Inspection·June 5, 2024

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 interview, observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, which included measurable objectives and time limits to meet a resident's medical, nursing, and mental, and psychosocial needs for 1 of 6 residents (Resident #1) reviewed for care plans. Resident #1's comprehensive care plan dated 05/02/2024, inaccurately reflected the resident was receiving a regular texture diet. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings were: A record review of Resident #1's face sheet reflected Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of dysphagia (swallowing difficulties), Cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information and following instructions), Obesity (abnormal or excessive fat accumulation that presents a risk to health), and metabolic encephalopathy (a problem in the brain cause by a chemical imbalance in the blood). A record review of Resident #1's Quarterly MDS assessment, dated 04/26/2024, reflected Resident #1's BIMS score was 15 which indicated resident is cognitively intact. Resident #1's Quarterly MDS also reflected that Resident #1 was receiving a mechanically altered diet. A record review of Resident #1's Care Plan, dated 05/02/2024, reflected that Resident #1 was on regular texture diet. A record review of Resident #1's Physician Order, dated 06/05/2024, reflected Resident #1's mechanical soft texture diet start date was 09/22/2022 and was still a current order. A record review of Resident #1's Dietary Profile, dated 04/26/2024, reflected Resident #1's current texture of food was mechanical soft. In an interview with Resident #1 on 06/05/2024 at 11:10 am, Resident #1 stated she received a mechanical soft diet. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675311 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 06/05/2024 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)