Health inspection·September 16, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/16/25 at 5:00 p.m., he stated he saw and assessed Resident 1 at the facility on the afternoon of 8/19/25 and ordered the PRN Morphine Sulfate to treat Resident 1's moderate to severe pain due to her recent digestive system surgery and her current medical diagnoses. MD 1 added that Medical Doctor 2 (MD 2), who was familiar with Resident 1 then took over the care of Resident 1 on the evening of 8/19/25 and was Resident 1's attending physician for the remainder of her stay in the facility.During an interview with Resident 1 on 9/16/25 at 5:08 p.m., she stated she asked the facility nurse repeatedly for pain medication when she began experiencing pain after being admitted to the facility on [DATE], and over the next several days (from 8/18/25 through 8/21/25) she experienced severe pain that was not controlled despite her using her call light to request more pain medications multiple times, which left her feeling, scared, terrified and alone. She added that one nurse (referring to LN 1), would either not answer the call light, turn the call light off, or just come in her room and stare at her like he didn't believe me.During a concurrent interview and record review with the Director of Nursing (DON) on 9/16/25 at 11:30 a.m., Resident 1's August 2025 MAR was reviewed. The DON stated nursing staff who had cared for Resident 1 from 8/19/25 through 8/21/25 were not working during the Surveyor's visit, so they were not able to be interviewed, and she didn't know why Resident 1 was not administered the ordered Morphine Sulfate to treat her documented high pain levels and instead had only been administered Acetaminophen ordered for the treatment of mild pain. The DON stated her expectation was that nursing staff administered the pain medication that correlated with the resident's pain level, adding that if the physician order was unclear, nursing staff needed to verify the order with the physician. The DON reviewed Resident 1's MAR and confirmed Resident 1's physician ordered pain assessments indicated, Assess for Pain QS (every shift) .and chart using 1-10 Scale: 0= No pain,1-3 = Mild Pain, 4-6 = moderate pain, 7-9 = Severe Pain, 10= Excruciating (pain) every shift for pain scale. The DON confirmed there was no documentation on Resident 1's MAR of Resident 1's pain assessment on 8/19/25 for morning shift. The DON confirmed Resident 1's pain level on her MAR the evening of 8/18/25, was documented as six (6), and Resident 1's pain level was not documented on her MAR the morning shift of 8/19/25. The DON also confirmed Resident 1's MAR indicated her pain had increased in level and severity over time on the evening and night shift of 8/19/25 from level six (6) to level seven (7), after multiple administrations of Acetaminophen to treat mild pain. The DON stated she did not know if Resident 1's increasing pain level and severity was reported to the physician, as directed in one of the interventions listed in Resident 1's nursing care plan under the focus area for Pain, as the DON could not find any documentation in the chart stating the physician was notified about Resident 1's increasing pain on 8/19/25.During an interview with the facility Pharmacist, on 9/17/25 at 4:25 p.m., the Pharmacist confirmed the order for Resident 1's PRN Morphine Sulfate was entered electronically, by MD 1 on 8/19/25, at 5:52 p.m. The Pharmacist explained that due to Resident 1's listed Morphine allergy in her chart, an electronic fax was sent for clarification of the Morphine order to the ordering physician's office fax number, as was the standard practice of the pharmacy. The Pharmacist confirmed there was no follow up communication or inquiry from the ordering physician or from facility staff and if such an inquiry had occurred, it would have been documented in the electronic record in the pharmacy system. During a review of Resident 1's August 2025 MAR, from 8/29/25 through 8/31/25 indicated Resident 1 was administered Morphine Sulfate for documented pain assessment levels, of six (6), seven (7) and eight (8) after a hospitalization from 8/21/25 to 8/28/25, for which no adverse effects of Morphine Sulfate were documented. During an interview with MD 2 on 8/18/25 at 4:55 p.m., he stated there were no contraindications for Resident 1 to receive the Morphine Sulfate (ordered by MD 1on 8/19/25) for moderate to severe pain relief. MD 2 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555120 If continuation sheet Page 2 of 3 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 09/16/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete did not know the reason Resident 1 was not treated for her moderate to severe pain experienced from 8/19/25 through 8/21/25 and added that Resident 1 was eventually administered Morphine Sulfate for pain relief, around the time closer to the end of her stay in the facility (8/28/25-8/31/25).A review of the facility's policy titled, Administering Medications, dated 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications administered in accordance with provider orders. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication, will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns.A review of the facility's policy titled, Pain Assessment and Management, dated 2022, indicated, The purpose of this procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. Acute pain (or significant worsening of chronic pain) should be assessed after the onset and reassessed as indicated until relief is obtained. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.A review of the facility's document titled, Job Description: Registered Nurse (RN) Prepared by: Human Resources (02-2024) indicated, The primary responsibility of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty. Such supervision must be accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility and may be required by the Director of Nursing (DON) and or/Assistant Director of Nursing (ADON) when applicable, to ensure that the highest degree of quality care is maintained at all times. Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered. Review medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses notes to determine if the care plan is being followed. Event ID: Facility ID: 555120 If continuation sheet Page 3 of 3