Health inspection·February 25, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure quality care was given to one of four sampled residents (Resident 1), when the Medical Doctor (MD) was not notified when Resident 1 had six days of low body temperature. Residents Affected - Few This failure could have contributed to Resident 1 being found unresponsive on 2/1/25 and transferred to [ACUTE CARE HOSPITAL NAME] for further evaluation and treatment in the Hospital Intensive Care Unit (ICU). Findings: During a review of Resident 1 ' s clinical record titled, admission Record (a document that contained Resident 1 ' s demographic information), indicated Resident 1 ' s diagnoses included dementia (general term for a decline in mental abilities that affects memory, thinking, and behavior), bariatric surgery (weight loss surgery), protein calorie malnutrition (health problems associated with consuming a lack of calories), and anemia (low red blood cells that resulted in low oxygen in the blood). A review of Resident 1 ' s clinical record titled, SBAR [Situation, Background, Assessment, Recommendation- a communication tool] COC [Change of Condition] 911 Transfer, dated 2/1/25 at 5:17 p.m., by Licensed Nurse (LN) 1, indicated Resident 1 was found unresponsive and starting out into space. Resident 1 ' s lungs had gurgling sounds (could have indicated fluid in the lungs), and the arms and legs were swollen (puffy). Resident 1 ' s vital signs (temperature, heart rate and respiratory rate per minute, and blood pressure) were: body temperature was low at 93.3 degrees (°) Fahrenheit (F - unit of measurement - normal range 97°F through 99°F), heart rate was low at 49 beats per minute (bpm - normal range 60 bpm-100 bpm), blood pressure was elevated at 131/89 (normal range less than 120) / (normal range is under 80). 911 (emergency help needed) was called and Resident 1 was transferred to [ACUTE CARE HOSPITAL NAME]. During a review of Resident 1 ' s clinical record titled, Weights and Vitals Summary, indicated: 1/25/25 at 2:53 p.m. - Body temperature - 96.8 °F 1/27/25 at 6:54 a.m. - Body Temperature 96.1 °F 1/29/25 at 4:13 p.m. - Body Temperature 94.4 °F 1/30/25 at 3:41 p.m. - Body Temperature 94.1 °F Page 1 of 5 555355 555355 02/25/2025 Vintage Faire Nursing & Rehabilitation Center 3620-B Dale Rd Modesto, CA 95356

F 0684 1/31/25 at 6:27 a.m. - Body Temperature 96.1 °F Level of Harm - Minimal harm or potential for actual harm 1/31/25 at 11:12 p.m. - Body Temperature 96.3 °F Residents Affected - Few A review of Resident 1 ' s clinical record at [ACUTE CARE HOSPITAL NAME], titled, Hospitalist Discharge Summary, admit date [DATE] and discharge date [DATE], indicated on 2/1/25, Resident 1 was admitted from the facility to [ACUTE CARE FACILITY NAME] with altered mental status (confusion), dehydration (lacking water in the body), hypernatremia (excess salt in the blood), acute kidney injury (kidneys were newly damaged), and bradycardia (slow heart rate). Resident 1 ' s temperature upon arrival was 86.7 °F (low). Blood glucose (sugar) was 66 (low - normal range 70-99), Sodium level was 151 (high normal range 135-145), Chloride level was 120 (high - normal range 96-106). Resident 1 was treated for sepsis (overwhelming infection in the body). During Resident 1 ' s stay in the ICU (from 2/1/25 through 2/10/25), Resident 1 was intubated (a machine did the work of breathing for Resident 1) twice, was on Norepinephrine (medication used to treat life threatening low blood pressure), received multiple blood transfusions (blood was transferred from a donor person to Resident 1 via an intravenous [IV] line - tube placed in the vein to deliver medications), and Resident 1 needed a Bair Hugger (a system used to warm up the core body temperature). During a phone interview on 3/5/25, at 9:50 a.m., with LN 2, LN 2 stated when she administered medications to Resident 1, Resident 1 stated she was cold and requested additional blankets. LN 2 stated the temperature LN 2 entered (for Resident 1) could have been entered in error because it was outside the normal parameters. LN 2 stated the process for when temperatures were taken by the Certified Nursing Assistant (CNA) (and were outside of the normal range), the CNA was supposed to inform the LN so the LN could assess the Resident and re-take the temperature. LN 2 stated if the vital signs were still outside the normal range, the doctor should be notified. During a phone interview on 3/5/25, at 12:40 p.m., with LN 3, LN 3 stated a low body temperature could have indicated Resident 1 was in distress. LN 3 stated she did not recall calling the MD regarding the low body temperature on 1/27/25 or 1/31/25. During a phone interview on 3/5/25, at 12:43 p.m., with LN 4, LN 4 stated Resident 1's low body temperatures could have been a sign of hypothermia (significant and dangerous drop in body temperature) or sepsis. During a phone interview on 3/5/25, at 12:45 p.m., with CNA 1, CNA 1 stated the CNAs and LNs assessed vital signs once per shift (8-hour shift) and as needed or ordered by the MD. CNA 1 stated when Resident 1 ' s temperature was not within the normal range, the nurses should have re-checked Resident 1 ' s temperature