Other·October 27, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of entity reported incident #CA00501126. Representing the Department of Public Health: HFEN, 29825 Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility.

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(b)(11)

F157 11/02/2017 A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in §483.12(a). The facility must also promptly notify the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7QED11 Facility ID: CA030000057 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555098 (X3) DATE SURVEY COMPLETED 10/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENHAVEN HEALTHCARE CENTER 455 Florin Road Sacramento, CA 95831 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to immediately consult with the resident's physician and notify the resident's Responsible Party (RP) when there was a significant change in condition for 1 of 3 sampled residents (Resident 1). This failure resulted in the physician being unable to intervene and prevent further decline in condition for Resident 1 and the RP being uninformed. Findings: Resident 1 was admitted to the facility with multiple diagnoses including heart disease, dementia (a group of diseases that cause a permanent decline of person's ability to think, reason and manage his own life), skin wounds and diabetes (a condition where the body cannot use sugar normally). Resident 1's MDS (Minimum Data Set, an assessment tool), dated 8/12/15 and again 9/10/15, indicated her cognition (conscious mental activities) was moderately impaired and she required limited FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7QED11 Facility ID: CA030000057 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555098 (X3) DATE SURVEY COMPLETED 10/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENHAVEN HEALTHCARE CENTER 455 Florin Road Sacramento, CA 95831 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to extensive assistance with ADL's (Activities of Daily Living). Review of Resident 1's document titled Preferred Intensity of Care (medical orders to be honored by health care workers during a medical crisis), signed by her RP on 9/5/15, indicated Resident 1 wanted: 1. Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure that is done when someone's breathing or heartbeat stopped) 2. Artificial Nutrition/Hydration from a Nasogastric or Gastrostomy Tube (feeding tubes) 3. IV (intravenous) Fluids other than Antibiotics 4. Antibiotics (medications that kill bacteria or slows the growth of bacteria) 5. Oxygen 6. Transfer to Acute Hospital Review of Resident 1's physician progress note, dated 9/5/15, indicated multiple diagnoses and a recent hospitalization from 8/30/15 to 9/4/15 for persistent weakness, weight loss and a bacterial urinary tract infection. She was sent back to the facility for short term rehabilitation and wound care. Review of Resident 1's nurses' notes, dated 10/12/15 at 10:25 p.m., indicated her vital signs were stable, there was no shortness of breath, respiratory distress or pain. Review of Resident 1's last vitals signs, dated 10/13/15, from 12:07 a.m. to 12:08 a.m., indicated; temperature 97.3, pulse 78, respirations 16, and blood pressure 113/86 (all within normal limits). Resident 1's nurses' note, dated 10/13/15 at 9:42 a.m., indicated Licensed Nurse (LN) 2 checked the resident around 5:30 a.m. and she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7QED11 Facility ID: CA030000057 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555098 (X3) DATE SURVEY COMPLETED 10/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENHAVEN HEALTHCARE CENTER 455 Florin Road Sacramento, CA 95831 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was noted to not have any breathing, pulse or blood pressure. The oxygen level in the blood was unobtainable and Resident 3 was cool to the touch. During an interview with Certified Nurses Aid (CNA) 3 on 9/20/16 at 8:18 a.m., she was asked what happened the night of the incident. She said, "[LN 2] asked if I could help do a [pressure ulcer] treatment and said [Resident 1] needed three treatments. First treatment she was very responsive. Then, her roommate put her [call] light on later. When I went to see [Resident 1], she looked bad. I asked [LN 2] if she was a DNR [Do Not Resuscitate]. I asked, 'What are we going to do?' He said, 'I hope it doesn't happen on our shift. I don't want to do do CPR.' Later, she was cold, even with blankets on. She wasn't responding during the second [pressure ulcer] treatment. I kept him informed... I kept going back to tell him of my concerns... [LN 2] came and got me to ask if I thought she was still breathing... There was a pulse ox [device to record oxygen level in the blood] on her finger but she was already gone." During an interview with the Director of Nurses on 9/8/16 at 11:40 a.m., she was asked about LN 2 and his termination. She said, "He failed to follow procedures, including assessing Change of Condition, in a timely manner." During a telephone interview with the Director of Nurses (DON) on 2/10/17 at 1:26 p.m., she said, "When we were reviewing this case, we felt he [LN 2] failed to assess a change of condition ..." Review of the facility policy and procedures titled "Change in a Resident's Condition", dated 1/15/10, indicated, "4 The Charge Nurse will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7QED11 Facility ID: CA030000057 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555098 (X3) DATE SURVEY COMPLETED 10/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENHAVEN HEALTHCARE CENTER 455 Florin Road Sacramento, CA 95831 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE responsible for making all notifications to physicians...and the resident's representative. 5 Before notifying the physician, the nurse must observe and assess the overall condition utilizing physical assessment and medical record review. 6 Emergency notifications will be made immediately by phone.." . FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7QED11 Facility ID: CA030000057 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555098 (X3) DATE SURVEY COMPLETED 10/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENHAVEN HEALTHCARE CENTER 455 Florin Road Sacramento, CA 95831 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 7QED11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000057 (X5) COMPLETE DATE If continuation sheet 6 of 6