Vineyard Post Acute

Inspectors wroteBased on interviews and record reviews, the Licensed Nurses (LN) failed to notify the Responsible Party (RP, a person designated to makes healthcare and/or financial decisions for a person who is no longer able) for one resident (Resident 1) of three sampled residents, when:LN 1 (Licensed Nurse 1) did not notify Resident 1's RP that Resident 1 had eloped (when a resident leaves the facility unattended, without permission, or without staff awareness) on 2/28/26;and,LN 2 did not notify Resident 1's RP on 3/1/26 that Resident 1 had a fever of 100.4 degrees Fahrenheit (F, a unit measurement of temperature). These failures decreased the facility's potential to ensure Resident 1's RP was well informed regarding Resident 1's health status and plan of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate supervision to one resident (Resident 1) of three sampled residents, when Resident 1 eloped (when a resident leaves a facility unattended, without permission, or without staff awareness) from the facility on [DATE]. This failure decreased the facility's potential to prevent injury illness to Resident 1.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure only authorized personnel had access to one out of four medication carts when Medication cart #2 was unlocked when it was unattended. This failure could result in unauthorized access to medications and unintentional ingestion which could lead to overdoses, drug interactions, or severe adverse effects. During a concurrent observation and interview on 3/10/26 at 12:25 p.m., while walking in the hallway with the Nursing Supervisor (NS), medication cart #2 that was parked outside of room [ROOM NUMBER], was unlocked and unattended. The NS walked over medication cart # 2 and locked the cart. The NS stated medication carts should always be locked when left unattended. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of care were followed for one of three sampled residents (Resident 1) when: 1. A physician's weekly order to collect labs was not followed, 2. A SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [COC] among the residents) was not initiated after the facility received abnormal lab results pertaining to Resident 1's kidney (organs that filters blood to removed waste, excess fluid and toxins from the body) function, and; 3. The abnormal lab results was not reported to Resident 1's physician. This failure increased Resident 1's risk for prolonged pain, discomfort, and a delay in care and treatment which decreased the facility's potential to prevent Resident 1's kidneys from critical injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was properly contained when an outside garbage dumpster was overfilled, which prevented the lid from closing, and resulted in the food debris and trash surrounding the area and garbage can lids in the kitchen were not closed and the exterior surfaces were smeared with food debris. These failures decreased the facility's potential to prevent an infestation of insects and other pests, prevent offensive odors and contribute to cross-contamination from unsanitary environmental conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to properly dispose of and monitor destruction of an assortment of medications when:The collection receptacle had multiple fully intact medications of different forms which were retrievable by staff; and,24 medication disposition sheets, representing 172 prescriptions, were not signed or witnessed by licensed staff. This failure decreased the facility's potential to prevent drug diversion (illegally taking prescription drugs for unauthorized use, like self-medication, selling, or addiction) and theft of resident medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure its medication rate was below five percent when four errors were observed during 28 medication passes, resulting in a 14.29% error rate. This failure decreased the facility's potential to ensure medication was administered as ordered by the physician and decreased the expected efficacy of the medication. (Cross-reference F760 & F761)

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure two residents out of 10 sampled residents were free from significant medication errors when:Resident 20 received a dose of Metoprolol Tartrate (medication used to treat heart and blood vessel conditions by slowing heart rate and lowering blood pressure) 45 minutes late; and,Resident 4 would have received a dose of expired lispro insulin (a rapid acting medication which manages blood sugar levels via an injection into the fatty tissue just under the skin) if not asked by the surveyor to recite the expiration date a third time prior to entering the resident room. These failures decreased the facility's ability to maintain medication safety and placed the residents at risk for harm. (Cross-reference F759 & F761)

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired insulin (a hormone medication used to control blood sugar levels) vials were removed from the facility's medication carts when inspection of two medication carts revealed one expired vial of insulin in each location. This failure decreased the facility's opportunity to maintain resident safety and placed these residents at risk for harm. (Cross-reference F759 & F760)

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. The following were observed in the facility kitchen: kitchen floors were dirty and littered with food debris and trash; the ceiling vent cover located directly over the clean and ready-to-use dish storage area was covered with reddish-black and blackish-brown dirt and dust; the wall behind the hand-washing sink was cracked and uneven, with heavy orange and black colored residue in the crevices; one plastic green cutting boards were excessively scratched with deep gashes; and, the stove top/burners had extensive caked-on food and rust-colored residue;2. The temperature log for a resident snack refrigerator indicated out-of-range temperatures recorded on multiple days;3. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure bathroom call lights (a system to notify nursing staff for help) were accessible when two pull strings to trigger the call light system were too short for residents to reach and four pull strings were missing in six sampled bathrooms. This failure decreased the facility's potential to respond to residents' calls for assistance and increased the risk for falls. During an observation on 12/15/25 at 9:13 a.m. in room [ROOM NUMBER] and subsequently in Rooms 21, 24, 25, and 26, the bathroom call light systems had no call light string. During an observation on 12/15/25 at 9:27 a.m. in room [ROOM NUMBER] the bathroom call light system had a short pull string measuring approximately 10 in. (inches- a unit of measure). During an observation and concurrent interview on 12/16/25 at 12:10 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority after one resident (Resident 70) of six sampled residents experienced a decline in mental illness. This failure decreased the facility's potential to ensure Resident 70 received appropriate required mental health services and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 72) of 27 sampled residents obtained informed consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of bedrails when Resident 72's responsible party (RP- a person who makes health care decisions on behalf of the resident when the resident does not have the mental capacity to do so) did not give informed consent for the use of side/bed rails. This deficient practice decreased the facility's potential to decrease Resident 72's risk for falls, serious injury, and entrapment (when a person becomes trapped in the bed rail gaps, often resulting in serious injury or death).

