Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Vineyards Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia and hypertensive heart disease was placed NPO for a planned PEG procedure, and nursing staff withheld ordered BP medications without verifying this change with the physician, despite facility policy requiring evaluation and stabilization of co-morbidities such as hypertension before surgery. The resident subsequently had a critically elevated BP and was transferred to the hospital. In addition, over multiple occasions, staff administered PRN hydralazine for SBP readings above ordered parameters but did not obtain or document required follow-up BP checks or notify the physician when pressures remained high, contrary to facility policy and stated expectations from the DON and DSD.
A resident with Alzheimer's disease and dementia, documented to have impaired short-term memory and moderately impaired decision-making, had identified preferences for watching classical and musical movies and a care plan intervention for in-room activities. Despite this, the resident’s family member reported never seeing the resident engaged in activities, and the AD confirmed there were no activity progress notes showing that activities were provided. The DON acknowledged that lack of activities posed a risk of mental deterioration, and the facility’s own Quality of Life-Dignity policy stated residents should be encouraged to attend activities of their choice, highlighting that this policy was not followed for this resident.
The facility failed to store food items properly in the dry storage room, affecting all residents receiving food from the kitchen. A surveyor observed several food items stored directly on the floor, contrary to the facility's policy requiring food to be stored above the floor on shelves or racks. The Dietary Manager cited limited space as the reason, and the DON and Administrator confirmed this practice was not acceptable.
A facility failed to ensure a nurse, whose CPR certification had expired, did not perform CPR on a resident with a DNR order. The resident, with severe cognitive impairment and multiple health issues, was found unresponsive. Despite the DNR status, the nurse initiated CPR, influenced by the family's wishes. The facility lacked assurance of CPR-certified staff on each shift, and the DON expected adherence to POLST and CPR certification maintenance.
The facility failed to implement infection control precautions for two residents. One resident with a urinary catheter did not receive enhanced barrier precautions as staff entered the room and manipulated the catheter without wearing gowns or gloves. Another resident with a skin rash requiring contact precautions was not protected as a housekeeper entered the room without the necessary PPE. Staff acknowledged these oversights, and the facility's policies were not followed.
The facility failed to provide adequate space in resident rooms, with 18 out of 30 rooms not meeting the minimum requirement of 80 sq ft per resident. Residents expressed concerns about cramped conditions, and measurements confirmed the deficiency. The Administrator acknowledged the issue, citing the facility's construction in 1969 as a contributing factor.
A resident's oral antibiotic medication was administered over nine hours late, despite being available in the facility's Pyxis system. The delay occurred despite the facility's policy requiring medications to be administered within one hour of their prescribed time. Both the DON and LVN acknowledged the failure to follow the policy, which had the potential to worsen the resident's health condition.
Failure to Verify NPO Medication Orders and Monitor PRN Antihypertensive Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide care that met professional standards for a resident with dementia and hypertensive heart disease who was scheduled for PEG placement and placed on NPO status. An SBAR note documented that the resident was NPO in preparation for the procedure and that BP medications were withheld because of the NPO order. When the resident’s BP was checked at 1:00 p.m., it was critically elevated at 207/97 mmHg, and the resident was subsequently transferred to the hospital later that afternoon for critical high blood pressure. The DON stated that the expectation was for charge nurses to verify with the physician whether BP medications should be given when a resident is NPO for a procedure, but this verification did not occur. The facility’s own Surgery-Related (Pre- and Postoperative) Management policy indicated that the physician should evaluate residents scheduled for surgery with attention to cognition, function, and control of active co-morbidities such as hypertension, and that modifiable risk factors like blood pressure should be stabilized prior to transfer for surgery. The policy also required staff and the physician to review the relevance of preoperative medications and adjust them as needed. In this case, the resident’s antihypertensive regimen was altered by withholding BP medications due to NPO status without documented physician verification, despite the resident’s known hypertensive heart disease and poor cognition (BIMS score of 00). A second component of the deficiency concerns the facility’s failure to obtain and document follow-up BP readings after administration of PRN hydralazine as ordered. The physician’s order directed hydralazine 25 mg PO every 6 hours PRN for SBP >160. Record review, confirmed by the DON, showed multiple instances in May, July, and August where the resident’s SBP readings were significantly elevated (ranging from 183 to 198 mmHg), PRN hydralazine was administered, but no follow-up BP checks were documented. The DSD and DON both stated that licensed nurses were required to recheck BP 30 minutes after PRN hydralazine to monitor effectiveness, document the results, and notify the physician if BP remained elevated. The facility’s Acute Condition Changes policy required nurses to collect and report pertinent baseline information, including vital signs, and to contact the physician based on urgency, but this monitoring and communication process was not followed for the resident’s repeated episodes of severe hypertension.
Failure to Provide Ongoing Activities for Cognitively Impaired Resident
Penalty
Summary
Surveyors identified that the facility failed to provide an ongoing activity program to meet the needs of a resident with Alzheimer's disease and dementia. The resident was admitted with diagnoses including Alzheimer's disease and dementia, and an MDS assessment documented impaired short-term memory and moderately impaired decision-making capacity. An activity assessment showed the resident preferred watching classical and musical movies, and the activities care plan included an intervention to provide in-room activities. However, the resident’s family member reported not observing the resident participating in any activities while residing at the facility. During a concurrent interview and record review with the Activity Director, it was confirmed that there were no activity progress notes indicating that the resident had been provided with activities during her stay. The Activity Director stated that residents with Alzheimer's disease need activities to stimulate mental cognition. The DON stated that the risk for the resident in not having activities was mental deterioration. The facility’s policy on Quality of Life-Dignity indicated that each resident should be cared for in a manner that promotes well-being and that residents are encouraged to attend activities of their choice, including recreational and social activities, but the documented and reported lack of activities for this resident showed this was not carried out in practice.
Improper Food Storage in Dry Storage Room
Penalty
Summary
The facility failed to adhere to its policy regarding the proper storage of food items in the dry storage room, which affected all residents receiving food from the kitchen. During an observation, a surveyor noted several food items, including cases of potato pearls, poultry gravy mix, dessert mix, sandwich cookies, pasta, juice, cans of tomato soup, and nectar thickened lemon water, stored directly on the floor. The facility's policy mandates that food should be stored above the floor on shelves or racks, ideally 6 inches off the ground. The Dietary Manager acknowledged the issue, citing limited space as the reason for storing items on the floor. The Director of Nursing and Administrator later confirmed that storing food on the floor was not acceptable.
Failure to Adhere to DNR Order and CPR Certification Lapse
Penalty
Summary
The facility failed to ensure that a licensed nurse, who was not certified to perform cardiopulmonary resuscitation (CPR), did not perform CPR on a resident with a do not resuscitate (DNR) code status. This incident involved a resident with a medical history of type 2 diabetes mellitus, dysphagia following cerebral infarction, dementia, asthma, acute ischemic heart disease, atherosclerotic heart disease, and hypertensive chronic kidney disease. The resident's Physician Orders for Life-Sustaining Treatment (POLST) clearly indicated a DNR status, which was not adhered to by the staff. During the event, Registered Nurse (RN) #8, whose CPR certification had expired, initiated CPR on the resident despite the DNR order, after the resident was found unresponsive and not breathing. RN #8 stated that she felt compelled to act based on the family's wishes, despite the resident's documented DNR status. The Director of Staff Development acknowledged that there was no guarantee of having a CPR-certified staff member on each shift, and the Director of Nursing expected all licensed nurses to maintain CPR certification and adhere to residents' POLST in emergencies.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for a resident with an indwelling urinary catheter. Despite the facility's policy requiring the use of gown and gloves during high-contact activities, the Assistant Director of Nursing (ADON) entered the resident's room and manipulated the catheter without wearing the necessary protective equipment. Additionally, a Certified Nursing Assistant (CNA) rolled the resident without wearing a gown, acknowledging the oversight. The Director of Nursing confirmed that staff should wear a gown and gloves when interacting with residents on EBPs. The facility also failed to implement contact precautions for a resident with a skin rash requiring such measures. A housekeeper entered the resident's room without wearing a gown or gloves, despite the care plan's directive to use personal protective equipment (PPE) during high-contact activities. The Housekeeping Supervisor and Infection Preventionist later confirmed that the housekeeper should have worn a gown, gloves, face shield, and mask when entering the room of a resident on contact precautions.
Deficiency in Resident Room Space Standards
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum space standards, with 18 out of 30 rooms not providing at least 80 square feet per resident. This deficiency was identified through observations, interviews, and document reviews. Residents expressed concerns about the lack of space, and measurements confirmed that several rooms provided only 70 to 78 square feet per resident, falling short of the regulatory requirement. The issue was acknowledged by the facility's Administrator, who noted that the space constraints have been present since the facility's construction in 1969. Interviews with residents revealed that they felt cramped in their living spaces, and their cognitive assessments indicated they were aware of their surroundings and able to articulate their concerns. The Director of Nursing was not familiar with the room size requirements, indicating a lack of awareness or oversight regarding compliance with space standards. The Administrator confirmed the deficiency, acknowledging the facility's longstanding space limitations.
Failure to Administer Medication Timely
Penalty
Summary
The facility failed to follow their policy and procedure for administering medications timely for one of three sampled residents. Resident 1's oral antibiotic medication, Levofloxacin, was administered nine hours and sixteen minutes after it was ordered. This delay occurred despite the facility having the medication available in their Pyxis system, an electronic medication dispensing system linked to the pharmacy. The Director of Nurses (DON) and the Licensed Vocational Nurse (LVN 1) both acknowledged that the medication should have been administered within four hours of the order being received, as per the facility's policy and procedure titled 'Administering Medications'. Resident 1 was admitted to the facility with diagnoses of COVID-19, asthma, and hypertension. On February 5, 2024, Resident 1 returned from the acute care hospital emergency department with a discharge diagnosis of pneumonia and an order for Levofloxacin 750 mg by mouth daily for five days. The physician's order was documented at 10:44 PM, but the first dose of the medication was not administered until 8:00 AM the following day, resulting in a delay of over nine hours. During interviews and record reviews, both the DON and LVN 1 confirmed that the medication was not administered in a timely manner, which was a failure to follow the facility's policy. The DON stated that the expectation was for the licensed nurse to administer the medication within four hours if it was available. The facility's policy indicated that medications should be administered within one hour of their prescribed time unless otherwise specified. The delay in administering the medication had the potential to exacerbate Resident 1's health condition and compromise their overall health and well-being.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Livermore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stratford Villa Post-acute | 0.2 mi | ★★★★★ | 3 | 0 |
| Avondale Villa Post-acute | 0.2 mi | ★★★★★ | 1 | 0 |
| Creekview Skilled Nursing | 4 mi | ★★★★★ | 0 | 0 |
| Pleasanton Nursing And Rehabilitation Center | 5.1 mi | ★★★★★ | 11 | 0 |
| The Reutlinger Community | 10.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.