Other·February 15, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during a RECERTIFICATION survey. Representing the California Department of Public Health: 29470 HFEN RN, 36067 HFEN RN, 38831 HFEN RN, 37398 HFEN RN, 39603 HFEN RN Capacity: 99 Census: 95 Sample: 20 The following Facility Reported Incidents (FRI) was investigated during the RECERTIFICATION survey: Representing the Department of Public Health: 36067 HFEN RN. FRI CA00560498: Substantiated, refer to F 760. FRI CA00529876: Unsubstantiated. The following Complaint was investigated during the RECERTIFICATION survey: Complaint CA00569048: Unsubstantiated. Representing the Department of Public Health: 36067 HFEN RN.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/12/2018 §483.45 Pharmacy Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 1 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview, and record review, the facility failed to implement their policy for pharmaceutical services to meet the needs of each resident when one of two injectable (medication given into the skin) emergency drug kits (E-kits) was expired. This failure had the potential for residents to receive expired medications which could FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 2 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prevent the effectiveness of treatment. Findings: On 1/11/18 at 9:30 a.m., during a concurrent observation and interview in the medication room on station one, an E-Kit was secured with two red plastic strips. The Director of Nursing (DON) stated an unopened E-kit would have two green strips, "The red plastic strips indicates the E-kit has been opened." Taped on the outside of the E-Kit was a document titled, "Injectable Emergency Drug Kit." The document indicated an expiration date of 11/1/17 on the upper right corner. The DON stated the E-Kit was expired. On 1/11/18 at 10:10 a.m., during a concurrent observation and interview in the medication room on station one, a 10 mg (milligram)(unit of measurement)/(per) ml (milliliter)(unit of liquid measurement) vial (a small glass container) of Vitamin K (a medication to clot blood) indicated an expiration date of 1/11/17. The Consultant Pharmacist (CP) opened the expired E-kit and stated the Vitamin K was expired. The CP stated she checked the E-Kits in the facility on a monthly basis for expiration dates, "I should have caught it [expired E-Kit], but I missed it." On 1/11/18 at 10:18 a.m., during a concurrent observation and interview in the medication room on station one, the DON removed a document from inside the opened E-Kit. The document was titled, "Emergency Drug/Contingency Supply Form (form used when nursing staff remove the medication)," which indicated on 1/5/18, a 1 gm (gram)(unit of measurement) vial of Ceftriaxone (an antibiotic used to treat and prevent infections) had been removed by a nurse. On 1/12/18 at 7:00 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 3 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the DON stated the nurse who opened the E-kit on 1/5/18, should have called the pharmacy and had the E-Kit replaced. The facility policy titled, "Emergency Medication Supplies" dated 1/1/13, indicated, "...12.1 Facility should ensure that Emergency Medication Supplies remain in the nursing unit until either an item is withdrawn or one of it's contents is about to expire... Facility should contact Pharmacy for a replacement..." The facility document titled, "Injectable Emergency Drug Kit" undated, indicated, ..."STOP~ONCE KIT HAS BEEN OPENED FAX ORDER FOR REPLACEMENT KIT TO PHARMACY."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 02/20/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 4 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 25) was free from unnecessary medications when the resident was administered an antipsychotic (a class of medications administered for the treatment of a serious mental disorder) without resident specific behaviors identified for objective monitoring on Resident 25's physician order or in Resident 25's careplan. This failure placed the resident at risk for receiving an antipsychotic medication without FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 5 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE adequate monitoring for the effectiveness of the medication. Findings: On 1/10/18 at 7:38 a.m., during an observation, Resident 25 sat in a wheelchair in the dining room. Resident 25 ate breakfast independently. On 1/10/18 at 9:00 a.m., during an observation, Resident 25 sat quietly at the nurse's station in her wheelchair. Resident 25 was