Vineyards at Concord, the

Inspectors wroteBased on observation, record review, hospital record review, interviews and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual, the facility failed to ensure adequate fall risk/safety interventions were in place and functioning to prevent falls. Additionally, the facility failed to document and comprehensively investigate falls. Actual harm occurred on 02/11/26 when the facility failed to develop and implement an individualized fall program to prevent falls with injury for Resident #4, who exhibited severe cognitive impairment, had history of falls, and required substantial/maximal assistance with transfers, sustained a fall resulting in a displaced spiral fracture of the right femur requiring surgical repair. This affected two (Residents #4 and #18) of two residents reviewed for falls. The facility census was 27. Findings Include:1. [...]

Inspectors wroteBased on observation, interview, and utilization of the staffing tool the facility failed to maintain sufficient staffing to provide for resident care needs. This affected all residents in the facility. The facility census was 27 at the time of survey.

Inspectors wroteBased on observations, record reviews, interviews and review of job descriptions, the facility failed to be administrated in a manner that uses it's resources effectively and efficiently to ensure resident safety, failed to maintain an activities program directed by a qualified activities professional, failed to maintain sufficient staffing to provide for resident care needs and failed to ensure the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Registered Dietician (RD) were permitted to work enough hours to effectively complete their job. This deficient practice demonstrated significant breakdowns in administrative oversight and had the potential to affect all 27 residents residing in the facility.

Inspectors wroteBased on medical record review and interview, the facility failed to establish, maintain and implement written policies and procedures regarding the resident's right to formulate an advance directive. Additionally, the facility failed to develop and implement a comprehensive plan of care for do not resuscitate (DNR) code status. This affected four residents (#3, #4, #15 and #18) of four residents reviewed for advanced directives. The facility census was 27. Findings Include:1. [...]

Inspectors wroteBased on interview and observation, the facility failed to maintain an activities program directed by a qualified activities professional. This had the potential to affect all residents with the exception of one (Resident #2). The facility census was 27. Observation throughout the annual survey from 04/13/26 through 04/20/2026 revealed activities of music playing throughout the days in the common area and one activity on 04/15/26 of snack making with residents. No other activities were observed and no activity director was observed in the facility. Interview on 04/13/26 at 2:40 P.M. with Resident #2 stated that she didn't have an issue with the activities because she mostly stays in her room and watches TV and does not wish to attend any activities. Interview on 04/14/26 at 3:15 P.M. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure medications were stored securely for Resident #18. Additionally, the facility failed to dispose of expired medications on the medication cart. This affected five residents (#2, #4, #7, #15 and #18). The facility census was 27. Findings Include:1. Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. [...]

Inspectors wroteBased on observation and staff interviews the facility failed to follow diet orders when dietary staff served mechanical textured meat to residents on a regular diet during lunch meal. This had the potential to affect 18 ( #1, #2, #4, #6, #7, # 8, #11, #13, #14, #18, #21, #22, #23, #24, #25, #26, #27, and #29) who receive a regular diet. The facility census was 27. Observation on 04/15/26 at 12:15 P.M. with [NAME] #118 revealed the lunch meal was pork and sauerkraut, mashed potatoes and bread pudding. The pork and sauerkraut were made into mechanical texture and served to residents who are on a regular diet. Associate #118 confirmed pork was mechanical texture and she does this so residents receive the same looking meat and to reduce choking hazard. Pureed pork and sauerkraut was made with milk. [...]

Inspectors wroteBased on observations and staff interviews the facility failed to prepare and deliver meals timely according to dining schedule. This had the potential to affect affect 26 residents receiving food in the facility. The facility identified one resident (#5) who received nothing by mouth (NPO). The facility census was 27. Interview on 04/13/26 at 8:30 A.M. with [NAME] #118 regarding meal times-breakfast is served at 7:45/8:00 A.M., lunch is served at 11:45/12:00 P.M. and dinner at 4:30/5:30 P.M. Dining staff consist of cook and occasionally a hospitality aide. Observation on 04/13/26 at 12:21 P.M. lunch has not started to be served to 11 residents sitting in dining room. Hospitality aide present to assist. Observation on 4/14/26 at 9:00 A.M. breakfast starting to be served to residents in dining room. Observation on 4/15/26 at 8:50 A.M. breakfast was not being served yet. [...]

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to follow the menu, complete substitution log as needed and prepare meal with appropriate diet order. This had the potential to affect 26 residents receiving food in the facility. The facility identified one resident (#5) who received nothing by mouth (NPO). The facility census is 27. Review of the menu revealed lunch for 04/15/26 consisted of pork and sauerkraut, mashed potatoes, and pumpkin bread pudding. Observation on 04/15/26 at 12:15 P.M. with [NAME] #118 revealed lunch meal was being prepared that included pork and sauerkraut, mashed potatoes ( instead of scalloped potatoes per menu) and apple bread pudding ( instead of pumpkin bread pudding per menu). The pork and sauerkraut were made into mechanical texture and was prepared for residents who are on a regular diet. Interview on 04/15/26 at 12:30 P.M. [...]

Inspectors wroteBased on observation and interviews the facility failed to store food appropriately and ensure a sanitary environment. This had the potential to affect 26 residents who receive food from the kitchen. The facility had one resident (#5) who received nothing by mouth (NPO). The facility census was 27. Observation on 04/13/26 at 8:30 A.M. with [NAME] #118 during walk through revealed in the dry storage areas of concern included scoop in sugar container, 50-lb oats bag not sealed or dated and was located on the floor, no dates on beans, sugar and rice containers. Freezer areas of concern included no dates on bags of green beans, cauliflower, broccoli, carrots, tater tots or hashbrowns. Refrigerator areas of concern included pepperoni dated 01/26/26, deli cheese with no date, veggie and fruit tray with no date, and mustard with no label or date. [...]

Inspectors wroteBased on medical record review, observation, policy review and staff and resident interviews, the facility failed to ensure dignity and respect were shown to resident who needed assistance to eat. This affected one (#16) of one resident reviewed for assistance with eating. The facility census was 27. Medical record review for Resident #16 was admitted on [DATE]. Medical diagnoses included Huntington's disease, anxiety and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16's Brief Interview for Mental Status (BIMS) was 09 out of 15 indicating resident has moderate cognitive impairment. His functional status for eating was maximum assistance. Observation of the dining room on 04/13/26 at 12:00 P.M. revealed Resident #16 was among 11 unidentified residents sitting at the dining table waiting for lunch. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to notify the physician of significant weight loss. This affected two residents (#4 and #15) of three residents reviewed for nutrition. The facility census was 27. Findings Include:1. Review of the medical record for Resident #4 revealed an initial admission date of 01/02/26 with the latest readmission date of 02/17/26 with the diagnoses including but not limited to displaced spiral fracture of shaft of right femur, moderate protein calorie malnutrition, neuromuscular dysfunction of bladder, encounter for palliative care, anemia, osteoporosis, diabetes mellitus, insomnia, hypertensive heart disease, hyperlipidemia, delusional disorder, hypertension, history of falling, history of nontraumatic fracture. [...]

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to provide a written bed hold notice upon transfer to an acute care setting. Additionally, the facility failed to provide a comprehensive discharge summary upon a planned discharge from the facility. This affected two residents (#10 and #20) of four residents reviewed discharge. The facility census was 27. Findings Include:1. [...]

Inspectors wroteBased on resident record review, interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was completed within the first 14 days. This affected one resident (#20) of 15 sampled residents. The facility census was 27. Findings Include: 1. Review of the medical record for Resident #20 revealed an initial admission date 03/27/26 with the diagnoses of including but not limited to pyothorax, anemia, elevated white blood cell count, presence of heart valve replacement, presence of prosthetic heart valve, osteoporosis, nicotine dependence, convulsions, hyperlipidemia, depression, pleural effusion, hypothyroidism, mood disorder, atrial fibrillation and generalized anxiety disorder. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to develop a comprehensive plan of care to address resident needs and conditions. This affected two residents (#4 and #18) of 15 sampled residents. The facility census was 27. Findings Include:1. Review of the medical record for Resident #4 revealed an initial admission date of 01/02/26 with the latest readmission date of 02/17/26 with the diagnoses including but not limited to displaced spiral fracture of shaft of right femur, moderate protein calorie malnutrition, neuromuscular dysfunction of bladder, encounter for palliative care, anemia, osteoporosis, diabetes mellitus, insomnia, hypertensive heart disease, hyperlipidemia, delusional disorder, hypertension, history of falling, history of nontraumatic fracture. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to provide residents who were dependent on staff for nail care. This affected two residents (#15 and #19) of five residents reviewed for activities of daily living (ADL). The facility census was 27. Findings Include:1. Review of the medical record for Resident #15 revealed an initial admission date of 04/20/25 with the latest readmission of 05/25/25 with the diagnoses including but not limited to neuropathy, peripheral vascular disease, hypertensive heart disease, vascular dementia, major depressive disorder, cerebral infarction, dementia, hypertension, gout, insomnia and anxiety disorder. Review of the plan of care not dated revealed the resident had an activity of daily living (ADL) self-care performance deficit related to cerebrovascular accident, restlessness and dementia. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to comprehensively assess skin impairment upon discovery and subsequently weekly assessment thereafter. This affected one resident (#18) of one resident reviewed for skin impairment. The facility census was 27. Findings Include:Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. Review of the medical record revealed no documented evidence a comprehensive admission assessment was completed on admission to the facility. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to provide routine incontinence care. This affected two residents (#15 and #19) of three residents reviewed for bowel and bladder. The facility census was 27. Findings Include:1. Review of the medical record for Resident #15 revealed an initial admission date of 04/20/25 with the latest readmission of 05/25/25 with the diagnoses including but not limited to neuropathy, peripheral vascular disease, hypertensive heart disease, vascular dementia, major depressive disorder, cerebral infarction, dementia, hypertension, gout, insomnia and anxiety disorder. Review of the plan of care not dated revealed the resident had bladder incontinence related to dementia. [...]

