Health inspection·July 6, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the physician and responsible party (RP) for four days after one of three sampled residents (Resident 1) had a witnessed fall. Residents Affected - Few This failure resulted in the physician and Resident 1's RP not being informed of Resident 1's status and had the potential to result in delayed treatment of any complications related to the fall. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1's most recent admission was in May 2022. Resident 1's admission Record indicated diagnoses of unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities) with other behavioral disturbance, legal blindness, muscle weakness, difficulty in walking, history of falling. The admission Record also indicated Resident 1 had a responsible party (RP) for healthcare decisions. During a review of Resident 1's, SBAR & Initial Change of Condition/Alert Charting & Skilled Documentation (SBAR), effective date 5/4/23, the SBAR indicated Resident 1 fell when Certified Nursing Assistant 1 (CNA 1) transferred Resident 1 from the bed to the bedside commode on 5/4/23. The SBAR also indicated the physician was notified of the fall on 5/8/23, at 16:00; Resident 1's RP was informed of the fall on 5/8/23, at 17:00. During an interview on 5/24/23, at 10:48 a.m., with Director of Nursing (DON), DON stated Resident 1 fell on 5/4/23, and the physician and Resident 1's RP were notified of the incident on 5/8/23. DON also stated the fall notification should have been done as soon as possible. During a phone interview on 7/5/23, at 11:05 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he had not notified the MD and Resident 1's RP right after the incident because he had asked the CNA if the resident had fallen and was told Resident 1's knees had buckled during transfer, and the CNA had assisted Resident 1 to the floor. LVN 1 stated it was expected that the MD and RP were still notified of this type of incident (assisted fall). During a review of the facility's policy and procedure (P&P) titled, Falls and Their Causes, dated March 2018, the P&P indicated, Notify the resident's attending physician and family in an appropriate time frame: B. When a fall does not result in significant injury or condition change, notify the practitioner routinely (e.g., by fax or by phone the next office day). During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055212 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Vineyards Healthcare Center 76 Fenton Street Livermore, CA 94550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)