Inspection·August 7, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete two rooms and deep cleaned them daily. If there was an infection outbreak, the expectation was to deep clean those rooms daily to keep it from spreading. He stated if the rooms were not clean it could make the resident feel bad. He stated they were picking rooms systematically. During a slower workday, everyone would pitch in to assist with getting some of the rooms done. Interview and observation on 08/07/25 at 11:50 AM, the HSKE revealed she was the supervisor, and she made sure all her staff deep cleaned 2 rooms a week. She stated the staff used a disinfectant spray and wiped down everything. She stated when the residents were not in the room, they wipe down the beds and mattresses. She stated maintenance did all the broken items repairs. She stated there was a book at the nurses' station and they wrote all the repairs that needed to be done in the book, and he looked at it daily. She stated when they were going into the COVID positive rooms, they cleaned them last. She stated her staff gown up and sanitize. They disinfect and clean up everything. Record review of the facility's, undated, policy on Residents Rights reflected .You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of facility policy dated February 2021 and titled, Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible. Event ID: Facility ID: 675311 If continuation sheet Page 2 of 9 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 08/07/2025 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit and ensure an MDS was completed and electronically transmitted to the CMS System for within 14 days, after completion resident assessment within the required time frame, for 1 of 6 (Resident #19) residents reviewed for data transmission in that: The facility failed to complete and transmit Resident #19's quarterly MDS completed on 07/05/25. This failure could place residents at risk of not having their assessments transmitted timely and an incomplete record. Findings included:Record review of undated facility face sheet reflected Resident #19 was admitted to the facility on [DATE]. Medical diagnoses diagnosis included Hemiplegia and Hemiparesis following cerebral infarction (paralysis caused by a stroke), Covid 19, Malignant Neoplasm of the Prostate (prostate cancer), and Diabetes Mellitus type 2. Record review of Resident #19's quarterly MDS assessment dated [DATE] reflected the MDS had been completed but was not transmitted. In an interview on 08/07/2025 at 1:41PM, the MDSC stated she was not sure why Resident #19's quarterly MDS from 07/05/2025 was not transmitted. She stated the MDS was checked do not transmit. The MDSC stated that she was responsible for the transmission of the MDS but there was a system error. Record review of policy titled Electronic Transmission of the MDS dated 2021 and revised October 2023 reflected All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' Internet Quality Improvement and Evaluation System (iQIES) system in accordance with current OBRA regulations governing the transmission of MDS data. All staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the Resident Assessment Instrument (RAI) User's Manual, before being permitted to use the MDS information system. A copy of the RAI User's Manual is maintained by the resident assessment coordinator. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 3 of 9 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 08/07/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 5 residents (Resident #4) reviewed for accuracy of assessments.The facility failed on 6/8/2025 to accurately code Resident #4's hearing ability on his comprehensive MDS assessment.This failure could place residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included:Record review of Resident #4's comprehensive MDS, dated [DATE], indicated Resident #4 was a [AGE] year-old male, who was admitted to the facility on [DATE]. His diagnoses included: stroke (when a blood vessel in the brain leaks or bursts and causes bleeding in the brain), aphasia (inability to speak well), dysphagia (difficulty swallowing), hemiplegia (total or nearly complete paralysis on one side of the body) and muscle wasting and atrophy.Resident #4 did not have a BIMS score as question ‘C0100. Should Brief Interview for Mental Status be conducted? Was indicated as ‘0. No (resident is rarely/never understood)'. In ‘Section B Hearing' question B0200 indicated that Resident #4 was Highly impaired - absence of useful hearing and question B0700 indicated that Resident #4 was rarely/never understood. Record review of Resident #4's comprehensive MDS, dated [DATE], reflected that Resident #4 did not have a BIMS score as question ‘C0100. Should Brief Interview for Mental Status be conducted? Was indicated as ‘0. No (resident is rarely/never understood)'.In ‘Section B Hearing' question B0200 indicated that Resident #4 had Adequate no difficulty in normal conversation, social interaction, listening to TV' and question B0700 indicated that Resident #4 was ‘Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.Record review of Resident #4's care plan dated last revised 07/28/2025 reflected Resident #4 was very hard of hearing, could read lips, would communicate with head nods, and had a communication problem related to difficulty hearing and aphasia. Interventions included staff to look directly at him and talk slow so he could understand and give him time to process due to the stroke. Record review of a nursing note dated 09/01/2021 reflected, Resident admitted via EMS with personal belongings-hearing aide x1 placed inside table drawer. Unable to speak or help turn-total care x2. Does not appear to be in any pain. Resident is deaf but reads lips- does not appear to understand what is being asked of him and does not follow commands at all.Record review of Resident #4's weekly nursing summary dated 07/29/2025 reflected in section ‘D. Communication'Question ‘1. Ability to express ideas and wants, consider both verbal and non-verbal expression' was answered with ‘3. Rarely/never understood.'