Inspection Reports for
Vineyard Court Nursing Center

The complaint investigations included issues of quality of care related to positioning, resident rights, hydration, verbal abuse, abuse, misappropriation, and neglect. The facility was cited for failure to protect resident rights in all four complaint investigations.

The facility failed to ensure residents were treated with dignity and respect, evidenced by inappropriate language used by staff and lack of privacy during care for two residents. Specific incidents included a CNA checking a resident's brief in a hallway and another CNA using profanity towards a resident.

The complaint investigation substantiated that staff used inappropriate language and failed to provide privacy during care for two residents. Interviews with residents, representatives, staff, and review of video footage confirmed these findings.

The facility failed to ensure residents were treated with dignity and respect. Two residents were subjected to inappropriate language and care provided without privacy, violating resident rights.

Two complaint investigations were conducted: CI MS #2585966 related to resident neglect and quality of care concerning unavailable pain medication, and CI MS #491260 related to accidents/hazards involving resident smoking marijuana.

The facility failed to adequately supervise residents during smoking breaks, allowing two residents to smoke marijuana. Additionally, the facility failed to provide an ordered pain medication to a resident who had pain due to staff not following medication procurement procedures.

The facility failed to provide adequate supervision during smoking breaks, allowing two residents to smoke marijuana. Additionally, the facility failed to provide an ordered pain medication to a resident due to staff not following medication administration procedures.

The investigation was complaint-related, focusing on failure to implement care plans, maintain range of motion, and infection control practices. Substantiation status is not explicitly stated.

The facility failed to implement a care plan for an anti-contracture device for Resident #6, failed to maintain or improve range of motion for Resident #6 by not applying the anti-contracture device, and failed to implement infection prevention and control practices for Residents #6 and #7, including improper use and storage of medical devices.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to failure to implement comprehensive care plans for anti-contracture devices, failure to provide services to maintain or improve range of motion, and failure to implement infection prevention and control practices for residents with PEG tubes and nebulizer treatments.

The facility failed to provide 20-minute fire resistance rating smoke barrier doors in accordance with NFPA 101 standards. Specifically, the East Hall smoke barrier doors did not properly close upon activation of the fire alarm and sprinkler systems, affecting two of five smoke compartments and 33 of 54 residents.

The complaint investigation CI MS #25238 was substantiated with a citation for accidents and hazards (F689). The complaint investigation CI MS #25334 for alleged abuse was not substantiated and no deficiencies were cited.

The facility failed to immediately notify administrative staff and local police when a cognitively intact resident left the facility on foot after returning from a pass, resulting in a safety risk. The resident was found by police about a mile from the facility and was hospitalized. The facility implemented corrective actions including one-on-one observation, staff education, policy revisions, audits, and quality assurance meetings to prevent future elopements.

The investigation was complaint-driven regarding the facility's handling of Resident #1's elopement. The complaint was substantiated as staff failed to follow policies requiring immediate notification of administration and law enforcement. Resident #1 was found safe but had been missing for several hours.

The facility failed to promptly notify administration and law enforcement when Resident #1 left the premises on foot. Staff interviews and record reviews revealed inadequate supervision and communication, with the Nursing Supervisor instructing staff to only document the event rather than initiate emergency protocols. Resident #1 was found safe by police after being missing for several hours.

The complaint investigation involved medication storage and administration issues. The facility was found non-compliant for medication errors and storage, with a resident missing doses of heart medication leading to hospitalization and another resident accessing unsecured medication. The facility conducted investigations, terminated responsible staff, provided in-services, and implemented corrective actions prior to the survey.

The facility failed to ensure proper medication administration and storage, resulting in a resident missing two doses of an antiarrhythmic medication which led to hospitalization. Additionally, a medication bottle was left unsecured allowing a resident to access and ingest pills. The facility corrected these deficiencies prior to the survey.