neatly dressed and groomed. On 1/12/18 at 8:30 a.m., during an interview and concurrent record review, the Director of Nursing (DON) reviewed Resident 25's record and was unable to find documentation of resident specific behaviors identified to monitor for the use of the antipsychotic, Olanzapene (a medication used to treat a serious mental disorder). The DON reviewed Resident 25's physician orders and care plans and stated there were no documented resident specific behaviors identified for staff to monitor. The DON stated when a resident was initially admitted, the resident was monitored for a "blanket list" of behaviors because the staff don't know the resident. The DON stated, "We don't really have specific behaviors, [we] monitor for all behaviors." The DON stated the Interdisciplinary Team (IDT) (a team consisting of various department staff who are involved with the plan of care for a resident) reviewed, on admission and on a quarterly basis, behaviors documented for a resident. The DON stated the IDT then decided on the specific behaviors to be monitored for that particular resident. The DON stated Resident 25 should have had specific behaviors identified. The DON stated the resident was taking Olanzapine prior to her admission to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 6 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 25's admission assessment titled, "IDT Admission Assessment..." dated 10/17/17, indicated, "I. Psychotropics...2. Behaviors noted: no new behaviors noted at this time... 4. Psychotherapeutic [treatment of mental disorders] medication: OLANZapine Tablet 5 MG [milligram] [a unit of measure] 1 tablet by mouth at bedtime 4a. If med not new, note length of time used and why: [no documentation recorded]...10. IDT evaluation of behavior and / or current psychotropic medications (rationale to continue / reduction plan): will review need of medication." Review of Resident 25's clinical record indicated Resident 25 was admitted on 10/16/17. The Consultant Pharmacist's (CP) recommendation dated 11/1/17 through 11/26/17, indicated, "Recommendation: Please clarify indication for olanzapine 1) The specific diagnosis/indication requiring treatment...2) The symptom criteria or behavior..." The consultant pharmacist's recommendation was signed by the physician on 12/3/17. Review of Resident 25's physician orders dated 12/4/17, indicated, ""OLANZapine Tablet 5 MG Give 1 tablet by mouth at bedtime for Behavioral/psychological symptoms of dementia [a persistant or chronic disorder of the mental processes caused by brain disease or injury marked by memory disorders, personality changes and impaired reasoning]." Review of Resident 25's physician orders dated 12/4/17, did not indicate resident specific behaviors to monitor for the use of the medication,Olanzapene. On 1/12/18 at 8:54 a.m., during an interview, the facility Consultant Pharmacist (CP) stated she had made a recommendation in November 2017 for Resident 25's physician to specify a diagnosis for the use of the antipsychotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 7 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication and also to identify the specific behaviors exhibited by the resident to monitor. The pharmacist stated she should have identified the lack of a specific diagnosis and specific behaviors for monitoring prior to November 2017. The CP stated monitoring of behaviors was important in evaluating the effectiveness or need for the antipsychotic. The CP stated without monitoring specific behaviors it was difficult to justify the need or continued use of the antipsychotic. Without behavior monitoring, can't assess if she [Resident 25] needs an antipsychotic." The CP stated the number of behavioral incidents of the resident should be available to the MD (Medical Doctor), Pharmacist and staff on a monthly basis so the resident did not receive an unnecessary medication.

