without consistently doing a monthly monitoring and evaluation of resident-specific behavioral symptoms, and did not attempt non-pharmacological interventions prior to the intiation of mirtazapine (medication for depression). These failures increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.