Health inspection·February 5, 2025

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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055189 If continuation sheet Page 2 of 4 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 055189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fairfield 1260 Travis Blvd Fairfield, CA 94533 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 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055189 If continuation sheet Page 3 of 4 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 055189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fairfield 1260 Travis Blvd Fairfield, CA 94533 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 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055189 If continuation sheet Page 4 of 4