Vineyard Park at North Creek

The facility failed to ensure that the negotiated service agreements for 3 of 3 sampled residents included behavioral concerns and appropriate interventions. Residents were placed at risk of harm because staff lacked documented plans to manage aggression, limit unsafe interactions, and provide needed behavioral assistance.

The facility altered Resident 3's quetiapine by mixing it with soda without documentation or an order from a pharmacist or other authorized practitioner confirming that the medication could be safely altered.

Resident 3 refused prescribed medications on 59 occasions, but the facility did not document an evaluation of the significance or outcome of the refusals or notify the resident's physician or primary care practitioner, resulting in missed medical follow-up.

The facility failed to notify the Department in writing within ten calendar days of a change in the facility administrator.

Facility failed to secure hazardous chemicals in the Memory Care Unit (MCU) including cleaning agents and aerosol disinfectants in an unlocked cupboard.

The facility failed to ensure that pets living on the premises were certified by a veterinarian to be free of diseases transmittable to humans.

Facility failed to complete assessments related to the use of bed side rails (BSR) for residents 5, 6, and 8.

Facility failed to document necessary health support services, roles, and alternate plans for catheter management (Resident 3), wound care (Resident 4), and safety interventions for bed side rails (Resident 1).

The facility failed to ensure the resident or their representative signed the Negotiated Service Agreement (NSA) at least annually for 7 of 7 sampled residents.

Facility failed to facilitate activities at least three times a week in the Memory Care Unit, resulting in lack of structured activities observed.

The facility failed to notify a primary care physician in a timely manner to get clarification on medications, resulting in a resident going without prescribed eye drops for approximately two weeks.