Health inspection·January 7, 2026

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 adequately assess and initiate timely emergency response for one of three sampled residents (Resident 1) when Licensed Nurse (LN) 3 did not call 911 after Resident 1 had a very low oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) than normal and showed signs of distress and altered level of consciousness.This failure had the potential to delay the initiation of treatment for Resident 1, which could potentially led to respiratory arrest. Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was re-admitted on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs) and acute and chronic respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in the body) with hypoxia (lack of oxygen in tissue).During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/30/25, the MDS indicated Resident 1 had intact cognition.During a review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated 6/19/25, the POLST indicated Resident 1 was full code.During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/22/25, the SBAR indicated, Resident 1 was noted with hypoxia, altered level of consciousness and shortness of breath.During a telephone interview on 1/7/26 at 12:21 p.m. with LN 3, LN 3 stated, on 12/22/25, while administering bedtime medications, LN 3 entered Resident 1's room and attempted to wake him up and observed that something was different about his condition. LN 3 stated, Resident 1 was experiencing difficulty breathing and was on continuous oxygen. LN 3 stated, she increased the oxygen flow rate; however, his O2 sat remained low. LN 3 further stated that although Resident 1 was responsive, his responses were inappropriate, and his behavior was not consistent with his baseline. LN 3 also stated that she contacted the on-call physician, who gave an order to send Resident 1 to the emergency room.During a review of Resident 1's Nurse's Notes (NN), dated 12/22/25, the NN indicated, at approximately 9 p.m. the nurse entered Resident 1's room to administer medications and found him awake, was able to take medication but repeatedly saying the same sentence. The NN indicated, LN 3 asked Resident 1 if he was okay, and he opened his eyes and closed them again. The NN indicated, Resident 1's O2 sat was at 84% (normal values for a healthy adult on room air is 95% to 100% measured by a pulse oximeter [small, clip-on device that non-invasively measures blood oxygen levels] indicating sufficient oxygen in the blood. Levels below 90% suggest significant hypoxemia [ lower-than-normal levels of oxygen in the blood] requiring medical attention), while on 3 liters of oxygen via nasal cannula, the oxygen was increased to 4 liters; however, the O2 sat remained low, around 82-83%. The physician was called at 9:30 p.m., and an order was received to send the resident to the emergency room for hypoxia. A Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055189 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 01/07/2026 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)