immediately, alerted the LN to assess Resident 1, and if the temperature was still low, the MD should have been notified. CNA 1 stated when an abnormal temperature was taken, the temperature displayed red on the thermometer screen. During a concurrent phone interview and record review on 3/5/25, at 12:50 p.m., with the Director of Nursing (DON), the faciliy ' s documents titled, Job Description [JD]/Performance Evaluation Certified Nursing Assistant (CNA), dated 11/13/17; the faciliy ' s document titled, Job Description/Performance Evaluation LVN/LPN [Licensed Vocational Nurse/License Practical Nurse], dated 11/13/17; and the faciliy ' s document titled, Job Description/Performance Evaluation Registered Nurse, dated 11/13/17, were reviewed. The CNA JD indicated, . notify charge nurse/supervisor of significant changes in condition or concerns . including . resident health/status change . The LVN/LPN JD indicated, . Provides accurate assessment, . and monitoring of Patients for . early detection of changes in 555355 Page 2 of 5 555355 02/25/2025 Vintage Faire Nursing & Rehabilitation Center 3620-B Dale Rd Modesto, CA 95356

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition . Supervises . CNAs providing quality services in accordance with facility policies . The RN JD indicated, . Provides accurate assessment, over-sight, and monitoring of Patients for quality medical management and early detection of changes in condition . regularly monitors documentation/Progress Reports to facilitate point of care . The DON acknowelged the JDs were not followed when re-assessment of the temperatures were not documented in a timely manner and the MD was not notified of abnormal temperatures on (on 1/25/25, 1/27/25, 1/29/25, 1/30/25, and 1/31/25). During a concurrent interview and record review on 3/5/15, at 12:51 p.m., with the Director of Nursing (DON), the Policy and Procedure (P&P) titled, Temperature, Pulse and Respirations, dated 8/14, was reviewed. The P&P indicated, . Purpose - to measure body temperature . Assessment Guidelines . skin . temperature . Care Plan Documentation Guidelines . identify the appropriate problem under which to list vital signs measurement as an approach . consider listing possible risks and complications . The DON stated the nurses should have looked at Resident 1 ' s entire condition and reported it to the Medical Doctor (MD). The DON agreed the above temperatures (on 1/25/25, 1/27/25, 1/29/25, 1/30/25, and 1/31/25) were not within normal limits and there was not any documentation in Resident 1 ' s medical record that indicated the MD had been notified on the dates listed above. Based on interview and record review, the facility failed to ensure quality care was given to one of four sampled residents (Resident 1), when the Medical Doctor (MD) was not notified when Resident 1 had six days of low body temperature. This failure could have contributed to Resident 1 being found unresponsive on 2/1/25 and transferred to [ACUTE CARE HOSPITAL NAME] for further evaluation and treatment in the Hospital Intensive Care Unit (ICU). Findings: During a review of Resident 1's clinical record titled, admission Record (a document that contained Resident 1's demographic information), indicated Resident 1's diagnoses included dementia (general term for a decline in mental abilities that affects memory, thinking, and behavior), bariatric surgery (weight loss surgery), protein calorie malnutrition (health problems associated with consuming a lack of calories), and anemia (low red blood cells that resulted in low oxygen in the blood). A review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation- a communication tool] COC [Change of Condition] 911 Transfer , dated 2/1/25 at 5:17 p.m., by Licensed Nurse (LN) 1, indicated Resident 1 was found unresponsive and starting out into space. Resident 1's lungs had gurgling sounds (could have indicated fluid in the lungs), and the arms and legs were swollen (puffy). Resident 1's vital signs (temperature, heart rate and respiratory rate per minute, and blood pressure) were: body temperature was low at 93.3 degrees (°) Fahrenheit (F – unit of measurement – normal range 97°F through 99°F), heart rate was low at 49 beats per minute (bpm - normal range 60 bpm-100 bpm), blood pressure was elevated at 131/89 (normal range less than 120) / (normal range is under 80). 911 (emergency help needed) was called and Resident 1 was transferred to [ACUTE CARE HOSPITAL NAME]. During a review of Resident 1's clinical record titled, Weights and Vitals Summary , indicated: 1/25/25 at 2:53 p.m. – Body temperature - 96.8 °F 1/27/25 at 6:54 a.m. – Body Temperature 96.1 °F 555355 Page 3 of 5 555355 02/25/2025 Vintage Faire Nursing & Rehabilitation Center 3620-B Dale Rd Modesto, CA 95356

