Vineyard Court Nursing Center

In the surveyor’s words

From the most serious findings on record at Vineyard Court Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 20, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF656Oct 20, 2023

  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. […]

• Immediate jeopardy, isolatedF697Oct 20, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF726Oct 20, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF755Oct 20, 2023

  Based 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. […]