Inspection·April 27, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Residents #182 and Resident #84 and waiting for that information from MDT. The MDSC stated the initial MDS assessment must be completed in 14 days and the quarterly assessment should be done every 3 months. She said non completion of comprehensive assessment on time would affect the effectiveness of the care plan. The MDSC stated she had completed a training on MDS at the beginning of her job. During an interview with the DON on 04/26/23 at 12:00 PM, she stated the MDS assessment was the responsibility of the MDSC. She stated completing the MDS assessments within 14 days of admission was important because nursing staff needed to know how to care for the residents and the care plan was developed with the information from MDS. The DON stated the MDSC had received MDS training from corporate MDSC. During an interview on 04/27/23 at 11:49 AM, the ADM stated the MDSC was responsible for the MDS assessments and the MDSC was supervised by the DON and the Corporate MDSC. When asked about the trainings that was provided to MDSC, ADM stated the Corporate MDSC should have trained the facility's MDSC, but he was hired after the MDSC, so he was not sure of what training the MDSC received. When the investigator asked about the monitoring at the facility for efficiency, the ADM stated the issues were discussed daily in the morning meetings, also issues were reviewed during QAPI if they were brought to their attention. The ADM stated the deficiencies if any in administration and nursing care would be addressed with training and education and in extreme situations with disciplinary actions. The ADM stated delayed MDS data submission would affect quality of care due to ab insufficient care plan, as the information from the MDS was important in developing care plans. Record review of the facility's document New MDS Nurse Training dated 02/01/23 reflected, on 03/01/22 the MDSC received training on various aspects of the MDS. According to 'The Assessment Schedule for the RAI on website: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/mds2 , revised in December,2022 and accessed on 05/01/2023 revealed: .The timing requirements for a comprehensive assessment apply to both completion of the MDS (R2b) and the completion of the RAPs (VB2). For example, an admission assessment must be completed within 14 days of admission. This means that both the MDS and the RAPs (R2b and VB2 dates) must be completed by day 14 . .admission Assessments: The admission assessment is a comprehensive assessment for a new resident that must be completed within 14 calendar days of admission to the facility if: o this is the resident's first stay, o the resident has just returned to the facility after being discharged prior to the completion of the initial assessment, or o the resident has just returned to the facility after being discharged as return not anticipated. The 14-day calculation includes weekends. When calculating when the RAI is due, the day of admission is counted as Day 1. For example, if a resident is admitted at 8:30 a.m. on Wednesday. (Day 1), a completed RAI is required by the end of the day Tuesday (Day 14), 13 days after admission. If a resident dies or is discharged within 14 days of admission, then whatever portions of the RAI that have been completed must be maintained in the resident's discharge record.1 In closing the record, the facility may wish to note why the RAI was not completed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 2 of 7 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 675311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Healthcare Residence 601 E Reunion St Fairfield, TX 75840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 2 of 8 residents (Residents #19 & #25) reviewed for care plans. 1.Resident #19's comprehensive care plan did not address the resident's use of oxygen. 2. The facility failed to develop a comprehensive care plan that addressed Resident #25's refusal of privacy bag and placement of drainage bag for s/p catheter; and the care plan failed to address his need for assistances when eating. These deficient practices could place residents at risk of receiving inadequate interventions that were not individualized to their care needs. The findings included: Review of Resident #19's face sheet, dated 04/26/23, revealed an [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation (characterized by a worsening of the patients respiratory symptoms, dyspnea, cough and/or sputum, more than the usual day to day variations and requiring changes to their medication), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), allergic rhinitis (allergic reaction that causes sneezing, congestion, itchy nose and sore throat), pneumonitis due to inhalation of other solids and liquids (your lungs have been inflamed by solids or liquid substances). Review of Resident #19's physician's orders, dated 03/17/22, revealed Resident #19 may use oxygen at 2 liters per minute per nasal canula - may take off if oxygen saturation above 92% and no shortness of breath noted - may increase to 4 liters prn. Review of Resident #19's MDS, dated [DATE] revealed Resident #19's BIMS score