Health inspection·September 1, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to give appropriate care to Resident 1 ' s indwelling catheter tubing (a tube secured inside the bladder to drain urine into a bag outside the body). This failure resulted in Resident 1 having a urinary tract infection (UTI, an infection in any part of the urinary tract - kidneys, bladder, or urethra). Findings: A review of Resident 1's admission Record dated 7/14/23, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of a history of UTI. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/2/23, indicated the resident was usually able to understand others and usually understood by others. Resident 1 was totally dependent on one-person for toilet use (how resident cleanses self after elimination). Resident 1 had an indwelling urinary catheter, and the resident was always incontinent (unable to control) of bowel movement. A review of Resident 1's care plan titled, Indwelling Catheter, dated 5/26/23, indicated Resident 1 had an indwelling urinary catheter placed due to urinary retention (inability to empty all the urine from the bladder). The care plan indicated a long-term goal to show no signs and symptoms(s/sx) of urinary Infection through the review date. The target date was 8/14/23. The interventions included to clean peri-area (perineal which is the sensitive skin between the anus and vaginal opening), front to back, monitor/record/report to MD for s/sx of UTI: pain, burning, blood-tinged urine, cloudiness, no output, and deepening of urine color. During a review of Resident 1 ' s physician ' s orders dated 7/14/23, indicated the following orders: 1. indwelling catheter size Fr.(french) 18/30 (size or gauge/ milliliter- amount to inflate the retention balloon to prevent catheter from being expelled), 2. secure indwelling catheter to an anchoring device/leg strap to prevent movement of the catheter; and 3. to cleanse indwelling catheter site with water and soap every shift. Furthermore, Resident 1 was to receive antibiotics (antibacterial medication) for UTI, on 5/24/23, 6/24/23, and 7/12/23, indicating Resident 1 had three repeated episodes of acquiring a UTI in the span of three months after being admitted to the facility. During an interview on 8/7/23 at 3:05 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, he was the current regular night shift CNA assigned to Resident 1 and had been taking care of Resident 1 for a few months. CNA 1 stated, he never gave peri-care (cleaning of the private area) and (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 4 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 09/01/2023 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)