Vineyards at Concord, The

In the surveyor’s words

From the most serious findings on record at Vineyards at Concord, The, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 28, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725Apr 28, 2026

  Based 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. Findings include: Observation of meals during survey from 04/13/26 through 04/15/26 revealed meals were being passed late.Observation on 04/13/26 at 3:20 P.M., of Certified Nursing Assistant (CNA) #117 and CNA #127 provide incontinence care for Resident #19 revealed they wheeled her to her room from the dining room where she had been sitting since 8:00 A.M. upon entry to the facility. […]

• No harm, potential for more than minimal, widespreadF835Apr 28, 2026

  Based 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. Findings include:1. […]

• No harm, potential for more than minimal, patternF578Apr 28, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF680Apr 28, 2026

  Based 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. […]