Other·March 15, 2018

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 complaint #CA00470036. Representing the Department of Public Health: HFEN, 26367 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F155 SS=D RIGHT TO REFUSE; FORMULATE ADVANCE F155 DIRECTIVES CFR(s): 483.10(b)(4) 03/21/2018 The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all 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: KD9211 Facility ID: CA030000057 If continuation sheet 1 of 29 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 03/02/2018 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 adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the advanced directives of 1 of 3 sampled residents (Resident 1) were honored when Resident 1 experienced a change of condition that prevented him from swallowing food or fluids. This failure deprived Resident 1 and his family of the right to receive the intensity of medical care they had requested in his advance directives and contributed to his death after approximately 72 hours without significant food and fluid intake. Findings: The admission record for Resident 1 indicated he had been a resident of the facility for many years. His diagnosis included paralysis (a lack of control over one's motor function) and dementia (a loss of cognitive function). The section titled, "Advanced Directives" indicated Resident 1 wanted a trial period of tube feeding of food or fluids and other, "limited additional interventions." The clinical record for Resident 1 included the following information: A 1/28/13 POLST (Physician Orders for LifeFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 2 of 29 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 03/02/2018 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 Sustaining Treatment, this document served as actual physician orders for the steps to take in the event Resident 1 had a change of condition) form indicated Resident 1's Responsible Party (RP) had marked the boxes that indicated Resident 1 wanted intravenous fluids (IV) and tube feedings in the event they were needed. Medical Doctor 1's (MD 1) signature on the form was dated 1/30/13. A 1/19/14 care plan identifying the potential for dehydration indicated Resident 1 was at risk of dehydration due to his increased dementia and pureed diet. The care plan directed staff to "Honor...[advanced directives]". The care plan had not been updated with any resident specific interventions since its creation in 2014. A 10/20/15 Minimum Data Set (MDS, an assessment tool) indicated Resident 1 was able to feed himself at that time. The MDS also indicated Resident 1 was rarely or never able to make himself understood. A 10/21/15 Registered Dietician (RD) note indicated Resident 1 had an average oral food intake of 99% during the week of her assessment, and his weight was stable. He consumed a pureed diet. A 12/22/15 nursing note, written by the Unit Manager (UM) at 8:18 a.m., indicated Resident 1 was observed to let food drop out of his mouth. The UM notified MD 1 and the RP. There were no further nursing notes until the morning of 12/24/15. On 12/22/15 the UM faxed a communication to MD 1 requesting an order for a speech therapy evaluation. MD 1 responded on 12/23/15. MD 1 ordered a speech therapy evaluation and also ordered the staff to continue monitoring Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 3 of 29 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 03/02/2018 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 On 12/22/15 the UM updated the plan of care to address Resident 1's inability to swallow. The goal was to prevent Resident 1 from choking on his food. There was no documented evidence Resident 1's care plans were updated to address the dehydration that would result from the inability to consume food or fluid. On 12/23/15 at 11:00 a.m., the Speech Therapist (ST) notified MD 1 on a communication form that Resident 1 had a severe inability to swallow. The form was left for the MD to review when he came to the facility that same day. The ST noted Resident 1 had a very limited intake of nutrition and the resident's POLST included the provision of alternative feeding methods. The note indicated this issue, "probably needed to be addressed by the family." The ST requested 3 additional therapy visits. On 12/23/15, MD 1 signed and dated the ST note and ordered additional therapy visits. There was no documented evidence MD 1 spoke with Resident 1's family about the need to consider implementing the POLST orders of providing tube feeding of food or fluids. A report of Resident 1's oral consumption for the month of December indicated his food and fluids were provided to him in a pureed and/or thickened state and were tallied as a percentage total with no differentiation of solid food from fluids. The report indicated Resident 1 had refused his evening meal on 12/21/15, and all meals on 12/22/15. He had eaten only 10% of the combined food/fluid provided at lunch on 12/23/15, with no documented evidence of other intake for that day. On 12/24/15 the documentation indicated he ate 10% of his breakfast and only 5% of his lunch. He expired before dinner on 12/24/15, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 4 of 29 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 03/02/2018 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 approximately 72 hours after the last substantial meal he ate, the lunch on 12/21/15. A 12/24/15 nursing note written at 7:06 a.m. indicated nursing staff continued to monitor Resident 1 for