Inspectors wroteBased on observation, record review, interview, hospital record review and policy review, the facility failed to provide a comprehensive, resident centered plan of care to prevent, timely identify, and treat weight loss for residents. Additionally, the facility failed to ensure weights were obtained, documented, and monitored for weight loss, failed to ensure meal intake percentages were documented at every meal, and failed to ensure supplements were provided per order and failed to follow the recipe for supplements to ensure residents received the proper nutritional support. This affected two (Residents #4 and #8 ) of three residents reviewed for nutrition/weight loss. The facility census was 27.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure continuous positive airway pressure (CPAP) had physician ordered settings, cleansing and was stored in a manner to prevent potential infection. This affected one resident (#18) of one resident reviewed for respiratory care. The facility census was 27. Findings Include:Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure medications were available for administration. This affected one resident (#18) of two residents observed for medication administration. The facility census was 27. Findings Include:Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure a medication error rate of less than five percent. Twenty-five opportunities for error were observed with three medication errors made resulting in a 12 percent error rate. This affected one resident (#18) of two residents observed during the medication pass. The facility census was 27. Findings Include:Review of the resident's monthly physician orders for [DATE] identified orders dated [DATE] Omeprazole 40 milligrams (mg) by mouth daily and [DATE] B-Complex with Biotin and Folic Acid one tablet by mouth daily, Vitamin E 400 capsule by mouth daily. On [DATE] at 9:11 A.M., observation of Licensed Practical Nurse (LPN) #102 prepare the resident's morning medication revealed she placed two Omeprazole 20 mg capsules from a stock bottle with the expiration date of 03/26 in a clear plastic cup. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review revealed the facility failed to maintain infection control practices to prevent the potential spread of infection. This affected two residents (#5 and #20) of 15 residents reviewed for infection control. The facility census was 27. Findings Include: 1. Review of the medical record revealed Resident #5, specified, was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, severe dementia with anxiety, Alzheimer's disease, essential hypertension, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition with hallucinations and delusions, rejected care, and did not wander. Resident #5 is dependent for all care and has a gastric feeding tube placed. [...]

Inspectors wroteBased on medical record review, staff interviews, and facility policy review, this facility failed to ensure resident falls were reported, investigated and fall care plans were in place. This affected four (Resident #106, #56, #70, and #78) of the four resident reviewed for falls. The facility census was 19.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, this facility failed to report resident to resident abuse as well as injury of unknown origin to the appropriate agencies. This affected one (Resident #106) of the four residents reviewed for abuse and injuries. The facility census was 19.

Inspectors wroteBased on medical record review, staff interview and facility policy review, this facility failed to ensure all injuries of unknown origin was investigated. This affected one (Resident #106) of the four residents reviewed for injuries. The facility census was 19.

Inspectors wroteBased on record reviews and staff interview, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) was completed following the addition of a new mental health diagnosis. This affected two (#3 and #7) of the four residents reviewed for PASARR during the annual survey. The facility census was 21.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a stop date for as needed psychotropic medications. This affected two (#14 and #15) of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 21.

Inspectors wroteBased on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to complete required Minimum Data Set (MDS) assessments. This affected 10 (#1, #6, #9, #10, #12, #116, #117, #118, #164, and #166) of 17 residents reviewed for completed MDS assessments. The facility census was 23.

Inspectors wroteBased on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to timely complete and submit the Minimum Data Set (MDS) assessments. This affected eight (#1, #3, #4, #13, #116, #117, #164, and #166) of 17 residents reviewed for completed and submitted MDS assessments. The facility census was 23.