F 0684 1/29/25 at 4:13 p.m. – Body Temperature 94.4 °F Level of Harm - Minimal harm or potential for actual harm 1/30/25 at 3:41 p.m. – Body Temperature 94.1 °F 1/31/25 at 6:27 a.m. – Body Temperature 96.1 °F Residents Affected - Few 1/31/25 at 11:12 p.m. – Body Temperature 96.3 °F A review of Resident 1's clinical record at [ACUTE CARE HOSPITAL NAME], titled, Hospitalist Discharge Summary , admit date [DATE] and discharge date [DATE], indicated on 2/1/25, Resident 1 was admitted from the facility to [ACUTE CARE FACILITY NAME] with altered mental status (confusion), dehydration (lacking water in the body), hypernatremia (excess salt in the blood), acute kidney injury (kidneys were newly damaged), and bradycardia (slow heart rate). Resident 1's temperature upon arrival was 86.7 °F (low). Blood glucose (sugar) was 66 (low - normal range 70-99), Sodium level was 151 (high - normal range 135-145), Chloride level was 120 (high - normal range 96-106). Resident 1 was treated for sepsis (overwhelming infection in the body). During Resident 1's stay in the ICU (from 2/1/25 through 2/10/25), Resident 1 was intubated (a machine did the work of breathing for Resident 1) twice, was on Norepinephrine (medication used to treat life threatening low blood pressure), received multiple blood transfusions (blood was transferred from a donor person to Resident 1 via an intravenous [IV] line – tube placed in the vein to deliver medications), and Resident 1 needed a Bair Hugger (a system used to warm up the core body temperature). During a phone interview on 3/5/25, at 9:50 a.m., with LN 2, LN 2 stated when she administered medications to Resident 1, Resident 1 stated she was cold and requested additional blankets. LN 2 stated the temperature LN 2 entered (for Resident 1) could have been entered in error because it was outside the normal parameters. LN 2 stated the process for when temperatures were taken by the Certified Nursing Assistant (CNA) (and were outside of the normal range), the CNA was supposed to inform the LN so the LN could assess the Resident and re-take the temperature. LN 2 stated if the vital signs were still outside the normal range, the doctor should be notified. During a phone interview on 3/5/25, at 12:40 p.m., with LN 3, LN 3 stated a low body temperature could have indicated Resident 1 was in distress. LN 3 stated she did not recall calling the MD regarding the low body temperature on 1/27/25 or 1/31/25. During a phone interview on 3/5/25, at 12:43 p.m., with LN 4, LN 4 stated Resident 1's low body temperatures could have been a sign of hypothermia (significant and dangerous drop in body temperature) or sepsis. During a phone interview on 3/5/25, at 12:45 p.m., with CNA 1, CNA 1 stated the CNAs and LNs assessed vital signs once per shift (8-hour shift) and as needed or ordered by the MD. CNA 1 stated when Resident 1's temperature was not within the normal range, the nurses should have re-checked Resident 1's temperature immediately, alerted the LN to assess Resident 1, and if the temperature was still low, the MD should have been notified. CNA 1 stated when an abnormal temperature was taken, the temperature displayed red on the thermometer screen. During a concurrent phone interview and record review on 3/5/25, at 12:50 p.m., with the Director of Nursing (DON), the faciliy's documents titled, Job Description [JD]/Performance Evaluation Certified Nursing Assistant (CNA) , dated 11/13/17; the faciliy's document titled, Job Description/Performance Evaluation LVN/LPN [Licensed Vocational Nurse/License Practical Nurse] , dated 11/13/17; and the 555355 Page 4 of 5 555355 02/25/2025 Vintage Faire Nursing & Rehabilitation Center 3620-B Dale Rd Modesto, CA 95356

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few faciliy's document titled, Job Description/Performance Evaluation Registered Nurse , dated 11/13/17, were reviewed. The CNA JD indicated, . notify charge nurse/supervisor of significant changes in condition or concerns . including . resident health/status change . The LVN/LPN JD indicated, . Provides accurate assessment, . and monitoring of Patients for . early detection of changes in condition . Supervises . CNAs providing quality services in accordance with facility policies . The RN JD indicated, . Provides accurate assessment, over-sight, and monitoring of Patients for quality medical management and early detection of changes in condition . regularly monitors documentation/Progress Reports to facilitate point of care . The DON acknowelged the JDs were not followed when re-assessment of the temperatures were not documented in a timely manner and the MD was not notified of abnormal temperatures on (on 1/25/25, 1/27/25, 1/29/25, 1/30/25, and 1/31/25). During a concurrent interview and record review on 3/5/15, at 12:51 p.m., with the Director of Nursing (DON), the Policy and Procedure (P&P) titled, Temperature, Pulse and Respirations , dated 8/14, was reviewed. The P&P indicated, . Purpose – to measure body temperature . Assessment Guidelines . skin . temperature . Care Plan Documentation Guidelines . identify the appropriate problem under which to list vital signs measurement as an approach . consider listing possible risks and complications . The DON stated the nurses should have looked at Resident 1's entire condition and reported it to the Medical Doctor (MD). The DON agreed the above temperatures (on 1/25/25, 1/27/25, 1/29/25, 1/30/25, and 1/31/25) were not within normal limits and there was not any documentation in Resident 1's medical record that indicated the MD had been notified on the dates listed above. 555355 Page 5 of 5