Vineyard Court Nursing Center

Inspectors wroteBased on observation, resident and resident representative interviews, staff interviews, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect by the use of inappropriate language and by not providing privacy during care for two (2) of five (5) residents sampled. Resident #1 and Resident #4Findings include:Record review of facility policy titled, Resident Rights with date of 2022, revealed, The resident has the right to a dignified existence . 4. The resident has a right to be treated with respect and dignity. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to adequately supervise residents during smoking breaks which allowed residents to smoke marijuana for two (2) of three (3) residents reviewed for smoking. Resident #1 and #2Findings include:Record review of facility policy titled, Resident Smoking dated 10/24/22, revealed, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. 8. Any resident who is deemed safe to smoke will be allowed to smoke under supervision in designated smoking areas .During an interview on 8/26/25 at 3:35 PM, Resident #1 revealed he was a smoker and would smoke during scheduled smoke breaks. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to provide an ordered pain medication for a resident who had pain for one (1) of four (4) residents reviewed. Resident #1Findings include:Record review of facility policy titled, Pharmacy Services dated 3/14/24, revealed, It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to implement a care plan for the use of an anti-contracture device for (1) one of 16 resident care plans reviewed. (Resident #6)

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide the services to ensure a resident maintained/improved his/her highest level of range of motion (ROM) as evidenced by failure to apply an anti-contracture device for (1) one of (5) five residents reviewed for positioning and mobility. (Resident #6)

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review, the facility failed to implement infection control practices to prevent the possibility of the spread of infection for 2 (two) of sixteen sampled residents. Resident #6 and Resident #7. Findings Include: Review of the facility policy titled, Infection Prevention and Control Program, revised March 23, 2023, revealed, .Equipment Protocol: .b.) Single-use items must be discarded after use . Review of the facility policy titled, Enteral Tube Medication Administration Procedures, revised July 14, 2015, revealed, .Procedure: .10.) Clean feeding syringe . Review of the facility policy, Nebulizer Policy dated 02/06/15 revealed that .12. When not in use the nebulizer and the tubing should be stored in a zip lock bag . [...]

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review the facility failed to immediately notify administrative staff and the local police department to ensure the immediate safety of a cognitively intact resident who left the facility parking lot on foot when he returned after being out on pass with a friend for one (1) of three (3) residents reviewed. Resident #1.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure that a comprehensive care plan was implemented when a resident did not receive two (2) doses of a scheduled antiarrhythmic medication for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Findings Include: Record review of the facility policy titled Care Plans updated on 02/20/20 revealed that, Each resident will have a person centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care .Procedure: 6. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the interventions. [...]

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure that an antiarrhythmic medication was available for a resident which resulted in the resident being transported to the hospital emergency department for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Cross reference F760 Findings Include: Record review of the facility policy, Medication Shortages/Unavailable Medications with revision date of 01/01/13 revealed under Procedure: 3. If a medication shortage is discovered after normal Pharmacy hours: [...]

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure that a resident was free from a significant medication error as evidenced by not receiving two (2) doses of an antiarrhythmic medication which resulted in the resident being transported to the hospital emergency department for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Cross Reference F755 Findings Include: Record review of the facility policy Medication Errors updated on 02/03/2023 revealed, Medication/Treatment errors shall be documented on the Medication Error Report. An error shall be defined as any variation in administration of medication from the physician's orders and/or facility policy. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to ensure that a bottle of medication was locked securely inside a medication cart to prevent resident access by one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of the undated facility policy titled, Medication Storage revealed, .All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy . On 02/14/24 at 9:05 AM, an interview with the Administrator (ADM), revealed that she had reported the incident where Resident #1 took the bottle of Vitamin D3 off the med cart. [...]

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy the facility neglected to provide prescribed pain medication to a resident who experienced severe/uncontrolled physical pain and caused mental anguish or emotional distress as evidenced by the resident's verbalization of Just need to die for one (1) of five (5) residents reviewed for pain management. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. [...]

Inspectors wroteSurveyor: [NAME], [NAME] Based on staff and resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for administering pain medications as ordered (Resident #25), applying an anti-contracture device as ordered (Resident #32), and serving a correct therapeutic diet as ordered (Resident #26) for three (3) of 19 residents reviewed. The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. [...]

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident received adequate pain management as evidenced by a resident experiencing excruciating unrelieved pain for one (1) of five (5) residents assessed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility failed to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. [...]

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that staff were competent in medication administration, pain assessment and treatment, notification of providers and pharmacy when medications were needed, and in the procedure for using the automated medication dispensing system for obtaining needed medications for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. [...]

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review, the facility failed to acquire and administer the resident's pain medication in a timely manner causing Resident #25 to experience severe/uncontrolled pain multiple times for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. [...]

Inspectors wroteBased on staff and resident interviews, record review, and job description review the facility Administrator failed to ensure care was coordinated between the facility, Nurse Practitioner (NP) and the Medical Director (MD) for pain management for a resident who experienced severe/uncontrolled pain that resulted in the resident being transferred to the emergency room (ER) for pain control for one (1) of 19 sampled residents. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and Medical Director Agreement review, the facility's Medical Director (MD) failed to coordinate medical care and ensure that he or his Nurse Practitioner (NP) responded to the facility for pain control when a resident experienced severe/uncontrolled pain for one (1) of five (5) resident reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for a Resident, as evidenced by incorrectly coding anticoagulant medication usage during the 7-day observation look-back period for 1 (one) of three (3) residents sampled for anticoagulant use.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review the facility failed to apply an anti-contracture device as Physician prescribed for one (1) of 16 residents with limited range of motion.

Inspectors wroteBased on observation, staff interviews, record review and facility policy review, the facility failed to serve a resident a physician prescribed therapeutic diet as ordered for one (1) of five (5) residents observed for dining.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to complete a thorough investigation of a controlled substance medication discrepancy for one (1) of five (5) residents reviewed.

Inspectors wroteBased on record reviews, facility policy review, and staff interviews, the facility failed to accurately complete a Minimum Data Set (MDS) Significant Change Assessment, for a hospice resident for one (1) of 1 hospice residents reviewed. Resident #36.

Inspectors wroteBased on record review, facility policy review, and staff interviews, the facility failed to submit a Change in Status Form for a Preadmission Screening and Resident Review (PASARR) Level II Assessment request as evidenced by no Change in Status Form in the medical record for one (1) of four (4) residents reviewed for PASARR Level II. Resident #46.

Inspectors wroteBased on observations, facility policy review, and staff interviews, the facility failed to prevent the likelihood of cross contamination as evidenced by a Certified Nursing Assistant (CNA) not using hand sanitizer during the ice pass when going in and out of residents rooms and placing the ice scoop inside the ice cooler on top of the ice for one (1) of four (4) days of survey.