Health inspection·March 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was provided a home-like environment with comfortable sound levels when Resident 4 was constantly yelling vulgar, offensive, and derogatory language. This resulted in Resident 1 being unable to get a full night of uninterrupted sleep and decreased Resident 1's potential to reach his maximum healthcare potential. Findings: A review of Resident 1 ' s admission record indicated he was admitted in 2/13/25 with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/19/25, indicated Resident 1 had moderate memory impairment (difficulty remembering recent events, trouble with problem-solving, and changes in judgment, but it does not typically interfere with daily functioning). A review of Resident 2 ' s admission record indicated he was admitted in 12/17/24 with diagnoses which included diastolic congestive heart failure (Stiffness of the left ventricle of the heart which does not allow the heart to properly fill with blood). A review of an MDS dated [DATE], indicated Resident 2 had moderate memory impairment. A review of Resident 3 ' s admission record indicated he was admitted in 2/27/25 with diagnoses which included chronic ulcer (Open wound that persists for more than six weeks, despite appropriate treatment) of right lower leg. A review of an MDS dated [DATE], indicated Resident 3 had moderate memory impairment. A review of Resident 4 ' s admission record indicated he was admitted in 2/28/25 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. A review of an MDS dated [DATE], indicated Resident 4 had moderate memory impairment. A review of Resident 4's interdisciplinary team (a group of professionals from different disciplines who work together collaboratively to achieve a common goal) note dated 3/7/25 at 11:53 a.m., indicated, [Resident 4] .screaming at night and upsetting other residents. During a phone interview on 3/11/25 at 8:30 a.m., Anonymous Witness XX stated Resident 1 was gravely affected by Resident 4 ' s constant yelling throughout the day and night, which did not allow Page 1 of 2 555120 555120 03/11/2025 Vineyard Post Acute 101 Monroe Street Petaluma, CA 94954

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 to rest and sleep. Anonymous Witness XX stated Resident 1 was recovering from a stroke, and this was an essential time to recover from the neurological (an area of the brain) damage caused by the stroke, therefore he required to be able to rest through the night. Anonymous Witness XX also stated Resident 4 had violently attacked staff at the facility, and police had to be called for this incident. During an interview on 3/11/25 at 9 a.m., the Director of Nursing (DON) acknowledged Resident 4 was very aggressive, confirmed police were called, and Resident 4 had been transferred to a hospital due to his aggressive behavior. The DON stated Resident 4 was back at the facility and was doing better after the physician prescribed lorazepam (an antianxiety medication) for him. During an interview on 3/11/25 at 9:40 a.m., Resident 4 acknowledged he had been aggressive at the facility and yelled frequently for help from staff because staff were not answering his call light. Resident 4 confirmed he physically hit a female Certified Nursing Assistant (CNA) during care because she was hurting him while providing services. Resident 4 stated he became, aggravated with staff and was transferred to a hospital. During an interview on 3/11/25 at 10:15 a.m., Resident 1 stated Resident 4 screamed at all hours of the day and night to the top of his lungs, using vulgar, offensive and derogatory language towards staff. Resident 1 stated he had notified the charge nurses and the DON about it, but the situation persisted. Resident 1 acknowledged Resident 4 had been moved to another wing of the facility recently, but due to his aggressive behavior, he was returned to his previous room which was right next to his. Resident 1 stated he was unable to get a restful night ' s sleep because Resident 4 ' s screams constantly woke him up. Resident 1 stated this situation was very stressful to him, since he needed to recover from neurological damage caused by a stroke. Resident 1 stated things had not gotten better with Resident 4, he was still constantly yelling. During an interview on 3/11/25 at 10:35 a.m., Resident 2 stated he had heard Resident 4 screaming at all hours of the day and night and would be very upset if Resident 4 ' s room was next to his. During an interview on 3/11/25 at 10:42 a.m., Resident 3 stated he constantly heard Resident 4 screaming in a high aggressive tone, asking for staff help. Resident 3 stated staff were very gracious with him and worked hard. Resident 3 stated he believed Resident 4's needs could be better met at a mental health facility rather than a rehabilitation center. During interviews with CNA A on 3/11/25 at 11 a.m., Licensed Staff B on 3/11/25 at 11:30 a.m., CNA C on 3/11/25 at 11:45 a.m., and CNA D on 3/11/25 at 12 p.m., they all confirmed Resident 4 constantly used loud aggressive and offensive language toward staff and stated they did not feel this facility was the right place for Resident 4's care needs to be met. Record review of the facility policy titled, Homelike Environment, last revised in February of 2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include i. comfortable sound levels. 555120 Page 2 of 2