Health inspection·April 11, 2025

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/11/25, at 10 a.m., the facility's Administrator (ADM) confirmed that Resident 1 left the facility around 8 a.m., on 4/4/25 without staff's knowledge and crossed the street. The ADM explained that the resident was immediately placed on one-on-one supervision and a few hours later, the resident was sent to acute hospital for evaluation. The ADM stated, We refused to readmit her .she was not safe here .There is something acute going with her. The ADM confirmed that the facility had several conversations with GACH staff and continuously refused to readmit Resident 1 back to facility. The ADM stated, When she [Resident 1] started getting agitated and anxious we sent her to acute. [Resident 1] did not hurt anyone, but we determined that she was not safe here. The ADM did not provide any answer when asked if the resident was danger to herself or endangered other residents. During an interview on 4/11/25, commencing at 10:20 a.m., the Director of Nursing (DON) was asked to explain the facility's criteria for admission of new residents. The DON explained, We did not go to the hospital to physically assess if resident was appropriate for us .I reviewed her referral documents with the information I had at that time along with admission coordinator (AC) and determined that [Resident 1] was appropriate to be here and the resident was accepted. The DON stated that a day after admission Resident 1 left the facility without staff's knowledge (eloped) and that after she was brought back, the facility determined that the resident was not safe and sent her to ER. During a continued interview with DON on 4/11/25, at 10:20 a.m., the DON stated the facility will not readmit Resident 1 because it was not safe here, very busy street. The DON continued, She was focused on leaving all the time and we thought she needs more attention .Very unstable gait and unstable on her feet .somebody had to be with her all the time .She would sit down [in wheelchair] and then would get up .Talked non-stop about wanting to get new slippers. The DON stated that Resident 1 was dangerous because she could have been hit by a car when she crossed the street and added that she explained to the ER staff that facility did not have any amenities to keep [Resident 1] safe here with such a busy street and intersection [referring to the busy road near the facility]. The DON explained that Resident 1 became more confused on the second day after admission and there might have been changes in the resident's condition. The DON stated Resident 1 had not been seen by her physician when she was admitted and neither physician nor Nurse Practitioner (NP) assessed and evaluated Resident 1 after she was found wandering in the parking lot of another facility. The DON agreed that the resident was elderly and could have been confused seeing unfamiliar faces and a new place. The DON stated the facility placed Resident 1 on one-to-one supervision, but the resident insisted on leaving the facility. The DON stated, When we tried to redirect her and bring her back, she was getting agitated .Talked non-stop about wanting to get new slippers. The DON denied that the resident endangered other residents. The DON stated she was not aware if the facility attempted any other interventions beside one-on-one supervision before sending the resident to ER. During an interview with social services (SS) on 4/11/25, at 11:55 a.m., the SS stated when the staff brought Resident 1 from another facility, the resident had no physical behaviors and was not agitated or aggressive. The SS explained that Resident 1 was wearing non-skid socks and was talking about buying new slippers. The SS stated she stayed with the resident for some time and the resident was very confused .but not agitated .not combative . and repeatedly talked about new slippers. The SS stated the resident was not dangerous and did not present any behaviors of endangering other residents. During an interview on 4/11/25, at 12:10 p.m., Certified Nursing Assistant (CNA 1) stated after Resident 1 was brought back to facility, the resident looked confused, talked about random things .was not aggressive, not yelling and not screaming, and had no physical behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055189 If continuation sheet Page 2 of 5 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 04/11/2025 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/11/25, at 12:25 p.m., Licensed Nurse 1 (LN 1) stated that the resident explained that she left because she had things to do and needed to see her son when she was brought back. LN 1 stated Resident 1 took her morning medications and was cooperative during assessment. LN 1 added, No physical behaviors or agitation, she was not screaming or yelling . very confused and talked that she needed new slippers. LN 1 stated the resident was constantly attempting to get up from her wheelchair, but otherwise she was fine . She did not present a danger to herself, to her roommate or staff. LN 1 stated when she called NP to report that Resident 1 had elopement incident earlier in the morning, the NP ordered a wander guard (an electronic safety device used to alert staff for potential elopement) and one-on-one supervision. LN 1 stated the NP requested to send Resident 1 to ER. During the telephone interview with NP on 4/11/25, at 12:40 p.m., the NP stated, I did not see the resident .received a call informing about elopement .I was informed by staff that she was hard to redirect and determined she was not appropriate for the facility. The DON told me that the resident was pushing staff away and I ordered one-on-one supervision .Not sure if she had physical behaviors, except that she pushed staff who prevented her from getting out of wheelchair and walk away . and I gave a verbal order to send her [out]. The NP acknowledged that Resident 1 did not endanger other residents. When the NP was asked if the resident was danger to herself, the NP stated, I did not speak with resident, but from what I was told, she did not belong here. A review of the undated ' Transfer and Discharge from the Facility Policy,' indicated, It is the policy of this facility that each resident has the right to remain in the facility .unless a transfer or discharge from the facility is .necessary for the resident's welfare and the resident's needs cannot be met in the facility .The safety of individuals in the facility is endangered due to clinical or behavioral status of the resident. The policy further indicated that the facility would communicate appropriate resident's information to the receiving institution. The policy indicated, When a resident discharge is due to the resident's welfare and the facility cannot meet the resident's needs, documentation by the resident's physician must include: 1. The specific resident need the facility could not meet; 2. The facility's efforts to meet those needs .physician documentation regarding the necessary transfer and discharge. During a follow up interview with DON on 4/11/25, at 12:55 p.m., the DON stated that the basis for Resident 1's transfer to the hospital and refusal to readmit back to facility was because the facility could not meet resident's safety needs. The DON was unable to find any clinical records indicating that the resident was agitated, was not redirectable, and presented danger to self or other residents. The DON was not able to provide any documented evidence that the facility identified likely cause for Resident 1's increased confusion and validated that the resident was not evaluated by physician. The DON stated there was no physician documentation regarding the necessary transfer or discharge as indicated in the Transfer and Discharge policy. The DON agreed that beside wanting to leave and buy new slippers Resident 1 had no other behaviors and clarified, When she goes across the busy street and intersection, it is dangerous for her. The DON acknowledged that having wander guard and adequate supervision might have prevented Resident 1's elopement and subsequent transfer to ER. During a follow up interview with ADM on 4/11/25, at 1:15 p.m., the ADM stated, Once we accept the resident, we have responsibility to keep the resident safe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055189 If continuation sheet Page 3 of 5 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 04/11/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to provide adequate supervision, accurate assessment, and interventions for one of 3 sampled residents (Resident 1) to prevent the resident leaving the facility, when Resident 1 left the facility without staff's knowledge (eloped), crossed a busy street, and was found wandering on the parking lot of another facility. This failure resulted in exposing Resident 1 to health hazards and fatal accidents. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 4/3/25 after a brief hospitalization. Resident 1's multiple diagnoses included depression, muscle weakness and difficulty in walking. A review of Resident 1's hospital records dated 3/24/25 indicated the resident was brought to the hospital with confusion, weakness, and frequent falls at home. A review of the hospital document titled, Inter-Facility Transfer Report dated 4/3/25 indicated that Resident 1 was diagnosed with acute encephalopathy (impaired/altered mental status) caused by stroke (brain injury). The document indicated the resident was confused, had generalized weakness, and was at high risk for falls. A review of the facility's ' admission Assessment' for Resident 1 dated 4/3/25, at 1:55 p.m., described the resident as friendly .disoriented to . time, place, and person .mood .wanders mentally .slow comprehension. Per admission Assessment Resident 1 required staff's assistance with personal care, eating, transfer and ambulation. A review of the ' Elopement Assessment' dated 4/3/25, indicated the resident scored 4, which indicated low risk for elopement. A review of nursing progress notes dated 4/4/25, at 8:31 a.m., indicated that at 7:40 a.m., Resident 1 was observed with her walker standing by her room door. The Licensed Nurse (LN 1) documented that the resident informed LN 1 that she's just got things to do, trying to find her slippers. A review of social services (SS) progress notes dated 4/4/25, at 5:52 p.m., and written as LATE ENTRY indicated that the facility was notified by male bystander that Resident 1 was found in another facility across the street. SS documented that Resident 1 was brought back to the facility. During an interview on 4/11/25, at 10 a.m., the facility's Administrator (ADM) confirmed that Resident 1 left the facility around 8 a.m., on 4/4/25 without staff's knowledge and crossed the street. The ADM stated, The street is very busy and dangerous .two (2) lines each, and acknowledged that the resident could have gotten hurt or killed. During an interview on 4/11/25, at 11:55 a.m., SS stated she was at the nursing station when a concerned citizen entered the building and informed staff that he found Resident 1 wandering in parking lot across the street. The concerned citizen informed the staff that he thought the resident lived at another facility and took her there. The SS stated when the SS and Certified Nursing Assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055189 If continuation sheet Page 4 of 5 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 04/11/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (CNA 1) went to another facility, Resident 1 was wearing socks. SS stated the resident was confused and insisted that she needed to buy new slippers. During an interview on 4/11/25, at 12:55 p.m., the Director of Nursing (DON) stated that Resident 1 had no wander guard (an electronic safety device used to alert staff for potential elopement) because she scored low on elopement assessment. Upon reviewing the elopement assessment completed on 4/3/25, the DON validated the elopement assessment was inaccurate. The DON stated if the elopement assessment was accurate, the resident would score as high risk for elopement and would have a wander guard placed which would alert the staff when she left the facility. The DON stated the resident was confused, continuously wandered around the building and into other residents' rooms at night, and required lots of redirection and staff supervision. The DON acknowledged that it was unsafe situation that Resident 1 crossed the busy street during busy morning commute and agreed that the resident could have been injured or killed. A review of the facility's ' Elopement Risk Precautions and Procedures,' with the revision date of 6/24 indicated, It is the policy of the facility to identify residents who are wanderers or who are a threat to leave the facility unattended without the knowledge of the facility staff .Purpose: To ensure resident's safety .Procedure: Obtain information during pre-admission or admission .regarding .potential for elopement .Staff is responsible for knowing or recognizing the resident who has exit seeking behavior to intervene as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055189 If continuation sheet Page 5 of 5