Inspection·January 22, 2026

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few kidneys filter waste from muscle metabolism) was 1.34 mg/dL [a normal range is 0.60-1.20]. The report also indicated Resident 1's BUN/CREAT ratio (a medical marker of kidney function) was 31 [a normal range is 9-30]. Resident 1's WBC, BUN, creatine, and BUN/CREAT was all flagged as high. A review of Resident 1's EMR indicated no evidence that a SBAR was completed on 1/02/26, or that the physician was contacted regarding the abnormal lab results that were reported to the facility on 1/02/26. A review of Resident 1's SBAR form, dated 1/03/26 at 5 p.m., indicated, [Resident 1] Increased edema [swelling in the body tissues caused by excess fluid buildup] to BLEs [bilateral lower extremities]. A review of Resident 1's SBAR form, dated 1/04/26 at 9 p.m., indicated, Decrease urine output.lower abdominal pain or tenderness.AM [morning] staff reported the resident [Resident 1] have difficulty voiding [urinating]. The writer performed a bladder scan [a device used to measure how much urine is in the bladder] and results shows the resident [Resident 1] is retaining urine about 1 L [liter- a metric unit of capacity]. A review of Resident 1's progress notes, type Nurse's Note, dated 1/07/26 at 11:31 a.m., indicated, Resident [Resident 1] notes with c/o [complaints of] pain level 10/10 [numerical pain scale ranging from 0 [no pain] to 10 [worst imaginable pain]], located in her back. Resident noted to be in distressed.MD [medical doctor] order for resident to be sent to ER [emergency room] for further evaluation.A review of Resident 1's ED (Emergency Department) Provider Notes dated 1/08/26, indicated, Chief complaint.patient presents with back pain.BUN 102 mg/dL, creatine 1.67 mg/dL.Clinical Impressions.Back pain.urinary tract infection [UTI- an infection in the bladder/urinary tract].AKI [acute kidney injury- a sudden loss of kidney function where the kidneys can no longer filter waste from the blood, leading to a buildup of waste products and fluid in the body].dehydration [a condition where your body loses more fluid than it takes in].During an interview on 1/22/26 at 2:43 p.m. with Licensed Nurse 1 (LN 1), she stated when lab values were out of range nurses were required to report this information to the MD for review. LN 1 further stated provider notification should be documented by the reporting staff in the resident's EMR. During an interview and concurrent record review on 1/22/26 at 12:05 p.m., the DON stated she expected nursing staff to contact the MD to report critical or abnormal lab results and document this notification. The DON stated she expected a SBAR to be completed if lab values were out of range. The DON verified Resident 1's MD orders for weekly CBC and BMP placed on 12/10/25. The DON confirmed Resident 1's December 2025 eMAR indicated that the CBC and BMP were completed on 12/17/25, but there was no evidence of this on Resident's 1 EMR. The DON stated, I don't know what happened to this [the lab collection]. The DON was given the opportunity and inquired with the facility's medical record department to provide documents indicating the CBC and BMP were collected, and results communicated to the MD, but she was unable to provide the evidence requested. The DON further confirmed Resident 1's BUN of 42 mg/dL, creatine of 1.34 mg/dL, BUN/CREAT ratio of 31, and WBC of 14.2 K/mm3 from 1/02/26 should had been reported to the MD, but was unable to locate evidence of this. The DON further stated, I would expect that [the labs] to be included in the SBAR to inform the MD so that the doctor can do the interventions right away. The DON stated, If an elevated BUN is left untreated, it can cause kidney injury. The DON stated if nurse staff documented an order as complete, she expected it to be completed. A review of the facility policy and procedure (P&P) titled, Test Results, revised in 2007, indicated, The resident's attending physician will be notified of the results of diagnostic tests [medical procedures used to identify, rule out, or monitor disease]. Should the test results be provided to the facility, the attending physician shall be promptly notified of the results.The director of nursing services or charge nurse receiving the test results, shall be responsible for notifying the physician of such test results.A review of the facility's P&P titled, Change in a Resident's Condition or Status, revised in 2021, (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 01/22/2026 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 indicated, Our facility promptly notifies the resident, his or her attending physician.of changes in the resident's medical.status.A review of the facility's P&P titled, Charting and Documentation, revised in 2017, indicated, The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.The following information is to be documented in the residents medical record.changes in the resident's condition.Documentation in the medical record will be.complete, and accurate.A review of the facility's P&P titled, Job Description: LPN (Licensed Practical Nurse) LVN (Licensed Vocational Nurse), dated 2018, indicated, Notify the resident's attending physician.when there is a change in the resident's condition.Administer professional services such as.taking blood.Obtain.lab tests as ordered.A review of the facility's P&P titled, Job Description: RN (Registered Nurse), dated 2024, indicated, Notify the resident's attending physician.when there is a change in the resident's condition.Obtain.lab tests as ordered. Event ID: Facility ID: 555120 If continuation sheet Page 3 of 3