Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Vineyards At Concord, The during CMS and state inspections, most recent first.
Surveyors found that during a lunch meal, pork and sauerkraut intended for residents on regular diets were prepared and served in a mechanically textured form to multiple residents whose orders specified regular diets. A dietary staff member stated she routinely prepares the meat this way so all residents receive similar-looking portions and to reduce choking risk, and also reported using milk in the pureed pork and sauerkraut to add calories and nutrients. Record review confirmed that numerous affected individuals were on regular diets, and facility leadership acknowledged that serving mechanically textured meat to these residents and not following the established puree recipe was inappropriate.
Surveyors found that two residents with severe cognitive deficits and multiple chronic conditions, both dependent on staff for personal hygiene per their MDS and care plans, had long, jagged, and visibly dirty fingernails with brown material under the nail beds on repeated observations. Care plans for ADL self-care deficits and altered ADL function included staff responsibility for checking, trimming, cleaning nails, and assisting with ADLs, yet these interventions were not carried out. The DON confirmed the poor nail condition for both residents, and the LNHA acknowledged there was no facility policy addressing nail care.
Two residents with severe cognitive impairment and documented bladder incontinence care plans were not provided routine incontinence care or scheduled toileting. One resident, always incontinent and dependent on staff for toileting and hygiene, remained seated in the dining area for many hours until staff observed that his pants were saturated with urine, confirming that incontinence care had not been provided. Another resident, also always incontinent and care planned to be toileted every two hours, remained in the dining area for an extended period without toileting; when CNAs eventually provided care, they found a brief and liner completely saturated with strong ammonia-smelling urine, and staff acknowledged the resident had not been toileted for quite some time.
Two residents with severe cognitive impairment and documented abnormal weight loss experienced significant, ongoing weight decline while the facility failed to implement a comprehensive, resident-centered nutrition plan. For one resident with Alzheimer’s and prior hospital weight loss, an RD recommended supplements, but no specific supplement order was written, weights were not consistently updated in the EHR, meal intake percentages were frequently undocumented, and multiple MD/FNP visits did not address the continued weight loss. For another resident with protein-calorie malnutrition and multiple comorbidities, there was no initial comprehensive nutrition assessment, no care plan for weight loss, and no evidence that RD-recommended house shakes twice daily were implemented, despite marked weight drops. Facility staff inconsistently documented meal intake, used a non-standardized whey protein "house supplement" instead of the RD-recommended Ready Pass for most residents, and prepared this supplement without a set recipe, while the MD was unaware of its use.
Surveyors found that the facility did not follow its Enhanced Barrier Precautions policy for two residents with invasive devices. One resident with a gastric feeding tube had tube feeding performed without gowns or gloves available in or outside the room, and no EBP orders were in place despite signage requiring gown and glove use for feeding tube care. Another resident receiving IV antibiotic therapy via a PICC/midline for pyothorax had IV medication administered by the DON, who used hand hygiene and gloves but did not don a gown or other required PPE, and the resident was not placed on EBP despite qualifying under facility policy.
Several residents with cognitive and physical impairments experienced multiple falls that were not consistently reported or investigated by staff, and individualized fall care plans were either missing or incomplete. Interventions such as alarms, low beds, and fall mats were not always documented in care plans or supported by physician orders, despite facility policy requiring these actions.
A resident with cognitive impairment and multiple health conditions experienced several injuries, including facial bruising, a swollen foot, and fractures, after reporting being punched and stomped on by another resident. Despite staff observations and the resident's statements, the facility did not report these incidents or conduct a thorough investigation as required by policy and state regulations.
A resident with cognitive impairment and a history of falls experienced multiple injuries, including a swollen foot, facial bruising, and a fractured pelvis. Despite policy requirements, the facility did not fully investigate or report these injuries, and the administrator did not submit a self-reported incident or conduct further inquiry into the causes of the injuries.
The facility failed to complete a significant change PASARR for two residents after new mental health diagnoses were added. One resident with multiple diagnoses, including schizophrenia, had a new diagnosis of unspecified psychosis, while another resident with heart failure received a new diagnosis of schizoaffective disorder. Interviews with an LPN and the DON confirmed that the necessary PASARR updates were not conducted.
The facility failed to ensure stop dates for as-needed psychotropic medications for two residents. One resident had orders for Hydroxyzine and Xanax without stop dates, while another had a topical gel containing Ativan, Benadryl, Haldol, and Reglan also lacking a stop date. The Director of Nursing confirmed these omissions during the survey.
