Vineyard Post Acute
VINEYARD POST ACUTE in PETALUMA, CA — inspection on March 30, 2026.
Found 2 citations. 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
During an interview with the DON on 4/1/26 at 2:42 p.m., the DON stated she checked
of the facility's policy and procedure (P&P) titled Wandering and Elopements dated March 2019
shall.notify the resident's legal representative (sponsor).document relevant information in the resident's medical record.A review of the facility's P&P titled, Change in Resident's Condition or Status, dated February 2021 indicated, Our facility promptly notifies the resident.and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.).Unless otherwise instructed by the resident, a nurse will notify the resident's representative when.there is a significant change in the resident's physical, mental, or psychosocial status.Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his.medical care or nursing treatments.
555120 03/30/2026
Vineyard Post Acute 101 Monroe Street Petaluma, CA 94954
concurrent observation and interview with Resident 1 on [DATE] at 2:40 p.m., Resident 1 was
1 stated he did not remember if he had his wander alarm on or if the door alarm sounded. Resident 1
lobby, Resident 1 pointed toward the closest baseball field from the facility to indicate where he had gone when he left the facility at night. In order to get to the baseball field, Resident 1 would have had to cross a neighborhood intersection with a three-way stop sign to get to the nearest baseball field.During a concurrent record review and interview with the DON (Director of Nursing) on [DATE] at 3:45 p.m., the DON stated nobody noticed that Resident 1 had left the facility.
The DON also stated she was not sure if Resident 1's care plan was updated after the elopement incident on [DATE].
The DON reviewed Resident 1's care plan regarding his risk of wandering and elopement dated initiated on [DATE] and acknowledged it had not been updated to indicate Resident 1's elopement incident on [DATE].
During an interview with the Activity Director (AD) on [DATE] at 10:29 a.m., the AD stated she was on leave from work which started on [DATE] and the Human Resources Director (HRD) helped with the activity department.
The AD stated she and anyone who was designated to carry out her duties while she was out on leave was responsible for keeping track of the expiration date of the Wanderguard(R).
During an interview with the HRD on [DATE] at 10:50 a.m., the HRD stated she did not recall anyone informing her that Resident 1's Wanderguard(R) had expired.
During an interview with the DON on [DATE] at 2:42 p.m., the DON stated there was a potential for Resident 1 to have fallen and sustained injuries when he eloped.
During an interview with the Maintenance Director on [DATE] at 4:31 p.m., he stated he checked the door alarm system to ensure it was functioning properly every Friday and that he kept a log of the weekly checks. He stated when the door alarm was activated, the alarm would be loud enough for staff to hear and respond to.
The Maintenance Director further stated there were monitors at Nurse Station 1 and Nurse Station 2 that would notify the nurses which door was alarming.
The Maintenance Director stated he was unable to determine how Resident 1 was able to leave the building through the front door without sounding the alarm.A review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated [DATE], indicated, The facility will identify residents who are at risk of unsafe wandering.If identified as at risk for wandering, elopement.the resident's care plan will include strategies and interventions to maintain the resident's safety.