difficulty swallowing. Furthermore, the nursing note indicated the speech therapy evaluation had been completed and the nursing staff awaited new treatment results. A 12/24/15 nursing note, written at 3:11 p.m., indicated Resident 1 had been assessed at 12 p.m. that day, and he had experienced a reduced oral intake. A 12/24/15 nursing note, written at 3:40 p.m., noted Resident 1 had been found dead at 2:55 p.m. The note indicated RP 1 was notified of the death. The facility's 10/06/09 policy titled "Physician Orders for Life-Sustain Treatment (POLST) noted "POLST orders will be honored by the staff....Resident's face sheet in the electronic health record will by updated to reflect the POLST form." There was no documented evidence the nursing staff implemented this policy. In an interview with UM on 1/6/16 at 11:30 a.m., she reported staff brought Resident 1's swallowing difficulties to her attention the morning of 12/22/15 and she had verified the resident was unable to swallow his food. She stated she notified MD 1 of the need for a swallow evaluation. She included Resident 1 on, "Event Charting" for difficulty swallowing. She explained with, "Event Charting" nursing staff were expected to assess and chart each shift for issues related to the resident's difficulty swallowing. The UM confirmed there were no event charting notes for the evening of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 5 of 29 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 03/02/2018 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 12/22/15. The UM confirmed there was no documented evidence of any nursing notes for 12/23/15. The UM reported she worked on 12/22/15 and 12/23/15. The UM reported the licensed nurses were responsible for entering the meal and fluid consumption information in Resident 1's chart. The UM also stated a decline in oral intake of food and fluid would require a review of a resident's advanced directives. The UM reported the ST had told her Resident 1 did not do well when his swallowing ability was evaluated. When asked how she addressed the potential dehydration that would result from a reduced intake of a pureed diet, she reported she only assessed his ability to swallow food, not fluid. In an interview with Licensed Nurse 1 (LN 1) on 1/6/16 at 11:50 a.m., he reported Resident 1 would sit up in his wheelchair to eat breakfast in the common area and stay up in his wheelchair until after he ate lunch. On 12/24/15 during the morning shift, Resident 1 appeared weak and the staff put him back to bed. LN 1 reported he was aware that Resident 1 was not eating or drinking. When asked, he reported he had learned in nursing school a person could only live about 72 hours without fluids. He reported he was unaware of how long Resident 1 had been unable to eat or drink. He reported he had not reported any changes to the RP or MD, because he was waiting for the ST to give him further directions. In an interview with LN 2 on 1/6/16 at 12:20 p.m., LN 2 verified she worked on the morning of 12/22/15 and 12/23/15, and she did not make any notes in Resident 1's chart, despite the initiation of event charting. She stated she was aware the ST was assessing Resident 1, and she was waiting for instructions from the ST before she proceeded. She reported she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 6 of 29 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 03/02/2018 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 did not review Resident 1's advanced directives. LN 2 also stated she did not report to the UM on either day because the UM was the one who told her Resident 1 could not swallow. In an interview with the ST on 1/6/16 at 12:27 p.m., the ST reported she completed an evaluation of Resident 1's ability to swallow on 12/23/15. Resident 1 was unable to consume food or fluids. She reported she made note of the need for a discussion about the advanced directives, but it was the responsibility of the nursing staff to ensure the advanced directives were followed. In an interview with MD 1 on 1/6/16 at 2:15 p.m., he reported he was unfamiliar with the details about Resident 1's case and provided information on a hypothetical basis. He reported that in a hypothetical situation he would have expected the nursing staff to request IV hydration at the point the ST verified a resident was unable to swallow. In an interview with LN 3 on 1/6/16 at 2:40 p.m., LN 3 reported she was not told Resident 1 could not swallow, she was told he refused his food. She reported she had observed him at dinner on 12/22/15 and he spit his food out. She reported Event Charting required the staff to monitor and chart on Resident 1 each shift. She confirmed she did not check to see if there was any vitals information, (blood pressure, temperature, respiration, and temperature) to review as part of the monitoring. LN 3 stated she did not chart on the 12/22/15 or 12/23/15 evening shifts. She reported she had learned from the UM that Resident 1's intake was poor, so she did not report to anyone his intake continued to be poor on her shifts. LN 3 reported she reviewed Resident 1's POLST form only to see if she needed to perform FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 7 of 29 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 03/02/2018 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 resuscitation or send him to the hospital. She had observed the boxes indicating resuscitation and hospitalization were desired if needed were left blank. She stated she did not review the rest of the POLST form for the interventions Resident 1's RP requested, IV fluids and tube feeding on a trial basis. When asked, she reported she had learned in nursing school that a person would live about 72 hours without fluids. In a second interview with LN 3 on 1/11/16 at 2:05 p.m., she reported the signs of dehydration included poor skin elasticity, and Resident 1's skin was always bad; the condition of the mucous membranes, and Resident 1's were not dry and cracking, but were not as moist as usual; and urine output would be reduced, and a darker color. She reported she had not asked the Certified Nursing Assistant (CNA) staff about the condition of Resident 1's urine. She reported she did not document he refused his medications because she could not tell how much of the medication mixed in applesauce Resident 1 spit out. In an interview with the Director of Nurses (DON) on 1/11/16 at 2:30 p.m., she reviewed Resident 1's clinical record and reported there was no documented evidence the licensed staff considered providing IV hydration in light of Resident 1's inability to take in food or fluids. In an interview with the RD on 1/11/16 at 2:40 p.m., she reported Resident 1 had been very stable over the years and she had estimated he required 1500 milliliters of fluid a day. She reported it was her expectation that once the ST completed her evaluation and determined Resident 1 could not swallow, the licensed nurses would contact her for a dietary assessment STAT (immediately) to address FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 8 of 29 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 03/02/2018 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 how they would meet his nutritional and fluid needs. She stated she had not been notified of Resident 1's sudden inability to swallow until after his death. In an interview with the RP on 1/19/16 at 10:30 a.m., she reported the nursing staff contacted her on the morning on 12/22/15 and reported Resident 1's inability to swallow. She had been told a ST would evaluate him the next day. On 12/23/15, she went to the facility at the request of the social service staff to sign papers that authorized a podiatrist to cut Resident 1's toe nails. While she was there, she observed Resident 1 looked particularly thin and hollow. She suspected he had not been eating prior to when the staff had notified her of his inability to swallow. While she signed the podiatry authorization, the social service person reported the ST completed the evaluation and would provide therapy. The RP reported nobody explained that Resident 1's inability to swallow meant he would not get enough fluids. Nobody explained to her that there was a limited time frame a person could live without hydration, nobody approached her to discuss the use of IV hydration, as requested in the POLST. The RP reported Resident 1 died on Christmas Eve and it felt horrible to not have anyone be there with him. She reported she would not have wanted the IV hydration forever, but she would have liked to have been able to delay her father's passing until the family could gather, and to do what they could to keep him alive through Christmas. In an interview with the DON on 2/2/16 at 2:30 p.m., she reported that when a resident experienced a change of condition the nursing staff were responsible for reviewing the POLST with the physician. She reported there was no documented evidence the nursing staff brought Resident 1's request for IV hydration, as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 9 of 29 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 03/02/2018 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 indicated in his advance directives, to the attention of the physician when Resident 1 could no longer swallow.

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

F157 03/21/2018 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 10 of 29 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 03/02/2018 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 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 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 notify the Responsible Party (RP) for 1 of 3 sampled residents (Resident 1) of the need to significantly alter the treatment plan to meet Resident 1's hydration needs when Resident 1 could no longer swallow food or fluids safely. This failure deprived Resident 1's RP the right to be included in critical end of life care decisions. Findings: The admission record for Resident 1 indicated he was a resident of the facility for many years. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 11 of 29 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 03/02/2018 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 1's diagnoses included paralysis (a lack of control over one's motor function) and dementia. The clinical record for Resident 1 included the following information: A 1/28/13 POLST form (Physician Orders for Life-Sustaining Treatment) indicated Resident 1's RP marked the boxes indicating intravenous fluids (IV) and tube feeding were desired in the event they were needed. Medical Doctor 1's (MD 1's) signature on the form was dated 1/30/13. On 1/19/14 Resident 1's clinical record was updated with a plan of care to address the resident's potential dehydration as a result of a pureed diet and advanced dementia. The care plan directed staff to "Honor...[advanced directives]" and had not been updated with any resident specific interventions since its creation in 2014. A 10/21/15 Registered Dietician (RD) note indicated Resident 1's average oral intake was 99% during the week of her assessment, and his weight was stable. Resident 1 consumed a pureed diet. A 12/22/15 nursing note, written by the Unit Manager (UM) at 8:18 a.m., indicated Resident 1 was observed to let food drop out of his mouth. The UM notified MD 1 and the RP of Resident 1's difficulty swallowing food. There were no further nursing notes until the morning of 12/24/15. On 12/22/15 the UM faxed a communication to MD 1 requesting an order for a speech therapy evaluation. MD 1 responded on 12/23/15. MD 1 ordered a speech therapy evaluation and to continue monitoring Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 12 of 29 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 03/02/2018 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 On 12/22/15 the UM updated the plan of care to address Resident 1's inability to swallow. The goal was to prevent Resident 1 from choking on his food. There was no documented evidence the care plans were updated to address the dehydration that would result from the inability to consume food or fluid. On 12/23/15 at 11:00 a.m., the Speech Therapist (ST) notified MD 1 on a communication form that Resident 1 had a severe inability to swallow. The form was left at the facility for the MD to review when he came to the facility. The ST noted Resident 1 had a very limited intake of nutrition and the resident's POLST included the provision of alternative feeding methods. The note indicated this issue "probably needed to be addressed by the family." The ST requested 3 additional therapy visits. On 12/23/15, MD 1 reviewed the ST note and ordered additional therapy visits. There was no documented evidence MD 1 addressed the need for alternative feeding methods with Resident 1's RP as suggested by the ST. In an interview with MD 1 on 1/6/16 at 2:15 p.m., he reported he was unfamiliar with the details about Resident 1's case and provided information on a hypothetical basis. He reported that in a hypothetical situation he would have expected the nursing staff to request IV hydration at the point the ST verified a resident was unable to swallow. A report of Resident 1's oral consumption for the month of December indicated his food and fluids were provided to him in a pureed and/or thickened state and were tallied as a percentage total with no differentiation of the solid food from the fluids. The report indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 13 of 29 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 03/02/2018 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 1 had refused his evening meal on 12/21/15, and all meals on 12/22/15. He had eaten only 10% of the combined food/fluid provided for lunch on 12/23/15 with no other documented intake for that day. On 12/24/15 the documentation indicated he ate 10% of his breakfast and only 5% of his lunch. He expired on 12/24/15, approximately 72 hours after the last documented substantial meal (consumed at lunch on 12/21/15.) A 12/24/15 nursing note written at 7:06 a.m. indicated nursing staff continued to monitor Resident 1 for difficulty swallowing. The speech therapy evaluation had been completed and the nursing staff awaited new treatment results. There was no documented evidence that RP 1 was notified of Resident 1's continued inability to swallow food or fluids. A 12/24/15 nursing note, written at 3:11 p.m., indicated Resident 1 had been assessed at 12 p.m. that day, and he was experiencing a decline in his oral intake. There was no documented evidence that RP 1 was notified of Resident 1's continued inability to swallow food or fluids. A 12/24/15 nursing note, written at 3:40 p.m., noted Resident was found dead at 2:55 p.m. The note indicated RP 1 was notified of the death. The facility's 1/15/10 policy titled, "Changes in a Resident's Condition" indicated, "The Charge Nurse will be responsible for making all notifications of changes to physicians, the resident, and the resident representative." The facility schedule indicated Licensed Nurse 2 (LN 2) was the charge nurse on the 12/22/15 and 12/23/15 day shifts. LN 1 was the charge nurse on the 12/24/15 day shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 14 of 29 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 03/02/2018 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 In an interview with UM on 1/6/16 at 11:30 a.m., she reported staff brought Resident 1's swallowing difficulties to her attention on the morning of 12/22/15 and she verified the resident was unable to swallow food at that time. She stated she notified MD 1 of the need for a swallow evaluation. She included Resident 1 on ,"Event Charting" for difficulty swallowing. She explained with, "Event Charting" nursing staff were expected to assess and chart each shift for issues related to the resident's difficulty swallowing. The UM reported she had worked on 12/22/15 and 12/23/15. She also stated a decline in oral intake of food and fluid would require a review of a resident's advanced directives. She reported the ST had told her Resident 1 did not do well when he was evaluated for his swallowing ability. When asked how she addressed the potential dehydration that would result from a reduced intake of a pureed diet, she reported she had only assessed his ability to swallow food, not fluid. In an interview with LN 1 on 1/6/16 at 11:50 a.m., he reported Resident 1 would sit up in his wheelchair to eat breakfast in the common area and stay up in his wheelchair until after he ate lunch. On 12/24/15 during the morning shift, Resident 1 appeared weak and the staff put him back to bed. LN 1 reported he was aware that Resident 1 was not eating or drinking. When asked, he reported he had learned in nursing school a person could only live about 72 hours without fluids. He reported he was unaware of how long Resident 1 had been unable to eat or drink. He reported he had not reported any changes, such as increased weakness, to the RP or MD, because he was waiting for the ST to give him further directions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 15 of 29 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 03/02/2018 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 In an interview with LN 2 on 1/6/16 at 12:20 p.m., she verified she worked on the morning of 12/22/15 and 12/23/15, and she did not make any notes in Resident 1's chart, despite the initiation of event charting on 12/22/15. She stated she was aware the ST was assessing Resident 1, and she was waiting for instructions from the ST before she proceeded. She reported she did not review Resident 1's advanced directives. LN 2 also stated she did not report Resident 1's condition to the UM on either day because the UM was the one who had told her Resident 1 could not swallow. In an interview with the ST on 1/6/16 at 12:27 p.m. she reported she completed an evaluation of Resident 1's ability to swallow on 12/23/15. Resident 1 was unable to consume food or fluids. She reported she had made note of the need for a discussion about the advanced directives with the family, but it was the responsibility of the nursing staff to ensure the advanced directives were followed. In an interview with the RP on 1/19/16 at 10:30 a.m., she reported the nursing staff contacted her on the morning on 12/22/15 to report Resident 1's inability to swallow. She was told a speech therapist would evaluate him the next day. On 12/23/15 she went to the facility at the request of the social service staff to sign papers authorizing a podiatrist to cut Resident 1's toe nails. While she was there she observed Resident 1 looked particularly "thin and hollow". She suspected he had not been eating prior to when the staff had notified her of his inability to swallow. The RP reported that at the time she signed the podiatry authorization, the social service person told her the ST had completed the evaluation and would provide therapy. The RP stated she had not been contacted by nursing staff with the results of the ST evaluation confirming Resident 1 could FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 16 of 29 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 03/02/2018 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 not swallow. She further stated nobody had explained to her that Resident 1's inability to swallow meant he would not be getting enough fluids. Furthermore nobody had explained to her that there was a limited time frame a person could live without fluids, and nobody approached her to discuss the use of IV hydration, as indicated in the advanced directives. The RP reported her father died on Christmas Eve and it felt horrible to not have anyone be there with him. She reported she would not have wanted the IV hydration forever, but she would have liked to have been able to delay her father's passing until the family could gather, and to do what they could to keep him alive through Christmas. In an interview with the DON on 2/2/16 at 2:30 p.m., she reported the documentation in Resident 1's clinical record indicated a nurse had contacted the family to report Resident 1's swallowing difficulties, and she confirmed there was no documented evidence the RP had been notified of the significance of being unable to eat or drink at the time the ST conducted her evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 17 of 29 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 03/02/2018 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

F322 NG TREATMENT/SERVICES - RESTORE EATING SKILLS CFR(s): 483.25(g)(2)

F322 03/21/2018

F327 03/22/2018 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on the comprehensive assessment of a resident, the facility must ensure that -(1) A resident who has been able to eat enough alone or with assistance is not fed by naso gastric tube unless the resident ' s clinical condition demonstrates that use of a naso gastric tube was unavoidable; and (2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. This REQUIREMENT is not met as evidenced by: 


F327 SS=G SUFFICIENT FLUID TO MAINTAIN HYDRATION CFR(s): 483.25(j) The facility must provide each resident with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 18 of 29 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 03/02/2018 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 sufficient fluid intake to maintain proper hydration and health. This REQUIREMENT is not met as evidenced by: Based on staff interview, family interview, and clinical record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was provided with the Registered Dietician's assessment of a daily need of 2320 milliliters of fluid a day to meet the resident's needs when he demonstrated he was no longer able to swallow. Resident 1 died on Christmas Eve, approximately 72 hours after his last known significant fluid consumption. Findings: The admission record for Resident 1 indicated he had been a resident of the facility for many years. His diagnosis included high blood pressure, paralysis (a lack of control over one's motor function) and