Health inspection·July 26, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed expired Novolog insulin for Resident # 36 with an open date of 6/25/2023 and should have been discarded after 28 days of opening. 2. Record review of facility face sheet dated 7/26/2023 indicated Resident #64 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of COPD (chronic obstructive pulmonary disease, breathing impairment). Record review of physician orders dated 12/16/2022 indicated an order for atropine sulfate solution 1% place 2 drops buccally every 2 hours as needed for increased secretions, furosemide solution 10mg/ml 4 m inhale orally via nebulizer every 6 hours as needed for shortness of breath, and glycopyrrolate capsule 14 mcg inhale orally via nebulizer every 4 hours as needed for increased secretions. Record review of comprehensive care plan dated 07/04/2023 indicated Resident # 64 had altered respiratory status related to COPD and to administer medications as ordered. Record review of quarterly MDS dated [DATE] indicated BIMS of 06 indicating severely impaired cognition. During an observation on 07/25/2023 at 9:30 am with LVN D the medication cart located on hall 300 revealed Resident # 64 had furosemide 10mg/ml inhalation solution with discard date of 7/20/2023, atropine sulfate 90 mcg inhaler with expiration date of 6/2023, and glycopyrrolate 14 mcg inhalation capsule with discard by date of 5/14/2023. 3. During a record review of the facility's drug destruction log for the last 9 months (October 2022, February 2023, March 2023, April 2023, May 2023, June 2023, and July 2023), revealed the drug destructions for controlled drugs dated 10/10/2022, 02/06/2023, 03/01/2023, 04/10/2023, 05/08/2023, 06/14/2023, and 07/10/2023 indicated that the attached pages of medication destruction did not include the initials of the consultant pharmacist and two witnesses. During an interview on 07/25/2023 at 9:45 am LVN D stated she had worked at the facility for 8 years and just moved to hall 300 located at station 1 a week ago. She stated she had been working on the medication cart to get it cleaned up but had not been able to get it done. She stated the nurses check the carts for expired medications when they could but there was no specific schedule. She stated she had not told anyone about the cart having expired medicine. She stated the nurses used a chart that helped with medication expiration dates or use by dates for knowing when medications like insulin would expire. She stated the risk of a resident receiving expired medications could be the medicine not working correctly. During an interview on 7/25/2023 at 10:04 am the ADON stated the nurses were responsible for checking the medicine carts for expired medicine and prior to administering any medicine. She stated she and the DON also checked the carts periodically but there was no actual system in place. She stated the risk of not removing expired medications or a resident receiving expired medication could be ineffective medication. During an interview on 7/25/2023 at 10:09 am the DON stated the medication carts were to be checked by the nurses and all medicine should be checked prior to administering. She stated she and the ADON performed audits monthly and removed expired medicines as needed but there was no formal documentation. She stated the pharmacist checked all medication carts monthly and would document the findings for her to review. She stated the risk to the resident receiving expired medication could be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676123 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 676123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Nursing & Rehabilitation Center 420 Moody 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 ineffective medication and going forward she would put in place a new monitoring system to ensure expired medications were removed from medication carts. She stated she was not aware that the medication destruction log pages had to be initialed by the pharmacist and 2 witnesses and thought the cover sheet was enough documentation. She stated she expected going forward the rule for proper documentation was followed and the risk could be a drug diversion. Residents Affected - Some During an interview on 7/26/2023 at 10:14 am the pharmacist stated she came to the facility monthly and the medications carts were audited a few months ago. She stated when she found expired medications on the medication carts she removed those medications and the ADON or DON were given the audit for review. She stated the medication carts storing expired medications could place residents at risk of receiving medications that were of poor quality. She stated she came to the facility monthly and that she completed drug destructions with the DON, ADON and/or Administrator at least quarterly but usually monthly. She stated she was not aware that each attached page to the drug destruction cover sheet had to be initialed by the pharmacist and 2 witnesses but would see that it was corrected on the next destruction. She stated she did not see a risk because she knew the medicines were destroyed. During an interview on 7/26/2023 at 10:45 am the administrator stated that the medication carts were the responsibility of the charge nurses and all expired medications should be removed timely to prevent a resident from receiving an expired medicine. She stated the DON and ADON were responsible for oversight of the medication chart audits and expected all medication carts to be free of expired medicine in order to prevent a resident from receiving medicine that could be ineffective. She stated that she was not aware of the need for initials on each attached page of the drug destruction but going forward expected the medication destruction rules to be followed to prevent a drug diversion. Record review of facility policy titled Recommended Medication Storage dated 7/2012 indicated, .Novolog expires 28 days after initial use regardless of product storage . No other policy provided by the facility in regard to medication storage. Record review of 22 TAC §303.1 Destruction of Dispensed Drugs (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676123 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 676123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Nursing & Rehabilitation Center 420 Moody 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 (iii) date of drug destruction. Level of Harm - Minimal harm or potential for actual harm (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; Residents Affected - Some (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse. Record review of facility policy and procedure titled Drug Destruction dated July 10, 2013, indicated, .2. Drugs to be destroyed under the supervision of a consultant pharmacist and at least one of the following DON, ADON, or Administrator and this policy failed to meet the standards of the regulation under 22 TAC 303.1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676123 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 676123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Nursing & Rehabilitation Center 420 Moody 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure a medication error rate of less than 5 percent. There were 3 errors out of 42 opportunities, resulting in a 7.14 percent medication error involving 3 of 9 residents (Resident #17, Resident #19, and Resident #70) reviewed for medication pass. Residents Affected - Some LVN C failed to administer the ordered dose of Vitamin D3 to Resident # 17. LVN D failed to administer the ordered water flush with medication administration through a feeding tube for Resident # 19. LVN C failed to administer the ordered dose of Vitamin D3 to Resident # 70. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders Findings: 1. Record review of facility face sheet dated 7/26/2023 indicated Resident #17 was a [AGE] year-old female admitted to facility on 09/25/2022 with diagnosis of schizophrenia (mental illness). During a medication pass observation on 7/25/2023 at 8:15 am LVN C administered Resident # 17 Vitamin D 3 25 mcg 1 tablet by mouth. Record review of physician order dated 09/29/2022 revealed an order for cholecalciferol (Vitamin D3) 25 mcg give 2 capsules by mouth one time a day. Record review of comprehensive care plan dated 06/21/2023 indicated resident with nutritional problem and to administer medications as ordered. Record review of quarterly MDS dated [DATE] indicated a BIMS of 03 indicating severe impaired cognition. 2. Record review of facility face sheet dated 7/26/2023 indicated Resident #19 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of quadriplegia (paralyzed from the neck down). During a medication pass observation on 7/25/2023 at 3:15 pm LVN D administered Resident # 19 medication via a gastrostomy tube. LVN D did not flush gastrotomy tube before administering medication and flushed the gastrostomy tube with 30 ml of water after medication administration. Record review of physician order dated 05/10/2023 revealed an order to flush gastrostomy tube with 60 cc of water before and after medication administration. Record review of comprehensive care plan dated 5/30/2023 indicated Resident #19 had potential fluid deficit related to tube feeding and required gastrostomy tube and to administer fluids and medicines as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676123 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 676123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Nursing & Rehabilitation Center 420 Moody 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 0759 Level of Harm - Minimal harm or potential for actual harm Record review of quarterly MDS dated [DATE] indicated a BIMS of 00 indicating severe impaired cognition and required a feeding tube. 3. Record review of facility face sheet dated 7/26/2023 indicated Resident #70 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of fracture of left femur (broken left leg). Residents Affected - Some During a medication pass observation on 7/25/23 at 8:10 AM LVN C administered Resident # 70 Vitamin D3 25mcg 1 tab by mouth. Record review of physician order dated 10/20/2022 revealed an order for cholecalciferol (Vitamin D3) 25 mcg give 2 capsules by mouth one time a day. Record review of comprehensive care plan dated 4/28/2023 indicated a risk for malnourishment and weight loss. Record review of quarterly MDS dated [DATE] indicated a BIMS of 05 indicating severely impaired cognition. During an interview on 7/25/2023 at 3:37 pm LVN D stated she had been at the facility for four years as the weekend charge nurse and had been a nurse for 21 years. She stated she should have flushed Resident #19's gastrotomy tube as ordered before and after giving his medication. She stated she had been trained on administering medicines through a gastrostomy tube but it had been a while and she was nervous. She stated the risk to the resident could be occluded tube or medication interactions. During an interview on 7/25/2023 at 10:01 am LVN C stated she had been a nurse 1 year and on hire she did receive training on medication administration and each order was to be checked before administering medications to each resident. She stated regarding Resident #17 and Resident #70 she just overlooked the Vitamin D3 order was for 2 tablets not 1 tablet. She stated the risk to resident receiving the incorrect dose of medicine could be the resident would not receive the full benefit of the medicine. During an interview on 7/26/2023 at 10:30 am the DON stated nurses are trained on hire and annually through a proficiency audit regarding medication administration. She stated the seasoned nurses on the floor oversee the new nurses orientation regarding different nursing task and then the ADON or herself ensure the checkoff's are done and each nurse was proficient. She stated she expected each nurse to administer medications correctly per the physician order. She stated the risk of medicines being given incorrectly could vary depending on what each medication was. During an interview on 7/26/2023 at 10:45 am the Administrator stated the DON and ADON were responsible for ensuring medications were given as ordered. She stated she oversees the in-service program and monitors the DON's audits she puts in place. She stated going forward she expected medications were to be administered as ordered and per policy and procedure to decrease the risk of medication errors. Record review of facility policy and procedure titled Enteral Medication Administration dated 1/25/13 indicated, .7. flush the tube with 30 ml water or according to physician order, 9. once all medications have been administered, flush the tube with 30 ml water or according to physician order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676123 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 676123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Nursing & Rehabilitation Center 420 Moody 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of facility policy and procedure titled Medication Administration procedure dated 2003 indicated, .20.the five rights of medication should always be adhered to 2. right dose . Record review of facility policy and procedure titled Ordering Medications dated 2003 indicated, .other functions that must be performed or verified by nursing staff include doses charted accurately on the MAR as ordered and as administered, medication dispensed accurately with proper handling. Event ID: Facility ID: 676123 If continuation sheet Page 7 of 7