Inspectors wroteBased on interview and record review, the facility failed to provide specialized rehabilitative services in accordance with the physician's orders for one resident (Resident 6) of four sampled residents when Resident 6 received physical therapy (PT) three times out of 12 scheduled sessions between 11/27/25 and 12/17/25 and received occupational therapy (OT) once out of three expected sessions between 11/27/25 and 12/3/25. This failure resulted in Resident 6 feeling frustrated and increased the risk of his physical deconditioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 42) out of 27 sampled residents when the oxygen concentrator in Resident 42's room had visible dust and debris in the vents and needed a filter change. This failure decreased the facility's potential to prevent bacteria and debris from directly entering Resident 42's lungs, placing her at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care within professional standards of practice when licensed nursing staff failed to administer physician ordered pain medications to treat her moderate to severe pain, which led to ceaseless pain that worsened in numerical order and severity. This failure resulted in Resident 1 experiencing severe pain and had the potential to result in suffering and feelings of abandonment. A review of Resident 1's admission record indicated she was admitted to the facility in August, 2025 with medical diagnoses which included surgical aftercare of the digestive system (postoperative care after a procedure of the digestive system, which includes monitoring for complications, managing pain and medications, and regular follow-ups with a doctor). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure professional standards of practice were conducted for one resident (Resident 1) of four sampled residents when Resident 1 did not have: · A sliding scale (a method used to manage blood sugar levels in people with diabetes, where insulin doses are adjusted based on current blood sugar readings) for use of insulin (a hormone produced by the pancreas that helps regulate blood sugar levels) and · Blood sugar parameters (levels that indicate when blood sugar is considered too high or too low) ordered for insulin administration. These failures placed Resident 1 at risk for ineffective monitoring of insulin usage and worsening of Resident 1 ' s condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was provided a home-like environment with comfortable sound levels when Resident 4 was constantly yelling vulgar, offensive, and derogatory language. This resulted in Resident 1 being unable to get a full night of uninterrupted sleep and decreased Resident 1's potential to reach his maximum healthcare potential.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection prevention and control program, for a census of approximately 90 residents, when the facility did not report an influenza outbreak to the local public health department (LPHD) for nearly three weeks. This failure had the potential to increase the transmission of influenza among all residents in the facility.

Inspectors wroteBased on interview and record review, the facility staff failed to recognize a cardiorespiratory arrest (a life-threatening medical emergency that occurs when the heart and lungs stop functioning properly) for one of three sampled residents (Resident 1), which resulted in a delay in performing CPR (or cardiopulmonary resuscitation, a procedure to keep the blood pumping when the heart stops or when it beats too ineffectively to circulate blood to the brain and other vital organs) on Resident 1 who was a full-code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) after he was found unresponsive. This failure led to Resident 1 ' s death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of five sampled residents was free from physical abuse when Resident 2 intentionally struck resident one in the head and held him down on the floor. This failure resulted in a physical injury and confinement to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when the resident consistently missed scheduled medications when out at dialysis for 1 (Resident #8) of 3 residents reviewed for dialysis.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors for 1 (Resident #8) of 3 residents reviewed for dialysis services. Staff failed to ensure Resident #8 received medications that were used to treat low blood pressure, atrial fibrillation, prevent blood clots, and treat diabetes when the resident was scheduled for dialysis. Further, the facility failed to ensure that the medication to treat low blood pressure was given within the parameters set by the physician for treatment of low blood pressure.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #10) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure physician orders were followed for supplemental oxygen flow rates for 1 (Resident #17) of 3 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored appropriately for 1 (Resident #11) of 20 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide occupational therapy as ordered by the physician for 1 (Resident #20) of 2 sampled residents reviewed for rehabilitation and restorative services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 1), who had a history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and amputation (surgical removal) of his right leg above the knee, received care consistent with nursing standards of practice and the resident's individualized care plan when: 1) Licensed nursing staff did not document daily skin assessments (to identify skin injury) for Resident 1, as indicated in his Nursing Care Plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes); 2) Licensed nursing staff did not document the condition Resident 1's remaining foot (left) for a period of approximately one month prior to the identification of his necrotic (necrosis; [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one resident (Resident 3) of four sampled residents when Resident 4 threw water on Resident 3. This failure resulted in Resident 3 feeling unsafe at the facility.