The complaint investigation was substantiated. Resident #4 missed two doses of prescribed antiarrhythmic medication due to pharmacy backorder and staff failure to notify or obtain medication, resulting in hospitalization for atrial fibrillation. Resident #1 accessed unsecured Vitamin D3 medication and ingested pills unsupervised, but no adverse outcome occurred. Both incidents were investigated, and staff involved were terminated. In-services and quality assurance measures were implemented.

The facility failed to ensure that a resident received two doses of a prescribed antiarrhythmic medication, resulting in hospitalization. Additionally, the facility failed to secure medication properly, allowing a resident to access and ingest medication unsupervised. Corrective actions including staff termination, in-services, and quality assurance meetings were implemented and validated by the State Agency.

The facility neglected to ensure Resident #25 received prescribed pain medications timely, resulting in severe, uncontrolled pain and verbalized suicidal ideation. Nursing staff lacked knowledge of how to obtain emergency medications from the automated medication system. Providers did not timely provide prescriptions to the pharmacy, causing delays. Administrative staff failed to recognize and address these issues. The facility also failed to follow care plans for pain management and other residents' needs, and staff competency and communication with providers were inadequate.

Complaint investigation MS #23049 was included in the annual recertification survey due to Resident #25's pain management concerns, including severe pain, emergency room visits, and suicidal ideation related to lack of pain medication.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including failure to ensure timely availability of pain medications for Resident #25, leading to severe pain, emergency room visits, and suicidal ideation. The facility also failed to properly implement care plans, provide therapeutic diets, and ensure competent nursing staff. Immediate Jeopardy was identified and removed after corrective actions.

The complaint involved a medication discrepancy identified on 10/9/23 where approximately 13 ml of liquid Dilaudid was missing for Resident #14. The facility reported the incident to the State Department of Health and Pharmacy Board. The resident was cognitively impaired and unable to be interviewed. The investigation was incomplete as it did not include resident interviews to verify medication administration and pain control.

The facility failed to complete a thorough investigation of a controlled substance medication discrepancy involving approximately 13 milliliters of Resident #14's liquid Dilaudid. The investigation lacked resident interviews to confirm medication receipt and pain control, and the Administrator acknowledged inexperience in handling the situation.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies in resident assessment accuracy after significant change, coordination of PASARR, and infection control practices, all at a D level severity.

The facility failed to accurately complete a Minimum Data Set (MDS) Significant Change Assessment for a hospice resident, failed to submit a Change in Status Form for PASARR Level II assessment for a resident, and failed to prevent cross contamination during ice pass due to improper hand hygiene and handling of ice scoop by a Certified Nursing Assistant.

The complaint investigation substantiated the allegation of involuntary seclusion of Resident #1. The facility was cited for Immediate Jeopardy and Substandard Quality of Care. The responsible nurse was allowed to work multiple shifts after the incident before termination. The facility failed to suspend the nurse pending investigation and delayed reporting to the Board of Nursing.

The facility was found to have placed Resident #1 in involuntary seclusion by blocking his room door with a linen cart and lift, causing mental anguish and risk of physical harm. The facility failed to suspend the responsible nurse immediately, allowing her to continue working. The situation was deemed Immediate Jeopardy and Substandard Quality of Care, which was removed after corrective actions including staff in-services, monitoring, and termination of involved employees.

The facility failed to consistently use signage to identify COVID-19 positive and negative resident rooms, with one of eight rooms on one hallway lacking proper signage. Staff were in-serviced on a new system of red and green tags to indicate COVID-19 status, and monitoring was implemented to ensure compliance.

The complaint investigations CI MS #15832 and CI MS #15858 were not substantiated related to quality of care, and no deficiencies were cited related to the complaints.

The facility was found not in compliance due to inaccurate completion of the Minimum Data Set (MDS) assessments for two residents, specifically related to anticoagulant medication coding and wandering status. No deficiencies were substantiated related to the complaints, and no adverse outcomes were identified for the affected residents.

Complaints MS#15832 and MS#15858 were investigated but not substantiated related to quality of care, with no citations related to the complaints.

The facility was found not in compliance with Medicare and Medicaid requirements. The State Agency did not substantiate the complaints related to quality of care but cited deficient practice at tag F641 during the survey.