dementia. The clinical record for Resident 1 included the following information: A Registered Dietician (RD) Nutritional Screening, dated 8/18/03, indicated Resident 1 required an estimated 2320 milliliters of fluid each day (A little more than 1/2 gallon.) A 3/4/10 physician order directed nursing staff to administer 37.5 milligrams of metoprolol (a high blood pressure medication) twice a day. A 1/28/13 POLST (Physician Orders for LifeSustaining Treatment) indicated Resident 1's Responsible Party (RP) marked the boxes indicating intravenous fluids (IV) and tube feeding were desired in the event they were needed. Medical Doctor 1's (MD 1's) signature FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 19 of 29 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 03/02/2018 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 on the form was dated 1/30/13. A 1/19/14 plan of care addressed Resident 1's potential for dehydration as a result of a pureed diet and advanced dementia. The care plan directed staff to, "Honor...[advanced directives]". The plan of care had not been updated with any resident specific interventions since its creation in 2014. A 8/29/14 physician order directed nursing staff to administer 12.5 milligrams of hydrochlorothiazide (a diuretic medication that helps remove excess fluid as a treatment for high blood pressure), once a day. A 10/20/15 Minimum Data Set (MDS, an assessment tool) indicated Resident 1 was able to feed himself at that time. The MDS also indicated Resident 1 was rarely or never able to make himself understood. A 10/21/15 RD note indicated Resident 1's average oral intake was 99% during the week of her assessment, and his weight fluctuated but remained stable between 145 and 150 pounds. He consumed a pureed diet. On 12/02/15 Resident 1's weight was recorded as 150 pounds. There was no additional subsequent weight information provided. The Vital Report in Resident 1's clinical record for the month of December 2015 included the following blood pressure readings: On 12/07/15 at 11:25 p.m., 141/83. On 12/12/15 at 10:10 p.m., 118/76. On 12/14/15 at 3:20 p.m., 116/73. On 12/14/15 at 5:46 p.m., 124/68. On 12/21/15 at 3:31 p.m., 135/71. A normal blood pressure reading would be under 120 and under 80. Resident 1's clinical record for the month of December 2015 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 20 of 29 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 03/02/2018 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 revealed blood pressure readings which would be considered normal to slightly elevated. A blood pressure reading of 141/83 is considered a high blood pressure. A 12/22/15 nursing note, written by the Unit Manager (UM) at 8:18 a.m., indicated Resident 1 was observed to let food drop out of his mouth. The UM notified MD 1 and the RP. There were no further nursing notes until the morning of 12/24/15. On 12/22/15 the UM faxed a communication to MD 1 requesting an order for a speech therapy evaluation. MD 1 responded on 12/23/15. MD 1 ordered a speech therapy evaluation and to continue monitoring Resident 1. On 12/22/15 the UM updated the plan of care to address Resident 1's inability to swallow. The goal was to prevent Resident 1 from choking on his food. There was no documented evidence the care plan for dehydration had been updated to address Resident 1's inability to consume food or fluid. On 12/23/15 at 11:00 a.m., the Speech Therapist (ST) notified MD 1 on a form for faxing, that Resident 1 had a severe inability to swallow. The form was not faxed, but left for the MD to review at the facility. The ST noted Resident 1 had a very limited intake of nutrition and the resident's POLST form included provision of alternative feeding methods. The form indicated this issue, "probably needed to be addressed by the family." The ST requested 3 additional speech therapy visits. On 12/23/15, MD 1 reviewed the ST note and ordered additional therapy visits. There was no documented evidence MD 1 followed through with the ST's recommendation to communicate to the RP the need to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 21 of 29 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 03/02/2018 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 implement the need for tube feeding of food and fluid as delineated in the POLST form MD 1 signed on 1/28/13. A report of Resident 1's oral consumption for the month of December indicated his food and fluids were provided to him in a pureed and/or thickened state and were tallied as a percentage total with no differentiation of the solid food from the fluids. The report indicated Resident 1 had been eating most of his meals between 12/1/15 and 12/16/15. Resident 1 had refused his evening meal on 12/21/15, and all meals on 12/22/15. He had eaten only 10% of the food/fluid combined lunch provided on 12/23/15 with no other documented intake for that day. On 12/24/15 the documentation indicated he ate 10% of his breakfast and only 5% of his lunch. Resident 1 expired before dinner on 12/24/15, approximately 72 hours after the lunch he consumed on 12/21/15. The Vital Report in Resident 1's clinical record for the month of December 2015 included the following additional blood pressure readings: On 12/21/15 at 3:31 p.m., 135/71 On 12/23/15 at 4:58 p.m., 129/70. On 12/24/15 at 12:36 a.m., 103/78. On 12/24/15 at 7:06 a.m., 101/55. These blood pressure readings demonstrated Resident 1's blood pressure was dropping, a possible indicator of dehydration. The 12/23/15 Medication Administration