F760 SS=G Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 02/20/2018 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure medication administered to residents was free of significant errors for one of 20 sampled residents (Resident 36) when Resident 36's physician ordered 7.5 milligrams (mg), (unit of measurement) of Coumadin (a medication which decreases the ability of blood to clot) and Resident 36 was administered Coumadin 12.5 mg. This failure resulted in administration of an incorrect dose of Coumadin to Resident 36 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 8 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE development of gastrointestinal (GI, pertaining to the stomach and the intestines) bleeding which required transportation to the General Acute Care Hospital (GACH) and transfusion of five units of blood. Findings: Review of Resident 36's clinical record titled, "Admission Record" (document containing resident personal information) indicated Resident 36 was admitted to the skilled nursing facility (SNF) on 10/26/17 with diagnoses that included End Stage Renal Disease (kidney failure), Type 2 Diabetes Mellitus (disorder which causes high blood sugar due to insufficient production of the hormone insulin which regulates blood sugar), and Muscle Weakness. Review of Resident 36's clinical record titled Minimum Data Set (MDS, a resident assessment tool used to plan care) dated 11/2/17, indicated Resident 36 had a Brief Interview for Mental Status (BIMS) score of 15 points out of a possible 15 points which indicated he was able to be understood, able to answer questions, knew the day, month and year and had good recall of recent information. On 11/22/17 at 8:55 a.m., during an interview and concurrent record review, the SNF Director of Nursing (DON) reviewed Resident 36's record and stated Resident 36's Medical Doctor (MD) ordered Coumadin 5 mg one time a day on 10/31/17 for prevention of deep vein thrombosis (DVT, development of a blood clot in a blood vessel). The DON stated the MD ordered blood tests on 10/31/17 to monitor for the safety and effectiveness of the Coumadin dosage. The DON stated the blood tests were ordered to be done every Monday, Wednesday and Friday and included prothrombin time (PT, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 9 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a blood test used to determine how long it takes the Resident's blood to clot and if the dosage of Coumadin is at a safe and effective level) and International Normalized Ratio (INR, a blood test used to determine the effectiveness and safety of Coumadin therapy). The DON stated Resident 36's MD wanted Resident 36's INR value to stay between 2.0 and 3.0 as an indication of safe and effective Coumadin therapy. The DON reviewed Resident 36's clinical record and indicated the following PT and INR results and medication adjustments: 11/1/17 PT 12.5 INR 1.0 Coumadin increased to 7.5 mg for two days starting 11/2/17 and then resume 5 mg daily 11/3/17 PT 15 INR 1.2 Coumadin 7.5 mg daily then resume 5 mg dose on 11/5/17 11/5/17 Coumadin 5 mg daily 11/6/17 PT 35.7 INR 3.0 daily 11/7/17 Coumadin 7.5 mg Coumadin 7.5 mg daily 11/8/17 PT 94.7 INR 7.9 administered No Coumadin The DON stated on 11/7/17 Licensed Nurse (LN) 1 had not realized Coumadin 5 mg was discontinued and the dosage changed to 7.5 mg daily. The DON stated on 11/7/17 LN 1 gave both the discontinued dosage of 5 mg of Coumadin and the new order for 7.5 mg of Coumadin for a total dose of 12.5 mg of Coumadin. The DON stated the error was discovered by the Assistant Director of Nursing (ADON) during clinical review on 11/8/17. The DON stated Resident 36's MD was notified of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 10 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the error on 11/8/17 because the extra dose of Coumadin placed Resident 36 at risk for bleeding. The DON stated on 11/9/17 Resident 36 had "coffee ground emesis" (vomited blood that resembles coffee grounds) and was sent to the GACH for evaluation. The DON stated the medication error occurred for two reasons. The DON stated first reason for the medication error was on 11/6/17 LN 2 transcribed the new order for Coumadin 7.5 mg one time a day but did not discontinue the order for Coumadin 5 mg one time a day. The DON stated LN 2 should have reviewed the record to see if there was a previous Coumadin order, but did not. The DON stated the medication administration record for 11/7/17 showed Coumadin 5 mg one time a day scheduled at 4 p.m. and Coumadin 7.5 mg one time a day scheduled at 8 p.m. The DON stated on 11/7/17 LN 1 administered two doses of Coumadin; Coumadin 5 mg at 4 p.m. and Coumadin 7.5 mg at 8 p.m. The DON stated LN 1 did not question why Resident 36 had two doses of Coumadin scheduled on the same day. The DON stated her expectation was LN 1 should double check the order for Coumadin and question why Resident 36 had two orders for Coumadin. On 11/22/17 at 10:10 a.m., during an interview, the ADON stated the administration of 12.5 mg of Coumadin instead of the ordered 7.5 mg of Coumadin on 11/7/17 was a significant medication error because it placed Resident 36 at high risk for bleeding. The ADON stated adverse outcomes of the excessive dose of Coumadin could