Vineyard Hills Health Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 10, 2021

  Based 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. […]

• No harm, potential for more than minimal, patternF803Jun 27, 2025

  Based 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. A #6 scoop (5.33 ounces) instead of a #8 scoop (4 ounces) of the mashed potatoes and meatloaf were given to 16 residents (Residents 2, 3,11, 20, 21,29, 31,39, 41,47,62, 73, 80, 85, 341, 640) on the soft and bite diet (a texture-modified diet where foods are bite sized, soft, tender and moist with no thin liquid dripping from food) and five… […]

• No harm, potential for more than minimal, patternF644Jun 6, 2024

  Based 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. Findings included: An undated facility policy titled, PASARR Screening for MD [mental disorder] and ID [intellectual disorder], indicated, [Name] facilities do not admit any new resident with mental illness or mental retardation unless the State Menal Health Authority has determined that the individual requires the level of services provided by [name] facilities. This determination shall be based on an independent physical and mental evaluation of the resident. 1. […]

• No harm, potential for more than minimal, patternF756Jun 6, 2024

  Based 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. Findings included: An undated facility policy titled Drug Regimen Review, Report Irregular, Act On revealed, The consultant pharmacist must devote sufficient number of hours during a regular scheduled visit, for the purpose of coordinating, supervising and reviewing the pharmaceutical services and review the drug regimen of each resident at least monthly. The review must include a review of the resident's medical chart. […]

• No harm, potential for more than minimal, patternF758Jun 6, 2024

  Based 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. Findings included: An undated facility policy titled, Drug Regimen is Free From Unnecessary Drugs/ Free from unnecessary Psychotropic Meds [medications]/ PRN [pro re nata, which meant an needed] Use, indicated, Each resident's drug regimen is free from unnecessary drugs. […]