. Question ‘1a. If impaired ability to make self-understood, choose the example that applies' was answered with ‘5) Unable to make needs known, all needs anticipated and met by staff.Question ‘2. Ability to hear (with hearing aid or hearing appliances if normally used)' was answered with ‘3. Highly impaired'Record review of Resident #4's progress note dated 07/29/2025 reflected, Resident's responsible party had inquired about hearing testing services. Resident to be referred to [hearing aid center] that services nursing home residents. Face sheet sent to [hearing aid center] for implementation of referral process.In an observation and attempted interview on 08/05/2025 at 10:31 AM Resident #4 was in his bed asleep and did not arouse when the surveyor was talking or nearing his bedside. After about 30 minutes of the state surveyor speaking with Resident #4's roommate, Resident #4 appeared to be awake. When asked by the surveyor about his stay at the facility, his care, and his daily activities, Resident #4 just blankly stared at the surveyor and did not respond with head gestures or words. In an additional attempted interview and observation on 08/06/2025 at 11:17 AM Resident #4 was lying in bed revealed when the state surveyor asked him how he was doing, he had a blank stare and shook his head in a ‘no' motion about 45 seconds after being asked. When the state Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 4 of 9 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 08/07/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete surveyor asked for permission to check his bedside table for hearing aids, he slowly moved his head to look in the direction of the surveyor's finger, but he did not respond with head movements or words. In an interview on 08/06/2025 at 11:29 AM with LVN A she stated she had worked at the facility almost 4 years. She stated that Resident #4 never pressed his call light. She stated that he worked with occupational therapy, received tube feedings, and that when the aides provided check and change of undergarments, he could hold the bed rail with his one good side. She stated that he was able to understand the staff, but he was not able to communicate his needs at all due to his diagnosis of stroke. She stated that he was not a big fan of being up out of bed. She stated that when Resident #4 first admitted , he had hearing aids , but she was unsure what happened with them, and she stated he was able to hear based on his ability to help during check and change. In an interview/observation on 08/06/2025 at 11:43 AM with CNA B she stated she had worked at the facility for about 5 years. She stated that a restorative aide works with Resident #4 in his room and that Resident #4 stopped using his call light at the beginning of 2025. When asked, she stated that the only things he would be using his light for was to notify of needing to have his brief changed or wanting to get into his wheelchair. CNA B then asked the state surveyor how the resident was supposed to communicate with the staff if he was deaf and could not press his call light now, and how the staff were supposed to know what he needed. The surveyor advised her to speak to her DON. CNA B stated that Resident #4 used to have hearing aids when he first admitted , the CNA's were responsible for putting them in and taking them out. She was not sure what happened to them. She showed the surveyor 1 hearing aid located in a sealed container in Resident #4's dresser. In an interview on 08/07/2025 at 9:31 AM with the DOR and the MDSC, the DOR stated that physically Resident #4 was able to press the call light, but he chose not to. She stated that he could grasp and lift 3lb weights, so they knew he was able to press the call light as well. She stated that he could help dress himself and that he would laugh and communicate by head gestures and smiles during therapy sessions. When the MDSC was asked why Resident #4 was marked as having adequate hearing this year versus being highly impaired last year, she stated that she was not the MDSC when his last year's assessment was conducted, but that this year she had interviewed him, and he had smirked at her, and nodded at her. The DOR stated she thought it was because he was reading lips, not because he was able to hear.In an interview on 08/07/2025 at 9:47 AM, the DON stated Resident #4 was put on the hearing aid referral list on 7/29/2025, she stated that they went through and assessed the residents who could benefit from being seen by the hearing aid company. She stated that Resident #4 had hearing aids in the past, but they were unable to determine if the hearing aids were working upon admission. She confirmed that he had a hearing impairment, and it was documented in the clinical record that he was deaf. In an interview on 08/07/2025 at 12:35 PM with the MDSC she stated that they did not have an MDS Accuracy policy, they just referred to the RAI Manual. Review of the Long-Term Care Facility RAI 3.0 User's Manual dated last revised October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status Event ID: Facility ID: 675311 If continuation sheet Page 5 of 9 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 08/07/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts reviewed.The facility failed on 07/27/2025 to sufficiently record the accurate reconciliation of controlled substances.This failure could place residents at risk of misappropriation of resident medication.Findings included:Record review on 08/05/2025 at 2:07 PM of the [NAME] wing medication cart's narcotic sign on and sign off sheet revealed that LVN E failed to sign that the narcotics were counted with LVN D when LVN E assumed the medication cart on 7/27/2025, and when she handed off the medication cart at the end of her shift on 7/27/2025 to LVN D.In an interview on 08/05/2025 at 2:30 PM with