Health inspection·February 25, 2025

F 0880 Provide and implement an infection prevention and control program. 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, the facility failed to maintain an effective infection prevention and control program, for a census of approximately 90 residents, when the facility did not report an influenza outbreak to the local public health department (LPHD) for nearly three weeks. Residents Affected - Some This failure had the potential to increase the transmission of influenza among all residents in the facility. Findings: During a concurrent interview and record review on 2/25/25 at 11:05 a.m., with the Infection Preventionist (IP), the facility ' s document titled, Line List Acute Respiratory Illness Outbreak In Long-Term Care Facilities (Including Influenza) (line list, a table that summarizes information about each case of an outbreak), dated 1/29/25, was reviewed. The IP stated the line list indicated, the facility had an influenza outbreak starting on 1/29/25 when two residents tested positive for influenza. The IP stated on 1/31/25 seven more residents tested positive for influenza and, during the outbreak, the facility, the facility had a total of 28 resident and [NAME] staff members who had tested positive for influenza. The IP stated, she hadn ' t notified the LPHD until 2/18/25, she had been away from work for nearly three weekly and the LPHD had not been notified while she was gone. The IP stated the local public health department should have been notified when the first case of influenza had been identified on 1/29/25. During an interview on 2/25/25 at 1:59 p.m., the Director of Nursing (DON) acknowledged she had not notified the LPHD regarding the influenza outbreak, because she thought the Administrator (ADM) was responsible for reporting the outbreak. During an interview on 2/25/25 at 2:10 p.m., the Director of Staff Development (DSD) stated she prepared the line list for the facility ' s influenza outbreak starting on 1/29/25, but had not sent the line list nor reported the outbreak to the LPHD, because she thought it was the responsibility of the ADM. During a concurrent interview and record review, on 2/25/24 at 3:30 p.m., with the ADM, the facility ' s policy and procedure (P&P) titled, Outbreak of Communicable Diseases, dated 9/2022, was reviewed. The ADM confirmed the P&P indicated, .An outbreak of influenza is defined as anything exceeding the endemic rate, or a singe case if unusual for the facility . A single case of influenza is reportable to the department of health . The administrator is responsible for: a. communicating data about reportable diseases to the health department .The ADM acknowledged he had not notified the LPHD of the influenza outbreak that started on 1/29/25, because the IP was responsible for reporting to the (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: 555120 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 555120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyard Post Acute 101 Monroe Street Petaluma, CA 94954 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)