Failure to Follow Regular Diet Orders When Serving Mechanically Textured Meat
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered diets by serving mechanically textured pork and sauerkraut to residents who were ordered regular diets. During a lunch observation, the scheduled meal of pork and sauerkraut, mashed potatoes, and bread pudding was prepared so that the pork and sauerkraut were mechanically textured and served in that form to residents on regular diets, affecting 18 residents who were ordered regular diets. The dietary associate who prepared the meal confirmed that she mechanically textures the pork so that all residents receive the same looking meat and to reduce choking hazards, and also confirmed that the pureed pork and sauerkraut were made with milk to add calories and nutrients. Review of medical records showed that these 18 residents were on regular diets, and the Administrator later confirmed that serving mechanically textured meat to residents on regular diets was not appropriate and that an existing puree recipe for the lunch meal had not been followed. This deficiency was cited under the requirement to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs and was investigated under Complaint Number 2984105.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary nail care for residents who were dependent on staff for activities of daily living (ADLs), specifically personal hygiene. One resident with severe cognitive impairment, multiple diagnoses including neuropathy, peripheral vascular disease, vascular dementia, cerebrovascular accident, and other chronic conditions had a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. Despite this, surveyor observations on two consecutive days showed the resident’s nails were long, jagged, and had a brown substance under the nail bed. The DON confirmed during interview that the resident’s nails were in need of nail care. Another resident, also with severe cognitive impairment and multiple diagnoses including hypertensive heart disease, atrial fibrillation, dementia with anxiety, Alzheimer’s disease, psychosis, and gastrointestinal conditions, had a care plan for altered ADL function. Interventions included providing set-up, supervision, cues, and assistance through completion of ADLs, encouraging participation at the resident’s optimal level, and providing oral care daily and as needed. The MDS indicated the resident was dependent on staff for toileting and personal hygiene and did not reject care. However, surveyor observations on two consecutive days found this resident’s nails were long, jagged, and dirty with a brown substance under the nails. The DON verified that the nails were in need of care, and the LNHA reported that the facility had no policy related to care of residents’ nails. This deficiency was cited under a complaint investigation.
Failure to Provide Routine Incontinence Care and Scheduled Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide routine incontinence care and toileting as outlined in residents’ care plans. One resident with severe cognitive impairment, vascular dementia, and multiple comorbidities was care planned for bladder incontinence with interventions such as establishing voiding patterns, monitoring intake and output, encouraging fluids, and monitoring for UTI symptoms. The resident was documented as always incontinent of bladder and frequently incontinent of bowel, and dependent on staff for toileting and personal hygiene. On the survey date, the resident was observed sitting at the dining room table continuously from the start of the survey in the morning until mid-afternoon. By 3:15 P.M., the resident’s pants were visibly wet near the groin, and a CNA confirmed the pants were saturated with urine and that routine incontinence care had not been provided. Another resident, also with severe cognitive impairment, dementia, Alzheimer’s disease, and multiple other diagnoses, had a care plan for actual bladder incontinence related to dementia and need for assistance with personal care. Interventions included toileting every two hours, assistance with toileting and cleansing, use of double briefs to protect dignity, provision of peri-care to maintain cleanliness and dryness, and observation for UTI signs and symptoms. The resident was assessed as always incontinent of bowel and bladder and dependent on staff for toileting and personal hygiene, with no documented refusal of care on the day in question. On that day, the resident was observed sitting at the dining room table from early morning until mid-afternoon without being toileted. When two CNAs finally provided incontinence care, they found the resident wearing a blue brief and a large liner that were completely saturated with strong ammonia-smelling urine. One CNA stated the resident was supposed to be toileted every hour and a half, and the other CNA acknowledged the resident had not been toileted for quite some time.