Record for Resident 1 indicated he had refused all of his medications, including the medications used to manage high blood pressure that day. A 12/24/15 nursing note written at 7:06 a.m., indicated nursing staff continued to monitor Resident 1 for difficulty swallowing. The note further documented the speech therapy evaluation had been completed and the nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 22 of 29 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 03/02/2018 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 staff was, "awaiting new treatment results". There was no documented evidence the nurse identified or responded to Resident 1's drop in blood pressure, despite Resident 1's refusal to take his blood pressure medications. A 12/24/15 nursing note, written at 3:11 p.m., indicated Resident 1 had been assessed at 12 p.m. that day, and he was experiencing a decline in his oral intake. There was no indication the nurse identified Resident 1's drop in blood pressure. A 12/24/15 nursing note, written at 3:40 p.m., noted Resident had been found dead at 2:55 p.m.. The note indicated RP 1 had been notified of the death. On 1/11/16 the Director of Nursing provided 2 pages from an unidentified nursing manual that represented the facility's procedure for monitoring for potential dehydration. The protocol identified dry mucous membranes, lower blood pressure, increased pulse, and unchanged or increased respirations as signs of dehydration. The protocol also identified relevant lab data, weight changes, and a decrease of urine output as other indicators of dehydration. In an interview with UM on 1/6/16 at 11:30 a.m., she reported Resident 1's swallowing difficulty was brought to her attention on the morning of 12/22/15 and she verified at that time the resident was unable to swallow. She stated she notified MD 1 of the need for a swallow evaluation. She included Resident 1 on, "Event Charting" for difficulty swallowing. She explained with, "event charting" the nursing staff were expected to assess and chart each shift for issues relating to the resident's difficulty swallowing. The UM confirmed there was no documented evidence FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 23 of 29 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 03/02/2018 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 of event charting notes for the evening of 12/22/15 or any nursing notes for 12/23/15. The UM reported she worked on 12/22/15 and 12/23/15. She reported the licensed nurses were responsible for entering the meal and fluid consumption information in Resident 1's chart. The UM also stated a decline in oral intake of food and fluid would require a review of a resident's advanced directives. She reported the ST had told her Resident 1 did not do well when his swallowing ability was evaluated. When asked how she addressed the potential dehydration that would result from a reduced intake of a pureed diet, she reported she had only assessed his ability to swallow food, not fluid. In an interview with Licensed Nurse 1 (LN 1) on 1/6/16 at 11:50 a.m., he reported Resident 1 would sit up in his wheelchair to eat breakfast in the common area and stay up in his wheelchair until after he ate lunch. On 12/24/15 during the morning shift, Resident 1 appeared weak and the staff put him back to bed. LN 1 reported he was aware that Resident 1 was not eating or drinking, and his blood pressure was low. When asked, he reported he had learned in nursing school a person could only live about 72 hours without fluids. He reported he was unaware of how long Resident 1 had been unable to eat or drink. He reported he had not reported any changes, such as Resident 1's weakness to the supervisor or an MD, because he was waiting for the ST to give him further directions. In an interview with LN 2 on 1/6/16 at 12:20 p.m. she verified she worked on the morning of 12/22/15 and 12/23/15, and she did not make any notes in Resident 1's chart, despite the initiation of event charting. She stated she was aware the ST was assessing Resident 1, and she was waiting for instructions from the ST FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 24 of 29 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 03/02/2018 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 before she proceeded. She reported she did not review Resident 1's advanced directives. She stated she did not report Resident 1's condition to the UM on either day because the UM was the one who had told her Resident 1 could not swallow. In an interview with the ST on 1/6/16 at 12:27 p.m., she reported she completed an evaluation of Resident 1's ability to swallow on 12/23/15. Resident 1 was unable to consume food or fluids. The ST reported she made note of the need for a discussion about the advanced directives, but it was the responsibility of the nursing staff to ensure the advanced directives were followed. In an interview with MD 1 on 1/6/16 at 2:15 p.m., he reported he was unfamiliar with the details about Resident 1's case and provided information on a hypothetical basis. He reported that in a hypothetical situation he would have expected the nursing staff to request IV hydration once the ST had verified a resident was unable to swallow. In an interview with LN 3 on 1/6/16 at 2:40 p.m., she reported she was not told Resident 1 could not swallow, she was told he refused his food. She reported she had observed him at dinner on 12/22/15 and he spit his food out. She reported, "event charting" required the staff to monitor and