Health inspection·January 22, 2026

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure professional standards of care were followed for one of three sampled residents (Resident 1) when: 1. A physician's weekly order to collect labs was not followed, 2. A SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [COC] among the residents) was not initiated after the facility received abnormal lab results pertaining to Resident 1's kidney (organs that filters blood to removed waste, excess fluid and toxins from the body) function, and; 3. The abnormal lab results was not reported to Resident 1's physician. This failure increased Resident 1's risk for prolonged pain, discomfort, and a delay in care and treatment which decreased the facility's potential to prevent Resident 1's kidneys from critical injury. A review of Resident 1's admission record indicated she was initially admitted to the facility in December 2025 with medical diagnosis which included displaced bimalleolar fracture of right lower leg (fractures of both the tibia [the larger bone in the lower leg] and fibula [the outer and smaller bone in the lower leg] resulting in injuries to both sides of the ankle [a joint that connects the foot to the lower leg]) and chronic kidney disease (a progressive condition where kidney damage prevents them from filtering waste from the blood effectively, leading to waste buildup and kidney failure). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 12/15/25, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12, which indicated her cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's order summary report indicated the following active order as of 12/10/25, CBC (complete blood count- a blood test that measures key parts of the blood), BMP (basic metabolic panel-a blood test that measures the body's chemical balance, metabolism [a chemical process that occurs in the body to convert food into energy], and kidney function) weekly in the morning every Wednesday for four (4) weeks. A review of Resident 1's electronic Medication Administration Record (MAR) dated December 2025 indicated the CBC and BMP were documented on 12/17/25 and 12/31/25 as completed [check marked]. A review of Resident 1's Electronic Medical Record (EMC) (other than the eMAR) did not include any evidence that the CBC and BMP were collected on 12/17/25. A review of Resident 1's Lab Results Report dated 1/02/26, indicated a CBC and BMP were collected on 12/31/25 at 7:05 a.m. The report indicated the CBC and BMP were reported on 1/02/26 at 11:51 a.m. The report was flagged [meaning, it required attention]. The report indicated Resident 1's WBC (white blood cells-a blood cell that helps attack infection or injury in the body) was 14.2 K/mm3 (thousands per cubic millimetermeasure of unit used to report WBC counts) [a normal range is between 3.8-10.1]. Resident 1's BUN (blood urea nitrogen- measures the amount of nitrogen from waste in the blood to evaluate kidney function) was reported as 42 mg/dL (milligrams per deciliter- a unit of measure) [a normal range is between 6-25]. The report indicated Resident 1's creatine (measures how efficiently Residents Affected - Few Page 1 of 3 555120 555120 01/22/2026 Vineyard Post Acute 101 Monroe Street Petaluma, CA 94954

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, 555120 Page 2 of 3 555120 01/22/2026 Vineyard Post Acute 101 Monroe Street Petaluma, CA 94954

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 555120 Page 3 of 3