Failure to Assess, Monitor, and Implement Nutritional Interventions for Residents With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide a comprehensive, resident-centered plan of care to prevent, timely identify, and treat weight loss, as well as failures in obtaining, documenting, and monitoring weights, documenting meal intake, and providing and preparing nutritional supplements as ordered. For one resident with Alzheimer’s disease, generalized anxiety, and abnormal weight loss, the RD/Administrator recommended adding four ounces of a nutritional supplement between or with meals, but no specific supplement type was documented and no corresponding physician order was entered. Despite documented abnormal weight loss prior to admission and subsequent significant weight loss after admission, multiple progress notes by the FNP and the Medical Director did not address the ongoing weight loss beyond general statements to monitor weight and intake. The resident’s weight declined from 156.8 lbs. prior to admission to 132 lbs. in February and then to 125.5 lbs. in April, yet there were no physician orders for supplements as recommended by the RD, and the resident’s meal ticket did not include any nutritional supplements. The same resident’s care plan, revised later for a nutritional problem related to weight loss prior to admission, contained general interventions such as encouraging compliance with diet and medications, monitoring weights as necessary, and providing supplements when awake or when intake was less than 75 percent. However, there was no evidence that specific supplement orders were written or implemented, and the MDS assessment did not reflect the resident’s weight loss. Meal intake documentation for this resident was incomplete and inconsistent, with multiple dates where no meal percentages were recorded and unclear documentation regarding whether supplements were received or accepted. Observation during a lunch meal showed the resident receiving a sandwich and grapes in the lobby, with no supplement observed. The RD acknowledged that staff were not consistently completing meal intake documentation, and the Medical Director stated he was unaware of the severe weight loss because current weights were not updated in the electronic record, making it appear that the weight had stabilized. For another resident with multiple diagnoses including moderate protein-calorie malnutrition, osteoporosis, diabetes, delusional disorder, and a history of falls and fractures, the facility also failed to adequately assess and address nutritional needs and weight loss. This resident experienced significant weight loss from 109 lbs. on admission to 103.5 lbs. within about two weeks, and then to 102.5 lbs., with the RD documenting that the resident was underweight for age and had a 5.9 percent weight loss in 30 days. The RD recommended adding house shakes twice daily for additional calories and protein and reported that the resident was added to the supplement list, but there was no evidence in the medical record that these recommendations were implemented. The resident’s weight later dropped to 89.5 lbs., a 12.68 percent loss in five days, without documentation of a reweigh to verify accuracy. There was no initial comprehensive nutritional assessment from the first admission to determine nutritional needs, and no care plan addressing the resident’s nutritional status or weight loss. Interviews revealed that the house supplement was made from a whey protein powder blend with creatine and amino acids, prepared without a standardized recipe, and that most residents received this house supplement rather than the Ready Pass supplement the RD had recommended for residents needing nutritional support. The Medical Director was not aware the whey protein powder was being used.
Failure to Implement Enhanced Barrier Precautions for Residents With Feeding Tube and IV/PICC Line
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy and maintain appropriate infection prevention and control practices for residents with invasive devices. For one resident with severe dementia, metabolic encephalopathy, Alzheimer’s disease, essential hypertension, dysphagia, and a gastric feeding tube, surveyors observed a tube feeding procedure during which no personal protective equipment (PPE) was available either outside or inside the room, and no gown was worn. Staff confirmed that proper PPE was not worn, that no gowns or gloves were set up outside or inside the room, and that the resident did not have EBP orders in place, despite a sign on the door stating that staff must wear gloves and a gown for high-contact care activities including feeding tube care. Review of the medical record confirmed there were no physician orders for EBP for this resident. For another resident admitted with pyothorax and multiple comorbidities, including anemia, prosthetic heart valve, osteoporosis, nicotine dependence, convulsions, hyperlipidemia, depression, pleural effusion, hypothyroidism, mood disorder, atrial fibrillation, and generalized anxiety disorder, the plan of care documented a pneumonia-like condition related to empyema and ongoing IV antibiotic therapy. Physician orders included maintaining a midline IV, flushing the IV line with normal saline, assessing the midline site every shift, maintaining and changing the dressing, and administering daily IV Ceftriaxone Sodium for pyothorax. During observation of the DON administering IV Ceftriaxone via a PICC line, the DON washed her hands, administered oral medications, set up the IV medication, washed her hands again, donned gloves, flushed the line, and connected the medication, but did not don a gown or mask for EBP. In interview, the DON verified she had not used PPE for EBP and acknowledged the resident was not on EBP, although the resident should have been under the facility’s EBP policy, which requires gowns and gloves for residents with open routes to their interior body, including feeding tubes and IVs, and PPE stations set up with gowns and gloves outside or just inside the doorway.
Failure to Report, Investigate, and Care Plan for Resident Falls
Penalty
Summary
The facility failed to ensure that resident falls were properly reported, investigated, and that individualized fall care plans were in place for all residents reviewed for falls. Four residents with significant cognitive and physical impairments experienced multiple falls, yet their incidents were not consistently documented or investigated according to facility policy. In several cases, there was no evidence of incident reports or investigations following falls, and fall interventions were either missing from care plans or not supported by physician orders. One resident with Alzheimer's disease and muscle weakness experienced several falls, including sliding out of bed and a chair, but not all incidents were reported or investigated, and interventions such as a pull string tab alarm, low bed, and fall mat were not included in the care plan or physician orders. Another resident with severe cognitive impairment and physical limitations had a care plan that identified fall risk but lacked specific interventions, and a fall incident was not reported or investigated. A third resident with dementia and impaired cognition experienced a fall with no subsequent care plan or investigation, and no fall interventions were ordered by a physician. A fourth resident with Huntington's disease and a history of repeated falls was found on the floor after rolling out of bed and later fell from a specialized chair, but there was no evidence of fall investigations or care plans addressing fall risk. Staff interviews confirmed these deficiencies, and a review of facility policy indicated that falls should be investigated and care plans updated, which was not consistently done for these residents.