LVN D she stated that she always signed off with someone when doing the narcotic count. She stated that 2 people always counted the cart, it was required that the person coming on shift and the person going off shift, were to count the cart together and sign that it was done. She stated she passed the cart off to LVN E on 7/27. She stated that immediately after counting they were supposed to sign off on the narcotic sign on and sign off log. She stated that once she finished counting, and signed the narcotic log, she did not stand there to watch the other person sign. She stated the purpose of counting the narcotics was to keep an accurate count of the narcotics and verifying that all medications were accounted for. She stated it helped if there was a medication discrepancy, they would know who worked. She stated a negative outcome was that if medications were not accounted for it was an issue of misappropriation. If she had a discrepancy in count, she had to immediately notify her DON. In an interview on 08/06/2025 at 1:10 PM with LVN E she stated that she had worked at the facility for about 5 years and recently went PRN. She stated that she did always count the cart at the beginning of her shift with the outgoing nurse and then she would count the cart at the end of her shifts with the oncoming nurse. She stated that she did not know why she did not sign the sign off sheet on 07/27/2025 but that it was hers and the facility's practice to not assume the medication cart until counting with the prior shift nurse. She stated that it was the responsibility of both the outgoing nurse and the oncoming nurse to sign the log as proof of the narcotics being counted together. She stated that a negative outcome would be that it could appear that the narcotics were not being counted amongst the shift changes. In an interview on 08/07/2025 at 9:17 AM with the DON she stated the purpose of the narcotic sign on and sign off log was to verify that the narcotic count on the cart was correct. When asked what would blanks on the narcotic log indicate to her, she stated that she would first question if a 2-person count occurred, but ultimately it would tell her if the cart was properly counted by the outgoing and ongoing nurse. She stated that signing the log was for quality control measures, and it could affect the residents' if their medications were not being counted and if doses were missing. She stated it was the responsibility of both nurses to sign the log when handing it off and when assuming it. She stated they (DON or ADON) should verify the logs weekly. She stated that when the sheet ran out of space, it would be turned into and verified by the ADON or DON.Review of the facility's policy titled ‘Controlled Substances' dated July 2025 reflected: Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record.The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Event ID: Facility ID: 675311 If continuation sheet Page 6 of 9 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 08/07/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #3, Resident #19, Resident #32, and Resident #33) reviewed for infection control.The facility failed to supply staff with proper eye/face PPE for Resident #19 who was in droplet isolation during an observation of supplies on 08/05/2025.MA C failed to properly sanitize the blood pressure cuff after use on Resident #3 and Resident #33 during an observation of medication administration on 08/06/2025.MA C touched medications with her fingers prior to administration to Resident #38 during an observation of medication administration on 08/06/2025.This failure could place residents at risk for infection by the spreading of germs that could lead to illness and hospitalization. Findings included: Resident #19Record review of undated facility face sheet reflected Resident #19 was admitted to the facility on [DATE]. Medical diagnosis included Hemiplegia and Hemiparesis following cerebral infarction (paralysis caused by a stroke), Covid 19, Malignant Neoplasm of the Prostate (prostate cancer), and Diabetes Mellitus type 2. Record review of Resident #19's Quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #19's care plan dated 07/27/2025 reflected he tested positive for covid 19 on 07/27/25 and interventions included Quarantine in their room. Notify family and encouraged to limit visitation and to wear masks while in the facility, full PPE when in a positive resident's room. Droplet and contact precautions.In an observation 08/05/2025 at 9:45am 4 (four) white plastic bins were located outside of rooms in the hallway. The bins contained PPE, blue gowns and surgical mask. Resident #19 had a sign on his room door indicating he was in isolation with droplet precautions. Staff were observed going in and out of Resident #19's room not wearing face shield or eye protection. There were no face shields or eye protection available/accessible for staff in the PPE bins.Resident #3Record review of undated facility face sheet reflected Resident #3 was admitted on [DATE]. Diagnosis included Heart Failure, Hyperglycemia (elevated blood sugar), Hypertension (elevated blood pressure), and Lack of Coordination. Record review of Resident #3's care plan dated 06/09/2024 and updated 12/27/2024 reflected an alteration in cardiovascular status (a disease process affecting the heart). Interventions included to monitor Vital Signs (blood pressure, heart rate, respirations, and temperature) everyday as ordered. Notify physician of any abnormal readings.Record review of Resident #3's quarterly MDS dated [DATE] reflected a Bims score of 15 indicating he was cognitively intact. In an observation of medication administration on 08/06/2025 at 9:44 AM, MA C checked Resident #3's blood pressure using an electronical wrist cuff. MA C completed the check and cleansed the blood pressure cuff with alcohol-based hand sanitizer and nose tissue. Resident #33 Record review of undated facility face sheet reflected Resident #33 was admitted on [DATE]. Diagnosis included Major Depressive Disorder, Hyperglycemia (elevated blood sugar), Anxiety, and Hypertension (elevated blood pressure).Record review of Resident #33's care plan dated 05/05/2025 reflected an alteration in cardiovascular status. Interventions included to Obtain blood pressure readings as ordered. Take blood pressure readings under the same conditions each time. For example, resident is sitting, use right arm.Record review of Resident #33's quarterly MDS dated [DATE] reflected a Bims score of 14 indicating she was cognitively intact. In an observation of medication administration on 08/06/2025 at 9:56AM, MA C checked Resident #33's blood pressure using an electronical wrist cuff. MA C completed the check and cleansed the blood pressure cuff with alcohol-based hand sanitizer and nose tissue. Resident #32Record review of undated facility face sheet reflected Resident #32 Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 7 of 9 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 08/07/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was admitted on [DATE] and readmitted on [DATE]. Diagnosis included Senile Degeneration of the Brain (a disorder of the brain resulting in confusion), chronic kidney disease (failure of the kidneys), Major Depressive Disorder (depression), and Lack of Coordination. Record review of Resident #32's quarterly MDS dated [DATE] reflected a Bims score of 14 indicating she was cognitively intact. Record review of Resident #32's care plan dated 06/09/2024 reflected an alteration in respiratory status. Goals included The resident will be free of signs of respiratory infections through review date. Interventions included Monitor/document/report to MD PRN any signs of respiratory infection Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing.In an observation of medication administration on 08/06/2025 at 10:10AM, MA C prepared Resident #32's medication for administration pushing her Thermotab (a medication administered to maintain sodium levels in the body) 1 tablet out of the multiple dose bottle with her bare fingers. In an interview on 08/07/2025 at 12:50 PM, MA C stated normally there were some types of disinfected wipes on the medication cart. MA C stated the facility kept a stock of disinfectant blue top wipes in the supply closet on the left side in storage, but staff did not have a key to access the supply room to obtain the wipes. MA C stated not using the proper disinfectant on equipment such as the blood pressure cuff could spread germs from one resident to another. MA C stated medications should not have been touched without gloves on, but the pill was stuck, and it would not come out of the bottle. MA C stated touching medication with unclean hands could lead to the spreading of infection. In an interview on 08/07/2025 at 12:55 PM, LVN A stated the facility had not provided eye covers, or face shields for staff to use in the droplet isolation rooms. LVN A stated she did not question the need for the eye shields because it had been so long since the facility had infections in the building that require the use of eye coverage. LVN A stated the risk for not using proper PPE when a resident was on droplet precautions would be spreading of the infection. In an interview on 08/07/2025 at 1:01 PM, the ADON stated she was the infection preventionist for the facility. The ADON stated the face shields were in the supply room and the staff could acquire them if needed. She stated not wearing proper PPE could increase chances of spreading germs. The ADON stated the MAs were expected to use proper sanitizing wipes when cleaning medical equipment that were located in the supply room. The medication aides are not expected to touch medications with their bare hands; they need to wear gloves and clean their hands if a medication were stuck in the bottle. The ADON stated not cleaning with appropriate disinfectant wipes and touching medications with their bare hands would allow for contamination of the medications and spreading of infections.In an interview on 08/07/2025 at 1:19 PM, the DON was responsible for monitoring infection control, and it was her expectation infection control polices be followed. The DON stated the risk to residents by not following proper infection control practices was spreading germs. Record review of facility policy titled Coronavirus Disease (Covid 19)-Using Personal Protective Equipment dated 2001 and revised September 2022 reflected: Personal protective equipment is provided to all employees, contractors, and volunteers free of charge.a. Eye Protection:(1) Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area.(a) Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face do not protect eyes from all splashes and sprays.(b) Ensure that eye protection is compatible with the respirator so there is not interference with proper positioning of the eye protection or with the fit or seal of the respirator.(3) Eye protection is removed after leaving the resident room or care area.(4) Disposable eye protection is discarded after use.Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment dated 2001 and revised September (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675311 If continuation sheet Page 8 of 9 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 08/07/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 2022 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.a. Non-critical items are those that come in contact with intact skin but not mucous membranes.(l) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers.(2) Non-critical environmental surfaces include bed rails, bedside tables.(3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal).a) Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPA- registered hospital disinfectants with a HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment.b) Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used. Event ID: Facility ID: 675311 If continuation sheet Page 9 of 9