Vineyard Post Acute
VINEYARD POST ACUTE in PETALUMA, CA — inspection on September 16, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID: