Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vineyard Hills Health Center during CMS and state inspections, most recent first.
The facility did not follow the approved dietary menu and portion sizes for multiple residents on specialized diets, including puree, soft and bite, minced and moist, and finger food diets. Residents received incorrect food items and portion sizes, such as mashed potatoes instead of whipped sweet potatoes, oversized portions of turkey, and improper scoop sizes for mashed potatoes and meatloaf. Dietary staff confirmed these deviations during interviews, and documentation review supported the findings.
Surveyors identified that the facility did not consistently document or respond to out-of-range medication refrigerator temperatures, failed to complete required temperature checks for medication storage areas, and did not label an insulin pen or a blood glucose test strip container with open or expiration dates as required by policy. These actions resulted in medications and supplies not being safely stored or tracked for integrity.
A dietary aide prepared sandwiches for residents without using required portion sizes or measurement tools, despite facility recipes specifying exact amounts. The aide had limited training, and there was no documentation of job-specific competency assessments or required evaluations, contrary to facility policy.
Surveyors found that oxygen tubing and nasal cannulas for three residents were either placed on the floor or not labeled with the date opened, as required by facility policy. Nursing staff confirmed that the equipment should have been stored properly and labeled, but these procedures were not followed.
The facility did not keep the walk-in freezer in safe working order, with repeated observations of ice buildup, condensation, a damaged baseboard, cracked tiles, and a door that did not close tightly. These issues were documented over several months in sanitation audits and confirmed by both the Kitchen Supervisor and Maintenance Director, who acknowledged the recurring problems and ongoing maintenance efforts.
A CNA did not receive the required 12 hours of annual in-service training, including dementia management and abuse prevention, as confirmed by a review of attendance records and acknowledgment by the DSD.
The facility failed to update PASARR Level I screenings for two residents. One resident, admitted with dementia, psychosis, and anxiety, did not receive a new PASARR after staying beyond 30 days. Another resident, with major depressive disorder and psychosis, did not have a new PASARR after receiving additional mental illness diagnoses. Interviews confirmed the need for updated screenings.
The facility failed to ensure the consultant pharmacist reported medication regimen irregularities for the extended use of as-needed psychotropic medications for five residents. Despite severe cognitive impairments and ongoing prescriptions for antianxiety medications without stop dates, the pharmacist did not identify any irregularities in the medication regimens. The pharmacist admitted to not considering the duration or stop dates for these medications when making recommendations.
The facility failed to ensure that PRN psychotropic medications were not ordered for more than 14 days for several residents, as required by policy. Residents with histories of anxiety and cognitive impairments had orders for lorazepam or Ativan without specified stop dates. Interviews revealed staff were unaware of the requirement for stop dates, and the pharmacist did not consider this in reviews, leading to non-compliance with regulatory standards.
The facility failed to implement enhanced barrier precautions (EBPs) for residents with urinary catheters and pressure ulcers. Observations revealed that staff did not use the required gown and glove precautions during high-contact care activities for three residents. Interviews indicated a lack of awareness and training on EBPs among staff, and the facility's Administrator acknowledged a misunderstanding of guidelines, leading to this deficiency.
A facility failed to notify the Ombudsman when a resident with moderate cognitive impairment was transferred to the hospital, as required by their policy. The resident, admitted with sepsis and alcoholic liver disease, was transferred for evaluation and treatment. The facility's policy requires notifying the Ombudsman of such transfers, but interviews revealed this was not being done at the time of transfer.
A facility failed to ensure the accuracy of a PASARR Level I screening for a resident with a history of major depressive disorder, anxiety, and psychosis. The screening incorrectly indicated no mental disorder diagnosis. Staff interviews revealed that the DON was responsible for verifying PASARR accuracy, but the error was not corrected upon admission.
Failure to Follow Approved Menu and Portion Sizes for Specialized Diets
Penalty
Summary
The facility failed to follow the approved dietary menu and portion sizes for multiple residents across various diet types during lunch meal services. Specifically, several residents on puree diets received mashed potatoes instead of whipped sweet potatoes when the facility ran out of the latter, and some residents on regular diets were served portions of roasted turkey that exceeded the prescribed three ounces. Additionally, residents on soft and bite, minced and moist, and puree diets received incorrect scoop sizes for mashed potatoes and meatloaf, resulting in deviations from the planned portion sizes. Two residents on finger food diets were served cut-up red potatoes instead of tater tots and whole meatloaf patties instead of meatloaf bites, contrary to the menu requirements. These deficiencies were identified through direct observation of meal service, staff interviews, and review of facility documents such as diet spread sheets and meal tickets. The dietary staff, including the Day Cook and Kitchen Supervisor, confirmed during interviews that incorrect scoop sizes and substitutions were used, and that menu items were not always prepared as required. The Registered Dietitian also acknowledged that the expectation is to follow the menu and portion sizes as approved. The affected residents were on a variety of specialized diets, including puree, nectar thick, soft and bite, minced and moist, and finger food diets, each with specific nutritional and consistency requirements. The failure to adhere to the approved menu and portion sizes had the potential to result in residents not receiving the Registered Dietitian's approved menu, which could impact their nutritional status and overall clinical condition.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the storage and labeling of drugs and biologicals. During inspection, it was found that when the medication storage refrigerator temperature was recorded as out of range, there was no documentation that maintenance was notified, no record of temperature adjustment, and no evidence that the temperature was rechecked within the required timeframe. The maintenance logbook did not contain any entries regarding the incident, and the Assistant Director of Nursing confirmed the lack of documentation and follow-up. Additionally, temperature logs for medication storage rooms and refrigerators were found to have multiple missing entries for both May and June. In some cases, entire shifts lacked temperature checks, and on one occasion, two different temperatures were circled for the same day, making it impossible to determine the correct reading. The facility's policy requires daily temperature checks for storage rooms and twice-daily checks for refrigerators, but these were not consistently performed or documented. Further deficiencies were observed in the labeling of medications and supplies. An insulin pen for a resident was found in the medication cart without an open date or expiration date, making it impossible to verify its usability according to policy. Similarly, a blood glucose test strip container lacked an open date, contrary to manufacturer instructions and facility policy, which require such labeling to ensure the strips are used within their effective period. These lapses resulted in medications and supplies not being safely stored or tracked to ensure their integrity.
Failure to Ensure Dietary Staff Competency and Adherence to Portion Sizes
Penalty
Summary
The facility failed to ensure that food and nutrition service staff had the appropriate competencies and skill sets to safely and effectively carry out their duties. During an observation, a dietary aide was seen preparing peanut butter and jelly sandwiches and tuna sandwiches for residents without using the required portion sizes or measurement tools, instead spreading ingredients by sight with a spatula. The dietary aide confirmed she had not used measurements and had only worked at the facility for three months. Facility recipes specified exact amounts for each sandwich, such as 1/4 cup of peanut butter and a #16 scoop of tuna, but these instructions were not followed during preparation. Further review of the dietary aide's personnel file revealed previous performance issues, including incomplete logs and improper food storage, for which educational information had been provided. The facility's orientation checklist was completed, but there were no job-specific competency assessments documented. The kitchen supervisor stated that competency is determined through preceptor training, but acknowledged that the aide had limited training due to illness and that no written competency checklist or 90-day evaluations were completed. Facility policies required adequate training and periodic written, competency-based evaluations for food and nutrition staff, but these were not implemented as required.
Failure to Maintain Infection Control for Oxygen Equipment
Penalty
Summary
Surveyors observed multiple failures in infection control practices related to oxygen therapy equipment for three of ten sampled residents. In one instance, oxygen tubing with a nasal cannula attached was found on the floor of a resident's room, connected to an oxygen concentrator. A licensed nurse confirmed that the tubing and cannula should have been stored in a plastic bag when not in use and labeled with the date opened, but acknowledged that these procedures were not followed. Additionally, oxygen tubing for two other residents was found without any date labeling, contrary to facility policy which requires tubing to be labeled with the date opened and changed every seven days. Licensed nursing staff confirmed that the required labeling was missing and should have been completed at the time the tubing was opened. These lapses were directly observed and confirmed by staff during the survey.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the walk-in freezer in safe operating condition, as evidenced by multiple observations of ice buildup and physical damage. During an initial kitchen tour, condensation was noted on the lower half of the freezer door, the baseboard was lifted and bent, and the tile flooring was cracked along the baseboard. Ice was present on the floor, lower back shelves, and on pipes near the condenser. These issues were consistently documented in the Registered Dietitian's sanitation audits from January through June, which noted a torn freezer seal, ice buildup, a loose threshold, and a door that did not close tightly. In June, the audit described the freezer as 'snowing.' Interviews with the Kitchen Supervisor and Maintenance Director confirmed ongoing awareness of these issues. The Kitchen Supervisor reported that ice in the freezer reappears within two hours of being cleaned and that maintenance is regularly informed about the pipe at the ceiling. The Maintenance Director stated that the freezer is defrosted monthly and that coils and condensers are wiped down, but acknowledged the presence of gaps and cracked tiles. The FDA Food Code was referenced, indicating that physical facilities should be maintained in good repair.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that one certified nursing assistant (CNA) received the required 12 hours of annual in-service training, which must include dementia management and abuse prevention and reporting. During an interview and record review with the Director of Staff Development, it was confirmed that the CNA, who was employed at the facility during the relevant years, did not complete the mandated in-service training for the year 2024. This deficiency was identified through a review of the CNA's Individual In-service Attendance Record, which showed the absence of the required training hours and topics for that year.
Failure to Update PASARR Screenings for Residents
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASARR) Level I screening when required for two residents. Resident #45 was admitted with a medical history of dementia, psychosis, and anxiety, and had a PASARR Level I screening indicating a 30-day exempted hospital discharge. However, a new PASARR was not completed after the resident remained in the facility beyond 30 days. Interviews with the Nursing Supervisor, Corporate Compliance Officer, and Administrator confirmed that a new PASARR should have been conducted. Resident #41 was admitted with major depressive disorder, anxiety, and psychosis. The resident received new diagnoses of unspecified psychosis and anxiety disorder, but no new PASARR Level I screening was completed following these new diagnoses. Interviews with the Admissions Coordinator and Corporate Compliance Officer indicated that the Director of Nursing was responsible for the PASARR process, and a new PASARR should have been completed when the resident received new mental illness diagnoses.
Failure to Report Medication Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the consultant pharmacist reported medication regimen irregularities to the physician for the extended use of as-needed psychotropic medications for five residents. The facility's policy required the consultant pharmacist to review each resident's drug regimen monthly and report any irregularities to the attending physician, medical director, and director of nursing. However, the pharmacist did not report the lack of stop or discontinue dates for as-needed antianxiety medications prescribed to these residents. The residents involved had severe cognitive impairments and were receiving antianxiety medications such as alprazolam and lorazepam without specified stop dates. For instance, one resident had an order for alprazolam as needed every eight hours, and another had an order for lorazepam as needed every six hours. Despite these ongoing prescriptions, the consultant pharmacist's reviews did not identify any irregularities in the medication regimens for these residents during the specified timeframes. During an interview, the consultant pharmacist acknowledged reviewing each resident's chart monthly and submitting recommendations. However, she admitted that she did not consider the duration or stop dates for as-needed psychotropic medications when making recommendations. This oversight led to the failure to report potential medication regimen irregularities, as required by the facility's policy.
Failure to Specify Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were not ordered for more than 14 days for five residents. These residents had physician orders for lorazepam, an antianxiety medication, without a specified stop or discontinue date. The facility's policy required that each resident's drug regimen be free from unnecessary drugs, including those used for excessive duration, and that the attending physician document the rationale for any extended time period in the medical record. Resident #54, admitted with a history of dementia, anxiety, and major depressive disorder, had a physician order for lorazepam without a stop date. Similarly, Resident #115, with intact cognition and a history of anxiety and major depressive disorder, also had an order for Ativan without a specified duration. Other residents, including Resident #43 with severe cognitive impairment, Resident #49 with a history of anxiety and psychosis, and Resident #45 with dementia and anxiety, all had similar orders for antianxiety medications without stop dates. Interviews with facility staff revealed a lack of awareness regarding the requirement for stop dates on as-needed psychotropic medications. The pharmacist did not consider the duration or stop dates when reviewing medication orders, and the Chief Compliance Officer and Social Services Director were unsure if a stop date was necessary. The Administrator believed that if a physician deemed the medication necessary, a stop date was not required, indicating a misunderstanding of the facility's policy and regulatory requirements.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for residents with urinary catheters and pressure ulcers, as observed during a survey. Specifically, the facility did not use the required gown and glove precautions during high-contact care activities for three residents. Resident #117, who had stage 3 pressure ulcers, did not receive care with EBPs during wound care provided by the Nurse Practitioner and Infection Preventionist. Similarly, Resident #40, who had an indwelling urinary catheter, did not receive catheter care with EBPs from two Certified Nursing Assistants. Additionally, Resident #1, with a stage 3 pressure ulcer, did not receive wound care with EBPs from a Licensed Vocational Nurse and a Certified Nursing Assistant. Interviews with staff revealed a lack of awareness and training regarding EBPs. LVN #1 and CNA #3 were unfamiliar with EBPs, and LVN #2 had not been trained on them. The Infection Preventionist also confirmed that staff had not been educated on EBPs. The facility's Administrator acknowledged a misunderstanding of the Centers for Medicare & Medicaid memo regarding EBPs, which led to the failure in implementing the necessary precautions. The Chief Operating Officer confirmed that EBPs had not been implemented in the facility.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Ombudsman when a resident was transferred to the hospital, as required by their policy. The policy mandates that before a resident is transferred or discharged, the resident and their representative(s) must be notified, and a copy of the notice must be sent to the Office of the State Long-Term Care Ombudsman. This notice should be in writing and include the reason for the transfer. However, the review of Resident #63's medical record showed no evidence that the Ombudsman was notified of the transfer to the hospital. Resident #63, who was admitted to the facility with a medical history of sepsis and alcoholic liver disease, had a moderate cognitive impairment as indicated by a BIMS score of 10. The resident was transferred to the hospital for evaluation and treatment based on a physician's order. Interviews with the facility's Administrator and Medical Records Supervisor revealed that the facility was not notifying the Ombudsman at the time of resident transfers or discharges, contrary to the facility's policy. The Ombudsman confirmed that they were not notified of resident transfers or discharges unless there was something unusual.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASARR) Level I screening for a resident upon admission. The resident, who was admitted on May 14, 2020, had a medical history that included major depressive disorder, anxiety, and psychosis. However, the PASARR Level I screening document dated May 15, 2020, incorrectly indicated that the resident did not have a mental disorder diagnosis. This discrepancy was identified during a survey, where it was noted that the PASARR should have reflected the resident's mental health diagnoses. Interviews with facility staff revealed that the Admissions Coordinator only ensured the PASARR was received from the hospital and did not verify its accuracy. The Director of Nursing (DON) was identified as the person responsible for ensuring the PASARR's accuracy, but was unavailable for an interview. The Nursing Supervisor and Corporate Compliance Officer confirmed that the PASARR was incorrect and should have captured the resident's diagnoses of depression, anxiety, and psychosis. The Administrator also acknowledged that the DON was responsible for reviewing the PASARR for accuracy and that a new PASARR should have been completed if inaccuracies were found.
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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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Nursing homes near Templeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coastal Oaks Special Care Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Bayside Care Center | 14.2 mi | ★★★★★ | 4 | 0 |
| San Luis Transitional Care | 19.7 mi | ★★★★★ | 7 | 0 |
| San Luis Post Acute Center | 20.3 mi | ★★★★★ | 1 | 0 |
| Mission View Health Center | 20.4 mi | ★★★★★ | 7 | 0 |
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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 June 2026) and official state health department websites.