Health inspection·December 12, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one of 3 sampled resident's (Resident 1) emergency contact person/s of Resident 1's change in condition (COC), when Resident 1 had a low blood sugar (BS) level, fell with resulting head injury, became unresponsive, and was sent to the hospital on [DATE]. This failure resulted in Resident 1's family being uninformed and unaware of Resident 1's COC. Findings: Review of Resident 1's admission record indicated Resident 1 was admitted to the facility in early November 2023 with multiple diagnoses including diabetes mellitus (a metabolic disease, involving inappropriately elevated blood sugar levels) with foot ulcer, difficulty with walking and mobility, need for assistance with personal care, and had a history of falling. Further review of the admission record indicated Resident 1's Family Member (FM) 1 was listed as his emergency contact #1 and power of attorney (a document outlining who is responsible for making decisions for another person) for care, and FM 2 was listed as emergency contact #2. Review of Resident 1's fall report dated 11/24/23 indicated, .This patient .had .an Un-Witnessed or Suspected Fall .Which occurred at approximately .11/24/2023 02:25 [2:25 a.m.] .Unable to communicate what occurred .Orientation Level Abnormal for this resident .Resident found on floor next to his bed .Responsible Party Notified .Self .MD Response .Transfer to Emergency Department for Evaluation . Review of Resident 1's medical record titled, SBAR [Situation Background Assessment Recommendation] COC 911 Transfer - V3 dated 11/24/23, indicated, .Situation .Patient appears to have had a hypoglycemic [low BS] episode (BS of 33) which caused him to have an unwitnessed fall with head injury. Patient was diaphoretic [sweating heavily] and unresponsive. He had a laceration [cut] above his left ear that appeared to be from fall .Transferred 911 to the hospital .Name of Family/Health Care Agent Notified .Name: [Resident 1] .Contact Type: [x]Agent [] Caregiver [] Emergency Contact [] Guardian [] Next of kin [] Personal . Review of Resident 1's medical record SNF [Skilled Nursing Facility]/NF [nursing facility] to Hospital Transfer Form dated 11/24/23, indicated, .Resident Representative . [Resident 1] Relationship .Self .Tel [Resident 1's home phone number] Notified of transfer? .Yes . Aware of clinical situation? .Yes . Further review of Resident 1's medical record failed to show that either of Resident 1's emergency (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555355 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vintage Faire Nursing & Rehabilitation Center 3620-B Dale Rd Modesto, CA 95356 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)