Failure to Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
This deficiency occurred when the facility failed to report suspected resident-to-resident abuse and injuries of unknown origin to the appropriate authorities, as required by both facility policy and state regulations. A resident with Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive, who was at risk for falls, experienced multiple injuries including a swollen and discolored right foot, facial bruising and swelling, a cut lip, and later, significant bruising and fractures to the right hand and hip. Documentation in the medical record and staff statements indicated that the resident reported being punched in the face and having her foot stomped on, and a CNA documented that the resident stated she had been hit by another resident. Despite these reports and visible injuries, the incidents were not reported to state agencies or law enforcement as required. The facility's internal investigation into the altercation between the two residents was limited. The administrator reviewed the incident and determined that no further investigation was warranted, and did not submit a Self-Reported Incident (SRI) to the state. Additionally, subsequent injuries to the resident's hand and hip were not reported or investigated as potential abuse or neglect. The facility's policy clearly required immediate notification of state officials and law enforcement in cases of suspected abuse or injury of unknown origin, but this protocol was not followed. Interviews with the administrator confirmed that the incidents were not reported because he did not consider them to be abuse, despite the resident's statements and physical injuries. The lack of reporting and investigation into these incidents resulted in non-compliance with regulatory requirements for timely reporting and investigation of suspected abuse, neglect, or injuries of unknown origin.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
This facility failed to ensure that all injuries of unknown origin were properly investigated, as required by policy. A resident with Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive, who was at risk for falls, experienced multiple injuries during their stay. The resident was admitted with moderately impaired cognition and had a care plan in place to address fall risk and safety needs. On one occasion, the resident was found with a swollen and discolored right foot and was transferred to the hospital for evaluation. Later, the same resident was noted to have facial swelling and bruising, and reported being punched in the face and having their foot stomped on. Staff documented an altercation between this resident and another, with both residents interviewed, but the investigation was limited and did not address all injuries. The administrator determined no further investigation was warranted and did not submit a self-reported incident or conduct further inquiry into subsequent injuries, including a right hand injury and a fractured pelvis. Facility policy required immediate investigation and documentation of all allegations or incidents of abuse or injury, including written statements from witnesses and involved parties. Despite this, the administrator confirmed that no investigation or report was completed for the resident's right hand injury or fractured pelvis, and the incident was not reported as required. This failure to investigate and report all injuries of unknown origin constituted a deficiency in the facility's response to alleged violations.
Failure to Complete PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a significant change Preadmission Screening and Resident Review (PASARR) for two residents following the addition of new mental health diagnoses. Resident #3, who was admitted with multiple diagnoses including hypertension, dementia, and schizophrenia, had a new diagnosis of unspecified psychosis added on 07/21/22. Despite this significant change, the facility did not complete a new PASARR designation. This was confirmed during an interview with a Licensed Practical Nurse (LPN) who verified that the new PASARR had not been completed. Similarly, Resident #7, admitted with diagnoses such as muscle weakness and heart failure, received a new diagnosis of schizoaffective disorder on 10/13/22. The quarterly Minimum Data Set (MDS) assessment indicated that the resident was rarely or never understood, yet no significant change PASARR was completed following the new diagnosis. This oversight was confirmed by the Director of Nursing (DON) during an interview, acknowledging that the necessary PASARR was not conducted for Resident #7.
Failure to Ensure Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure a stop date for as-needed psychotropic medications for two residents during the annual survey. Resident #14, who was admitted with diagnoses including anxiety disorder, had active physician orders for Hydroxyzine and Xanax, both antianxiety medications, without a specified stop date. The Director of Nursing confirmed the absence of stop dates for these medications, which were ordered on an as-needed basis. Similarly, Resident #15, admitted with Alzheimer's disease, dementia with anxiety and agitation, and depression, had an active physician's order for a topical gel containing a mixture of Ativan, Benadryl, Haldol, and Reglan to be applied every four hours as needed for agitation. This order also lacked a stop date. The Director of Nursing confirmed the absence of a stop date for this medication order as well. These findings affected two of the five residents reviewed for unnecessary medications, with the facility census being 21.
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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 Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of Valley View | 2.3 mi | — | 2 | 0 |
| National Church Residences Chillicothe | 10.7 mi | — | 11 | 0 |
| Westmoreland Place | 11 mi | — | 0 | 0 |
| Greenfield Skilled Nursing And Rehabilitation | 11.3 mi | — | 1 | 0 |
| Hopewell Grove Rehabilitation And Healthcare | 11.7 mi | — | 10 | 1 |
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