include bleeding, hypotension, (low blood pressure), weakness and lethargy (feeling very tired). The ADON stated LN 1 should have clarified the Coumadin order with Resident 36's MD because Coumadin 12.5 mg was a very high dose of Coumadin. On 11/22/17 at 10:35 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 11 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LN 3 stated the extra dose of Coumadin given to Resident 36 on 11/7/17 could have placed Resident 36 at risk for bleeding. LN 3 stated Coumadin administered at the SNF was routinely ordered for 8 p.m. LN 3 stated the Coumadin medication error occurred because there were two orders of Coumadin in place scheduled at different times. LN 3 stated LN 1 should have seen there were two orders for Coumadin and clarified the orders with Resident 36's MD. On 11/22/17 at 11 a.m., during a telephone interview, LN 1 stated on 11/7/17 she administered two doses of Coumadin to Resident 36; Coumadin 5 mg at 4 p.m. and Coumadin 7.5 mg at 8 p.m. LN 1 stated Resident 36 received a total of 12.5 mg of Coumadin on 11/7/17. LN 1 stated on 11/7/17 the Medication Administration Record (MAR) indicated Coumadin 5 mg was scheduled at 4 p.m. and Coumadin 7.5 mg was scheduled at 8 p.m. LN 1 stated she should have questioned the order and clarified the order with Resident 36's MD. LN 1 stated at 8 p.m. she forgot she gave Resident 36 Coumadin 5 mg at 4 p.m. and she gave Resident 36 Coumadin 7.5 mg. LN 1 stated the extra dose of Coumadin given to Resident 36 on 11/7/17 placed Resident 36 risk for bleeding. LN 1 stated 12.5 mg of Coumadin was a high dose of Coumadin. On 11/22/17 at 11:25 a.m., during a telephone interview, LN 2 stated she received the order for Coumadin 7.5 mg once a day from Resident 36's MD on 11/6/17. LN 2 stated she didn't know there was also an active order for Coumadin 5 mg once a day at 4 p.m. LN 2 stated she transcribed the new order for 7.5 mg of Coumadin but didn't discontinue Coumadin 5 mg scheduled at 4 p.m. LN 2 stated she should have double checked the orders but she didn't. LN 2 stated the extra dose of Coumadin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 12 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE given to Resident 36 placed Resident 36 at risk for bleeding and over dosage of Coumadin could even cause death. On 12/19/17 at 2:15 p.m., during a telephone interview, the SNF Consultant Pharmacist (CP) stated she was informed on 11/6/17 that Coumadin 5 mg was discontinued. The CP stated LN 1 administered two doses of Coumadin on 11/7/17; Coumadin 5 mg at 4 p.m. and Coumadin 7.5 mg at 8 p.m. The CP stated Resident 36 received a total of 12.5 mg of Coumadin on 11/7/17. The CP stated the increased dosage of Coumadin could possibly contribute to bleeding problems. On 12/22/17 at 11 a.m., during a telephone interview, Resident 36's MD stated he ordered Coumadin 7.5 mg on 11/6/17; not both 7.5 mg and 5 mg of Coumadin. The MD stated Coumadin was a blood thinner and increased the risk for bleeding. The MD stated he was informed that Coumadin 5 mg was discontinued on 11/6/17 but LN 1 administered two doses of Coumadin on 11/7/17; Coumadin 5 mg at 4 p.m. and Coumadin 7.5 mg at 8 p.m. Resident 36's clinical record titled, "[SNF] Order Summary Report" dated 10/31/17 indicated " ...PT/INR In House [perform the lab test within the SNF] every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday], For Coumadin Therapy. Keep INR between 2.0 3.0. Notify MD if INR is out of therapeutic range ..." Resident 36's "Order Summary Report" indicated, "Coumadin Tablet 7.5 mg. Give 7.5 mg by mouth on time a day for DVT prevention. Order date 11/6/17. Start Date 11/6/17. End date 11/8/17." Resident 36's clinical record titled, "Progress FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 13 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Notes" dated 11/8/17 at 11:30 a.m., indicated, "This writer was made aware of current INR taken minutes ago of 7.9. Upon further investigation appears resident received 12.5 mg total of Coumadin on last night shift 11/7/17. MD notified, resident stable. No s/s [signs or symptoms] of bleeding ...Orders to hold all Coumadin until INR is within parameter of 2.0 - 3.0. Continue with PT/INR check MWF [Mondays, Wednesdays and Fridays] ...Monitor closely for any s/s of bleeding." The progress note was electronically signed by the ADON. Resident 36's "Progress Notes" dated 11/9/17 at 1:11 a.m. indicated, "Patient [Resident 36] noted with coffee ground emesis and hypoxic [low oxygen levels], notified [MD] and obtain order for [MD] for acute transfer for eval [evaluation] and treat [treatment]." Resident 36's GACH clinical record titled, "[GACH] ED- [Emergency Department] Physician Final Report," dated 11/9/17, indicated "...Chief complaint: From [SNF] via [transported by] ambulance...more frequent apnea [breathing stops] periods per staff. Also reported coffee ground emesis prior to transport with possible aspiration [vomit enters the lungs]. Pt [Resident 36] takes Coumadin, none x (times) 2 days for INR 7.9...History of Present Illness...Patient [Resident 36] presents with altered mental status. The onset was 1 day ago...The character of symptoms is disoriented [does not know who he is, where he is or what day it is]. Baseline status [Resident 36's normal mental status] A&O x 3 [alert and oriented to person, time and place]...INR today elevated greater than 6.7...Noted melanotic [blood in the stool giving it a tarry appearance] stool ..." Resident 36's GACH clinical record titled, "Admission H&P [History and Physical] dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 14 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/10/17 at 10:30 a.m., indicated, "Chief Complaint: direct admission from SNF, low Hb [hemoglobin, part of the red blood cell that carries oxygen to the tissues of the body, a low result can be an indicator of blood loss, normal range is 14 - 18 mg/dl (milligrams per deciliter, a measurement of the amount of the hemoglobin molecule in a volume of blood)] at 4.8 [mg/dl], INR 7.8, coffee ground emesis, melena [dark sticky feces containing partly digested blood]...History of Present Illness : pt [patient] obtunded [difficult to wake up or obtain any response from]...ED Course: transfusion [blood transfusion] protocol initiated ... Vitamin K [medication used to treat over dosage of Coumadin] x 1 dose...Assessment: Anemia [low red blood count] secondary to acute blood loss...Supratherapeutic INR [INR results indicate Coumadin therapy is at a much higher than therapeutic dosage]...Coffee ground emesis...Dispo [Disposition] guarded, remain in ICU [intensive care unit]..." Resident 36's GACH clinical record titled, "[GACH] History and Physical," dated 11/10/17, indicated "...Patient [Resident 36] is 61 y/o [year old] male with h/o [history of] ESRD on HD [Hemodialysis, a treatment to replace the functions of the kidney when kidney failure has occurred] admitted with confusion, melena, emesis. Acute Blood Loss: due to GI bleed ...Coagulopathy [disorder of blood clotting] / Supratheraputic INR..." Resident 36's GACH clinical record titled, "[GACH] Final Report, Endoscopy [a procedure in which an instrument is introduced into the body to obtain a view of its internal parts]" dated 11/11/17, indicated "...duodenal ulcer [a crater-like wound in the lining of part of the small intestine]...Suspect that the ulcer bled primarily because of his being placed on Coumadin and the INR supratherapeutic on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 15 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555355 (X3) DATE SURVEY COMPLETED 01/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VINTAGE FAIRE NURSING & REHABILITATION CENTER 3620 Dale Rd Modesto, CA 95356 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admission." Resident 36's GACH clinical record titled, "[GACH] Discharge Summary" dated 12/1/17 indicated, "...Diagnosis ...Acute [sudden onset] duodenal ulcer with bleeding-patient admitted into ICU and received 5 units of packed red blood cells [transfusion of 5 measured bags of blood] ..." Review of professional reference, Pagnana, Kathleen. "Mosby's Diagnostic and Laboratory Test Reference, ninth edition." St. Louis: Mosby Inc., 2009, indicated, "Possible Critical Values: INR: greater than 5.5...Possible critical values: these values give an indication of results that are well outside the range of normal. These results require physician notification and usually result in some type of intervention." Review of the SNF policy and procedure titled, "Medication Administration Operating Guideline" dated 12/2013, indicated, "1...Administer medications using 5 rights, right dosage...Watch for odd orders..." The SNF policy and procedure titled, "Job Description / Performance Evaluation" undated, indicated, "Job title LVN/LPN [Licensed Vocational/Practical Nurse]...Takes, transcribes, and carries orders in accordance with professional standards...Clarifies incomplete, unclear, or atypical orders and instructions accordingly...Administers and safely monitors Coumadin Therapy..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L95B11 Facility ID: CA030000851 If continuation sheet 16 of 16