was 13 (out of 15) which indicated they were cognitively intact. Resident 19's MDS did reveal the use of oxygen. Review of Resident #19's Care Plan, dated 02/13/23, did not address the use of oxygen. Observation on 04/25/23 11:15 a.m. of Resident #19's room revealed Resident #19 using an oxygen machine inside of the room. Observation on 04/26/23 1:45 p.m. of Resident #19's room revealed Resident #19 using an oxygen machine inside of the room. Observation on 04/27/23 9:40 a.m. of Resident #19's room revealed Resident #19 using an oxygen machine inside of the room. Review of Resident #25's face sheet reflected a [AGE] year old male, admitted to the facility on [DATE] with diagnosis of Adjustment disorder with mixed anxiety and depressed mood (development of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 3 of 7 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 675311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Healthcare Residence 601 E Reunion St Fairfield, TX 75840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few emotional or behavioral symptoms in response to identifiable stressors), Major Depressive disorder, recurrent Moderate (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with doing normal day to day activities), Obstructive and reflux uropathy (when your urine can not flow through your ureter due to obstruction), Other Schizophrenia (a disorder that affects the person's ability to think, feel and behave clearly.), and Muscle wasting and atrophy (loss of muscle mass and shrinking of muscles that make them hard to use). Review of Resident's #25's MDS dated [DATE] revealed that on section G question H, indicated Resident #25 was dependent in eating, section C 0600 revealed a Bims score of 02, Section H 0200 shows urinary catheter and H0400 shows occasional bowel incontinence. Observation of Resident #25 on 4/25/23 at 08:30 a.m. revealed he was walking in the hallway, a privacy bag was not observed covering his Foley bag. Attempted to speak with resident, his is response was garbled and not in response to the conversation. An observation on 4/25/2023 at 230 p.m. revealed Resident #25 was resting in bed. His Foley bag was observed lying on floor next to bed with no privacy cover noted. Resident was sleeping and did not awaken to his name. An observation on 4/26/2023 at 830 a.m. revealed Resident #25 was in bed with his Foley bag lying on the floor with no privacy cover in place. Resident was laying in bed with his cover over his face, no interview was attempted. An observation on 04/26/23 at 1230 p.m. Observed CNA A hang Foley bag off the floor and Resident #25 was observed putting the Foley bag back on the floor. CNA A was observed assisting Resident #25 with his meal secondary to contracture of both hands. An observation on 04/26/23 at 2:30 pm revealed Resident #25 was ambulating in hallway. A privacy cover was observed covering his Foley bag. Approached resident who walked away while attempt to interview him. An observation on 4/27/23 at 11:30 a.m. revealed Resident#25 was in his room ambulating. A privacy bag was not observed on his Foley bag An interview with CNA B on 4/25/23 at 08:45 revealed Resident #25 either refused or removed his privacy covering and would throw Foley bag on the floor when it was hung from the bed or a chair. CNA B stated Resident #25 required assistance with eating at each meal. An interview with LVN A on 4/25/20 at 09:45 revealed Resident #25 either refused or removed his privacy covering and refused to have Foley bag changed to a leg bag during the day. LVN AF stated Resident #25 also refused to hang the Foley on the bed or chair and would throw it on the floor. When asked if that was care planned, LVN A stated they were not sure, but stated it should be as the behavior put the resident at risk for infections and catheter displacement. LVN A stated Resident #25 required assistance with eating secondary to muscle contractures in his arms. They stated that Resident #25 was sometimes he was able to use a weighted spoon and other times he was unable to lift it. An interview with CNA A on 4/26/23 at 0830 revealed Resident #25 would remove the privacy bag when placed unless someone he liked put it on. CNA A stated Resident #25 refused to have the Foley bag hang from the bed frame or a chair and would remove the Foley bag it and lay it on the floor. The CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 4 of 7 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 675311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Healthcare Residence 601 E Reunion St Fairfield, TX 75840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #25 required assistance with eating, some days he required cueing and on other days he required assistance with bringing the spoon to his mouth. An interview with LVN B on 4/26/23 at 10:30 a.m. revealed Resident #25 would allow her to place a privacy cover on his Foley bag but would often remove it shortly after. LVN A stated Resident #25 refused to leave the catheter bag hanging and would place it on the floor or sometimes lay it on the bed with him. LVN A stated Resident #25 did require assistance with eating and his ability to participate waxes and weans depending on