Health inspection·July 27, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment and services consistent with professional standards of practice to promote healing of a pressure ulcer (otherwise known as bed sore, a skin injury that result from unrelieved pressure ulcer on a body part, usually on a bony prominence like the tailbone, buttocks, and hips) when: Residents Affected - Few Facility staff did not continuously provide physician-ordered treatment to heal an existing Stage II (partial thickness skin loss that involves the deeper layers of the skin, may appear as a shallow crater) pressure ulcer on the sacrococcyx area (fusion of the bony structure on the base of the spine and the tailbone). This failure had the potential to result in the delayed healing and worsening of Resident 1's pressure ulcer from Stage II to unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed due to ulcer being obscured by slough (dried inflammatory fluids that are moist, stringy, yellow, tan, gray, green or brown) or eschar (necrotic tissue that is leathery or thick, and black, brown or tan). Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included rectal cancer, moderate protein-calorie malnutrition, and hypertensive heart disease with heart failure. Review of Resident 1's Braden Scale assessment (an assessment to measure risk of getting pressure ulcers) dated 5/23/23 indicated a score of 15 (score category; at risk 15-18, moderate risk 13-14, high risk 10-12, very high risk 9 or below). Review of Resident 1's Skin Assessment (Pressure Injury) dated 4/26/23 indicated Resident 1 was admitted with a Stage II pressure ulcer on the sacrococcyx area that measured 4 centimeters (cm) x 2 cm. The skin assessment indicated the wound bed was red with small amount of serous drainage. It also indicated, under comment, dry dressing. Review of Resident 1's Treatment Administration Record (TAR) for April 2023 indicated an order to cleanse sacrococcyx Stage II pressure ulcer with normal saline, pat dry and apply dry dressing every day shift. The wound treatment was started on 4/27/23, two days after Resident 1 was admitted to the facility. During a concurrent interview and review of Resident 1's TAR for April 2023 and Skin assessment dated [DATE] with Treatment Nurse (TN) 1 on 7/27/23 at 12:50 p.m., TN 1 stated, because the discharging hospital did not write a wound treatment order for Resident 1's pressure ulcer, the treatment nurse (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 3 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 07/27/2023 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)