chart on Resident 1 each shift. She confirmed she did not check to see if there was any vitals information, (blood pressure, temperature, respiration, and temperature) to review as part of the monitoring. She stated she did not chart on the 12/22/15 or 12/23/15 evening shifts. She reported she had learned from the UM that Resident's 1 intake was poor, so she did not report to anyone his intake continued to be poor on her shifts. LN 3 reported she reviewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 25 of 29 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 03/02/2018 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 1's POLST form only to see if she needed to perform emergency resuscitation or send him to the hospital. She observed the boxes indicating a desire for resuscitation and/or hospitalization were left blank. She stated she did not review the POLST form for the interventions Resident 1's RP requested, the IV fluids and tube feeding on a trial basis. When asked, she reported she had learned in nursing school that a person would live about 72 hours without fluids. In a second interview with LN 2 on 1/11/16 at 12:30 p.m., she reported Resident 1 was normally very good at taking his medications and was unable to take his blood pressure medications on the day shifts of 12/22/15 and 12/23/15. LN 2 was asked how she would assess a resident for dehydration. She reported she would review his blood pressure, temperature, pulse rate and respiratory rate. When presented with Resident 1's vitals record she confirmed there was no data for her to review and she had not asked a Certified Nursing Assistant (CNA) to obtain it. She reported she would check a resident's mucous membranes. She confirmed she had not looked at Resident 1's mucous membranes. She reported she would wait for the CNA staff to tell her if there was decreased urination. She had not received any reports from the CNA staff of low urine output, and she did not ask them about Resident 1's urine output. LN 2 reported she did not report Resident 1's inability to take his medications to the MD. In a second interview with LN 1 on 1/11/16 at 12:50 p.m., he reported he charted he gave Resident 1 his blood pressure medications, but in actuality, he had gone to the resident when the ST was performing her therapy on the morning of 12/24/15 and she had told him the resident could not swallow, so he did not give FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 26 of 29 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 03/02/2018 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 the blood pressure medications. He reported he was not aware Resident 1 had been unable to take his medications on 12/22/15 and 12/23/15. He reported he was not aware that his shift on 12/24/15 was the third day Resident 1 was unable to take his medications. In an interview with the Director of Nurses on 1/11/16 at 2:30 p.m., she reviewed Resident 1's clinical record and reported there was no documented evidence the licensed staff considered providing IV hydration in light of Resident 1's inability to take in food or fluids. In an interview with the RD on 1/11/16 at 2:40 p.m., she reported Resident 1 had been very stable over the years and she estimated he required 1500 milliliters (a fluid measurement) of fluid a day. She reported it was her expectation that once the ST had completed her evaluation and determined Resident 1 could not swallow, the licensed nurses would have contacted her for a dietary assessment STAT (immediately) to address how they would meet his nutritional and fluid needs. She stated she was not notified of Resident 1's sudden inability to swallow until after his death. In an interview with the RP on 1/19/16 at 10:30 a.m., she reported the nursing staff had contacted her on the morning on 12/22/15 and reported Resident 1's inability to swallow. She was told an ST would evaluate him the next day. On 12/23/15, she had gone to the facility at the request of the social service staff to sign papers authorizing a podiatrist to cut Resident 1's toe nails. While she was at the facility she observed Resident 1 looked particularly thin and hollow. She suspected he had not been eating prior to when the staff had notified her of his inability to swallow. At the time she signed the podiatry authorization form the social FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 27 of 29 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 03/02/2018 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 service person reported the ST had completed the evaluation and would provide therapy. The RP reported nobody explained to her that Resident 1's inability to swallow meant he would not be getting enough fluids. Nobody explained to her there was a limited time frame a person could live without hydration, and nobody approached her to discuss the use of IV hydration, as per the POLST form. The RP reported her father died on Christmas Eve and it felt horrible to not have anyone be there with him. She reported she would not have wanted the IV hydration forever, but she would have liked to have been able to delay her father's passing until the family could gather, and to do what they could to keep him alive through Christmas. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KD9211 Facility ID: CA030000057 If continuation sheet 28 of 29 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 03/02/2018 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: KD9211 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 29 of 29