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 (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 03/11/2025 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)