Health inspection·February 5, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility failed to practice appropriate infection prevention and control measures for one out of six sampled residents (Resident 1), when his Foley catheter (FC- a hollow tube inserted into the bladder to drain or collect urine) drainage bag was left on the floor. Residents Affected - Few This failure had the potential to cause Resident 1 to experience a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: A review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in August of 2024 with diagnoses of muscle weakness, essential hypertension (HTN- high blood pressure) and neuromuscular dysfunction of the bladder (nerves controlling bladder function are damaged leading to impaired bladder control). A review of Resident 1 ' s Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 11/9/24, indicated Resident 1 had no memory problem. During a concurrent observation and interview on 2/5/25 at 12:08 p.m., Resident 1 ' s FC drainage bag was noted on the floor. Resident 1 stated his FC drainage bag had been on the floor since this morning and added, this happens from time to time. During a concurrent observation and interview on 2/5/22 at 12:22 p.m., Unlicensed Staff A verified Resident 1 ' s FC drainage bag was on the floor and stated this was not acceptable as the drainage bag should be hung away from the floor for infection control. Unlicensed Staff A added, keeping the FC drainage bag on the floor put Resident 1 at risk for infections. During an interview on 2/5/22 at 1:27 p.m., the Director of Staff Development (DSD) stated a FC drainage bag should not be left on the floor and added, the FC drainage bag on the floor put Resident 1 at risk for infections. An interview on 2/5/25 at 2:31 p.m., the Director of Nursing (DON) stated the FC drainage bag should be kept off the floor to prevent bacteria from entering the catheter. The DON confirmed the FC drainage bag on the floor put Resident 1 at risk for a UTI. A review of the facility ' s policy and procedure (P&P) titled, Indwelling/Foley Catheter, revised Page 1 of 4 055189 055189 02/05/2025 Greenfield Care Center of Fairfield 1260 Travis Blvd Fairfield, CA 94533

F 0880 11/2024, the P&P indicated, .be sure the catheter tubing and drainage bag are kept off the floor . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055189 Page 2 of 4 055189 02/05/2025 Greenfield Care Center of Fairfield 1260 Travis Blvd Fairfield, CA 94533

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility failed to ensure two out of six sampled residents (Resident 1 and Resident 2) had their call light (a device used to communicate with staff when assistance is needed) within reach. Residents Affected - Few This failure could impair the residents ' ability to call for assistance when needed, potentially leading to safety concerns and delays in getting necessary care. Findings: A review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in August of 2024 with diagnoses of muscle weakness and neuromuscular dysfunction of the bladder (nerves controlling bladder function are damaged leading to impaired bladder control). A review of Resident 2 ' s Face Sheet indicated Resident 2 was admitted to the facility in October of 2022 with diagnoses of hyperlipidemia (HLP- high cholesterol) and anemia (a condition where the body does not have enough healthy red blood cells). During a concurrent observation and interview on 2/5/25 at 12:05 p.m., Resident 2 ' s call light was noted to be wrapped around the left side rail of the bed and out of the reach of Resident 2. Resident 2 stated she did not know she had a call light and would usually yell help! help! for someone to come. Resident 2 added, she wanted a call light, so she did not have to yell for help. During a concurrent observation and interview on 2/5/25 at 12:08 p.m., Resident 1 ' s call light was not observed near him. Resident 1 stated he did not know where his call light was and when he needed help, he had to yell help! for someone to come. During a concurrent observation and interview on 2/5/25 at 12:22 p.m., Unlicensed Staff A verified Resident 2's call light was wrapped on the left side rail of the bed and was not within her reach. Unlicensed Staff A stated this was not acceptable and added, the call light should always be within residents ' reach. Unlicensed Staff A stated he had witnessed Resident 2 yelling for help a few times when she was needing assistance. During a concurrent observation and interview on 2/5/25 at 12:25 p.m., Unlicensed Staff A verified Resident 1 did not have his call light within reach when it was found on the floor by the foot of his bed. During an interview on 2/5/25 at 1:05 p.m., Licensed Staff B stated the call light should always be within residents ' reach for safety and to ensure staff were alerted if residents ' needed help. During an interview on 2/5/25 at 1:27 p.m., the Director of Staff Development (DSD) stated call lights should always be within the residents ' reach and not having the call light within the residents ' reach could put residents at risk for accidents and not meeting their needs. During an interview on 2/5/27 at 2:31 p.m., the Director of Nursing (DON) stated call light should be within residents ' reach at all times, as the call light was how residents communicate with staff when they needed assistance and not having the call light within reach could result in delay of 055189 Page 3 of 4 055189 02/05/2025 Greenfield Care Center of Fairfield 1260 Travis Blvd Fairfield, CA 94533

F 0919 care, unmet resident needs, and accidents. Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy and procedure (P&P) titled, Call light/Bell , revised 1/2024, the P&P indicated, .call light only be out of reach during resident care to prevent injury and during the time when resident was out of bed, but would immediately be within reach after care or when resident is back to bed .place the call device within residents reach before leaving room . Residents Affected - Few 055189 Page 4 of 4