Health inspection·February 20, 2025

F 0692 oxygen], severe dehydration and hyperkalemia with AKI [acute kidney injury] . Level of Harm - Minimal harm or potential for actual harm During an interview on 2/11/25, at 1:24 p.m., Certified Nurse Assistant (CNA) 1 stated fluid intake was checked if there was an order in the resident's chart. CNA 1 further stated generally there was no charting of fluid intake. Residents Affected - Few During an interview on 2/11/25, at 1:55 p.m., Licensed Nurse (LN) 1 stated there would be an order in the resident's chart if a resident's intake and output (I&O) needed monitoring. During a concurrent interview and record review on 2/11/25, at 2:27 p.m., LN 2 confirmed Resident 1 did not have a physician order to monitor her intake and output. LN 2 stated Resident 1 was at risk of dehydration due to her refusal to eat or drink. LN 2 further stated she was not sure how intake and output was monitored for residents at the facility who had no order in place. LN 2 explained that monitoring I&O's would be a preventative measure and helpful for nurses to monitor for dehydration. During a concurrent interview and record review on 2/11/25, at 4:27 p.m., LN 3 confirmed Resident 1 was not on a fluid restriction. LN 3 stated only residents with a fluid restriction had their I&O monitored. LN 3 further stated there was no standard for monitoring I&O in the facility. During an interview on 2/12/25, at 1:12 p.m., the Medical Records (MR) stated the feature to monitor a resident's I&O used to be part of the facility's electronic health record system but was no longer available due to a corporate change. The MR further stated staff would only monitor the I&O if there was specific order for it. The MR stated she was not sure how a resident's input and output was monitored. During a concurrent interview and record review on 2/20/25, at 10:58 a.m., with LN 4, Resident 1's EHR was reviewed. LN 4 confirmed Resident 1 was not being monitored for I&O. LN 4 stated it was possible for Resident 1 to get dehydrated due to her behavior of refusing her meals. LN 4 further stated not monitoring I&O's was a risk for dehydration. LN 4 further confirmed Resident 1's reason for admission to the hospital on 6/13/24 meant Resident 1 was dehydrated. LN 4 stated Resident 1's dehydration could have been prevented with close I&O monitoring. During a concurrent interview and record review on 2/20/25, 3:51 p.m., with the Director of Nursing (DON), Resident 1's EHR was reviewed. The DON confirmed Resident 1 was at risk for dehydration. The DON further confirmed only meal percentages were documented, and no fluids were measured for Resident 1's fluid intake. The DON explained the RD's calculated recommendation for Resident 1's fluid intake was not followed because Resident's fluid intake was not monitored. The DON stated the amount of fluid Resident 1 drank in the facility could not be determined because fluid intake was not monitored. The DON further stated she expected the RD to review the resident's meal intakes, refusals, and medical history to determine if I&O's needed to be monitored for Resident 1. The DON confirmed no labs were ordered for Resident 1. The DON stated the MD should have ordered labs due to Resident 1's poor oral intake. The DON further stated the risk for not monitoring I&O's included patient safety, decline, and being transferred to the hospital. During a phone interview on 2/21/25, at 9:28 a.m., the RD stated fluid intake was not monitored for the residents. The RD further stated the overall percentage for the total meal documented by staff included the fluids a resident drank with meals. The RD stated the risk for not monitoring fluid intake would be dehydration and a decline in health. The RD further stated that the MD was the one to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555355 If continuation sheet Page 2 of 3 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 02/20/2025 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)

F 0692 determine if a resident needed their I&O's monitored. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 2/21/25, at 3:48 p.m., the Medical Doctor (MD) 1 stated Resident 1 was at risk for dehydration due to her history of refusing to eat or drink. MD 1 further stated I&O monitoring should be routinely monitored as protocol at nursing homes. MD 1 explained the LN or CNA should document the amount a resident ate or drank in the facility. MD 1 stated the elderly could get dehydrated right away. MD 1 further stated the facility could do a better job in documenting the fluid intake for residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555355 If continuation sheet Page 3 of 3