Inspectors wroteBased on interview and records review, the facility failed to develop a plan of interventions to address the risk of fall for one (1) of four (4) residents (Resident 1) when Resident 1 fell from his wheelchair at the nurses' station. This failure caused Resident 1 a bruise over his right forehead and a trip to the acute hospital for evaluation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) or four (4) residents (Resident 2) was treated with respect and dignity and access to care to promote maintenance and enhance his quality of life when Resident 2 was not provided his medication in a timely manner. This failure caused Resident 2 to feel helpless and unimportant.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer scheduled medications (medications to be administered at a specific time) for three of three sampled residents (Residents 1, 2, and 3) within the time frames required by the facility's policy on medication administration. 12 scheduled medications were administrated as late as three hours after their prescribed administration time for Residents 1, 2, and 3. These failures had the potential to cause discomfort and/or jeopardize the health and safety of Residents 1, 2, and 3.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 1), when a licensed nurse inputted a physician order for Glargine (Lantus) insulin (long-acting insulin (works throughout the day and night to provide you with low levels of insulin all the time) used to improve blood sugar control in people with Diabetes Mellitus (DM: a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose (sugar) in the blood) on Resident 1 ' s MAR (Medicine Administration Record) incorrectly. This resulted in: 1. A nurse attempting to administer to Resident 1 Glargine 55 units subcutaneous (Sub-Q injection is given in the fatty tissue, just under the skin) with his dinner instead of 10 units, and, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required information to Resident 1, on a document titled 30 Day Notice to Vacate or Pay, when the document did not include Statement of Resident Appeal Rights and the Ombudsman contact information.

Inspectors wroteBased on interviews and records review, the facility failed to assess, monitor, and provide necessary care for one of two sampled residents (Resident 1) when: 1. The facility did not provide the necessary nursing assessment for Resident 1 ' s underlying cause of vomiting; did not provide prompt intervention to prevent Resident 1 from further vomiting when Resident 1 started vomiting in the morning of 5/16/23 and was given first dose of Ondansetron (a medicine used to prevent and treat nausea and vomiting) at 8:51 p.m.; and did not monitor Resident 1 for possible complications associated with vomiting, when Resident 1 vomited three times within a 12 hour period. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct annual competency and skills check to licensed nurses and Certified Nurse Aides (C.N.A.) for year 2020. This failure may have resulted in incompetent staff providing care to residents.

Inspectors wroteBased on interview and record review, the facility failed to offer and document assistance with advanced directives for 10 out of 10 Sampled Residents (Resident 32, Resident 206, Resident 63, Resident 33, Resident 195, Resident 80, Resident 207, Resident 145, Resident 43, Resident 51). This failure had the potential to result in residents wishes for the provision of health care and choices for end of care treatment to not be met.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident call lights for six residents (Resident 80, 43, 145, 33, 31 and 75) were answered in a timely manner. This failure resulted in three residents' (Resident 80, 145, and 43) inability to control their bowel and bladder while waiting for help to use the bathroom.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their infection prevention and control program policies and procedures when: 1. Disposal bins for Personal Protective Equipment (PPE) were located outside of the resident rooms in the Yellow Zone and, 2. Two staff members were observed wearing incomplete PPE. These cumulative failures had the potential to increase the risk of transmission of communicable diseases such as the COVID-19 virus among the facility residents and staff, which may lead to severe illness and even death.

Inspectors wroteBased on interviews and records review, the facility failed to provide timely assistance to two of 18 sampled residents (Resident 80 and Resident 43). This failure caused the residents to lose control of bowel while waiting thereby lowering their self-worth and feeling bad.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and assist one resident (Resident 61) for medical equipment needs upon admission. This failure resulted in the resident not receiving the necessary equipment to get out of bed for activities of daily living and receive the highest level of care for health improvement.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure care plan interventions were implemented for two sampled residents (Resident 215 and Resident 82), and that a care plan was formulated upon one resident's (Resident 37) admission. These failures resulted in: a. Missed opportunities for the staff to timely identify Resident 215's changes in condition and therefore, not to provide potentially necessary interventions prior to his death, b. Potential for inconsistent and/or inadequate care provision for Resident 82's needs, and c. Increased potential for impaired communication that may negatively affect the delivery of care for Resident 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe respiratory care and oxygen therapy was provided to one resident (Resident 81). This failure had the potential to cause respiratory distress and further compromise the resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain consent for a psychotropic medication for one resident (Resident 195). This failure had the potential for the resident to be over medicated and not have the correct medication or dosage for his diagnosis.

Inspectors wroteBased on observation and interview, the facility failed to practice hand hygiene during meal services. This failure may have resulted to cross-contamination of residents' food and drinks and increase the potential for food-borne illness.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a sanitary environment for one sampled resident (Resident 71) when his bedside equipment were left dirty for three days. This failure could potentially contribute to cross-transmission by contamination of staff from hand contact with dirty surfaces, and medical equipment, or residents.