his mood. Review of Resident # 25's care plan dated 3/16/2023 revealed it did not address that Resident #25 did not want the privacy cover on his Foley bag, that Resident #25 would not keep the bag hanging and would place the Foley bag on the floor. Resident #25's care plan did not reflect his needs for assistance with eating. An interview with the MDSC on 4/26/23 at 2 p.m. revealed Resident #25's behaviors were not captured on the MDS dated [DATE]. The MDSC stated it should be noted in the MDT or morning meeting and she would update the care plan as appropriate. The MDSC stated each discipline in the MDT had a section they were responsible for completing the care plan associated with the section of the MDS they completed. The MDSC stated that a resident that refused a Foley bag covering, proper placement and needed assistance with eating was at risk for medical complications and dignity issues if not care planned. The MDSC said nurses would know that a resident was receiving oxygen per physician's orders. Interview with the DON on 04/26/23 at 1:20 p.m. the DON stated baseline care plans are completed by the DON or RN and the comprehensive care plans are completed by the MDSC. She uses the information from the MDS, MDT, and morning meetings to ensure care plans reflected the care each resident is receiving. The DON said if a resident was receiving oxygen therapy it should be care planned. The DON stated a resident would not receive adequate care to meet their needs if they are not care planned for it. In a subsequent interview at 2:30 p.m. the DON stated residents with behaviors that are not compliant with Foley management and needed assistance with eating are at risk for medical complications and dignity issues and should be on the care plan. Interview with the ADM 4/27/23 at 10:30 a.m. revealed care plans are updated by the MDS nurse. The ADM stated the MDSC was supervised by the DON and Corporate MDSC. The ADM stated his/her expectation is that the care plan is updated from the MDS, MDT and morning meetings and the MDSC is responsible for that. The ADM's stated expectation is that someone who is not compliant with his Foley care and who needed assistance with eating should have a care plan that reflects those needs and preferences. The ADM stated if there were concerns that were not addressed on the care plan it could result in dignity issues and medical complications. The ADM stated the resident receiving oxygen should be care planned for oxygen therapy. The ADM said if a resident was not care planned for oxygen the facility would be out of compliance and the resident would not receive adequate care. The ADM stated the Corporate MDSC should have trained the facility's MDSC, but he was hired after the MDSC, so he was not sure of what training the MDSC received. A record of review of the facility's Care Plan Policy dated 02/13/2007, reflected, the facility will develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetable to meet a residents medical, nursing and mental and psycho-social needs that are identified in the comprehensive assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 5 of 7 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 675311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Healthcare Residence 601 E Reunion St Fairfield, TX 75840 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 0656 Level of Harm - Minimal harm or potential for actual harm A record of review of the facility's IDT Inservice Care Plan not dated, reflected What needs to be Care Planned: A record of review of the facility's IDT Inservice Care Plan not dated, stated What needs to be Care Planned: Residents Affected - Few MDS: CAA's Psychotropic Medications (Anti-depressant, Hypnotic, Anti-Anxiety, Anti-Psychotic) Geri Chairs (comfort/positioning), Behaviors Medical Diagnosis Allergies Restraints Foley Catheters Feeding Tubes ADL's , even if they do not trigger on the CAA's Quality Measures ACTIVITIES: Residents likes/dislikes/preferences Residents Activities /preferences Update anytime there is a change Dietary Diets (ensure all restrictions are addressed) Update anytime there is a change SOCIAL SERVICES Code Status Discharge planning Psych Services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 6 of 7 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 675311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Healthcare Residence 601 E Reunion St Fairfield, TX 75840 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 0656 Update anytime there is a change Level of Harm - Minimal harm or potential for actual harm TREATMENT NURSE All wounds on the wound report Residents Affected - Few Make sure to update with any changes and resolve out once wound heals DON/ADON Acute Care plan related to incidents (bruises, falls, new orders related to the incidents) Make sure the intervention s are updated Safety Devices (hipsters, bolsters, alarms, anti-tippers, anti- roll back, wander guards) Infections (acute care plan) Weight loss Review and resolve when needed. The care plan needs to be resident centered. Discuss with the residents their preferences. Make sure their preferences are in the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 7 of 7