Vineyard Hills Health Center

Inspectors wroteBased on observations, staff interviews and facility document review, the facility failed to follow the menu when: 1. Five residents (Residents 8, 13, 36, 38, 63) received mashed potatoes instead of whipped sweet potatoes when the facility ran out of whipped sweet potatoes for the lunch meal on June 24, 2025. 2. Four residents (Residents 4, 18, 57, 76) received roasted turkey that was greater than 3 ounces for the lunch meal on June 24, 2025. 3. [...]

Inspectors wroteBased on inspection of the facility's Medication Storage Rooms, the facility's storage carts, and interviews with the facility's nursing staff, the facility failed to: 1. Follow the facility's policy when the Medication Storage Refrigerator was out of temperature range. 2. Follow the facility's policy when The Medication Storage Rooms and the Medication Storage Refrigerators were missing temperature checks for May and June. 3. Write the open date/expiration date on the pharmacy sticker for Resident 32's Insulin Pen located in the medication cart. 4. Indicate an open date on a blood glucose test strip container of when the container was first opened and placed in the medication cart. This failure resulted in medications not safely stored to ensure their integrity and has the potential for medication administration not to be effective.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff had appropriate competencies and skill sets to carry out the functions of the food and nutrition services when one kitchen staff (Dietary Aide - DA ) did not use portion sizes when making sandwiches that were made to be given to residents as an alternate. This failure had the potential to result in residents receiving food items that did not have appropriate amounts of macro and micronutrients which could result in a decrease in nutritional status and weight loss.

Inspectors wroteDuring a concurrent observation and interview on 6/24/2025, at 4:10 p.m. with LN3. observed the oxygen tubing for Resident 643 was not labeled with a date. LN3 confirmed there was no dated label on the oxygen tubing. LN3 stated, No, it's not there. During a review of the facility's policy and procedure (P&P) titled. Oxygen Procedure, undated, the P&P indicated in part, Purpose: Patients that require oxygen as ordered by a physician . The equipment will be maintained in a manner to ensure the best possible outcome for the patient. Protocol: . oxygen tubing and bag will be replaced weekly. Based on observation, interview and record review the facility failed to maintain infection control practices for three of 10 sampled residents when: 1. Oxygen tubing and nasal cannula (tubing device placed in a person's nose that delivers oxygen) was found on the floor of resident's room (Resident 55). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the walk-in freezer in safe operating condition when ice build up was present. This facility failure had the potential to affect the overall efficiency and temperature regulation within the freezer.

Inspectors wroteBased on interview and record review the facility failed to ensure that one certified nursing assistant (CNA1) received 12 hours of annual in-service which included dementia management as well as abuse prevention training and reporting. This failure had the potential to affect the quality of care and services provided to the residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to submit a new preadmission screening and resident review (PASARR) level I screening when required for 2 (Resident #41 and Resident #45) of 4 sample residents reviewed for PASARRs.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the Pharmacist reported medication regimen irregularities to the physician for the extended use of as needed psychotropic medication for 5 (Residents #43, #45, #49, #54, and #115) of 6 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure as needed psychotropic medication was not ordered for more 14 days for 5 (Residents #43, #45, #49, #54, and #115) of 6 sampled residents reviewed for unnecessary medications. Specifically, Residents #43, #45, #49, #54, and #115 had physician orders for as needed lorazepam (Ativan), an antianxiety medication, with no indicated duration/stop date.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure enhance barrier precautions (EBP) were implemented for 1 (Resident #40) of 2 sampled residents reviewed for urinary catheters and 2 (Resident #1 and Resident #117) of 2 sampled residents reviewed for pressure ulcer/injury. The facility further failed to ensure catheter tubing and a resident's genital area were cleaned during the provision of catheter care for 1 (Resident #40) of 2 sampled residents reviewed for urinary catheters.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure the Ombudsman was notified when residents transferred to the hospital for 1 (Resident #63) of 1 sampled resident reviewed for hospitalization.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) level I screening was accurate upon admission to the facility for 1 (Resident #41) of 4 sampled residents reviewed for PASARRs.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed policy and procedure for reporting a change of condition to the physician for one of two sampled residents (Resident 1) . This facility failure resulted in delay of care for Resident 1.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure food and ice were stored and served, and dishes and utensils were cleaned according to standards for food service safety when: 1. An ice machine was not kept in a sanitary condition putting residents at risk for foodborne illness. 2. A kitchen aid had long painted fingernails with no gloves while handling uncovered plates of food during meal service. 3. A potentially hazardous food capable of supporting bacterial growth associated with foodborne illness was not logged for proper cool down. 4. Dish machine water temperatures were low on several occasions. These failures had the potential to cause the growth of microorganisms and foodborne illness in a medically vulnerable resident population who consumed food at the facility. The facility census was 58.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the menus were followed when: 1) four residents (Resident #31, 1, 556, 357) on mechanical soft ground diet; 2) one resident (Resident #52) on a mechanical soft chopped diet; 3) two residents (Resident #356, 506) on a cut meat diet; and 4) two residents (Resident #55, 508) on a puree diet (diets with modified texture for people who have difficulty chewing or swallowing); did not receive the correct portion sizes of foods. This failure had the potential to result in not meeting the nutritional needs thus further compromising the medical status of the residents.

Inspectors wroteBased on observation, interview, and review of facility documents, the facility failed to ensure the walk-in freezer was maintained in safe operating condition when ice was built up in the freezer.