Inspection·June 26, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/26/24 at 2:00 PM, CNA A stated all the smoking residents' cigarette smoking materials were locked up at the nursing station and provided to them only at the scheduled smoking period. She stated, as per the ongoing practice , one of the staff members supervised them while they smoked. When the investigator asked her, where did she get the plan, she stated it was the usual practice at the facility. She said she did not look at the care plan in PCC. Residents Affected - Few Interview on 06/26/24 at 2:30 PM with the DON revealed there was no MDS Coordinator working at the facility. The DON said the MDS was completed at the corporate office for all the residents, and it was the responsibility of the IDT to make sure the care plan was up-to-date. She stated a proper care plan for smoking was necessary to ensure the safety of the residents who smoked and other residents and staff at the facility, from fire hazards. She stated there were two residents at the facility who smoked, and they smoked under the supervision of a staff member. The DON stated individual assessments and care plans for smoking were necessary as the capabilities to carry out smoking safely varies from resident to resident. The DON stated she checked the care plans and confirmed that the other smoker at the facility had a care plan for smoking. However, Resident #13 did not have a care plan for smoking. During an interview at 3:45 PM, the ADM stated a person-centered care plan was important to achieve the set goals as it gave direction to the staff for implementation of tasks. He stated the care plan for smoking was essential to minimize fire hazards occurring from smoking and thus ensure safety of everyone at the facility. The ADM stated the primary responsible person for developing a care plan was the MDS coordinator. However, it was the responsibility of every individual in the IDT to make sure the safe smoking assessment was conducted periodically and a care plan for smoking was developed for the residents who smoked at the facility. Record review of in-service records revealed there were no in- services on smoking, between 04/01/24 and 06/26/24. Review of the facility's Care Plan, Comprehensive Person Centered policy, dated March 2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problems areas and conditions . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 2 of 5 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 06/26/2024 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)

F 0656 12. The interdisciplinary team reviews and updates the care plan: . Level of Harm - Minimal harm or potential for actual harm . at least quarterly, in conjunction with the required quarterly MDS assessment Review of the facility's Smoking Policy-Residents policy, revised in August 2022, revealed: Residents Affected - Few . 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 3 of 5 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 06/26/2024 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)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one (Hand Sink #1) of one hand sink in the kitchen reviewed. Residents Affected - Some The facility failed to ensure the safe and sanitary operation of the solitary hand sink (Hand Sink #1) in the kitchen which resulted in the contaminated water from the hand sink coming out of the floor of the dishwasher area. This failure puts residents at risk for inadequate hand hygiene by staff, food borne illness and decreased quality of life. Findings included: An observation on 06/25/2024 at 6:40 AM revealed the hand sink, when used, the water came out of the floor drain in the dishwasher area adjacent to the hand sink. The water coming out of the floor drain after hand sink use was clear but had a strong foul odor. In an interview on 06/25/2024 at 6:41 AM, DIET AIDE F stated to turn the water and do not use the hand sink as it drained out of the floor drain in the dishwasher area. He stated the hand sink drain line had been backed up for a couple of weeks and their maintenance director would unclog it when he had time. He did not know the last time the maintenance director had to unclog the drain line. In an interview on 06/25/2024 at 6:44 AM, COOK G stated the drain line from the hand sink to the sewer line would back up if they used the hand sink which resulted in the water from the hand sink coming out of the floor drain. She said it had been that way for a couple of weeks. She said they recently remodeled the kitchen and when they put the hand sink in place, the drain started backing up. She reported the hand sink issue to the DM and used the other sinks in the kitchen to wash her hands when needed. In an interview on 06/25/24 at 10:15 AM, the DM stated the hand sink was an issue for a while but then a plumber snaked it and it worked again. She stated it must have backed up again and their maintenance director would just need to clear the drain line again. The kitchen floor was recently replaced and they recently moved the hand sink back into place. She stated maybe it messed up the pipes because the maintenance director fixed it again this morning and the water draining from the hand sink no longer came out of the floor drain in the dishwashing room. She stated the inability for staff to wash their hands at a designated sink put residents at risk of staff having poor hand hygiene and residents at risk for food borne illness due to contamination. She stated they just notify the maintenance director verbally of any maintenance needs in the kitchen and he fixed everything as needed. She said they do not have a maintenance log or other form of record keeping for maintenance requests from the kitchen. She stated she knew the two nursing stations had maintenance request books, but the kitchen did not use those books for logging their maintenance requests. She did not know why the kitchen did not have a maintenance log book. In an interview on 06/25/2024 at 2:30 PM, the MAINTENANCE DIRECTOR stated he had to snake the drain from the hand sink and it started draining normally. He stated the line can be clogged due to grease etc, and when needed, he cleaned out the line. He stated the DM notified him it was clogged this morning and then he unclogged it within a few hours. He stated if the hand sink in the kitchen was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 4 of 5 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 06/26/2024 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)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not operational, then the staff would have to use a sink not designated for hand washing to wash their hands. He stated this could put residents at risk for contaminated foods causing illness. In an interview on 06/26/24 at 11:30 AM, the ADMIN stated the MAINTENANCE DIRECTOR cleared the hand sink drain line yesterday and it was now fully operational. He stated the sink line should not have been clogged as it made the hand sink non-operational. He stated dietary staff would have to use a different sink until the hand sink was finished. He stated they may look into putting in a second hand sink, so that if one is not working they always have an extra. He stated not having an operational hand sink put residents at risk for food borne illness due to lack of hand hygiene. Review of Equipment Maintenance policy undated revealed a log of required maintenance will be kept to ensure maintenance requests are completed as required and timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 5 of 5