Health inspection·July 28, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 resident has the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 of 5 (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was sent out to the hospital when Resident #1 complained of pain in her lower back on 07/17/2025. This failure could place residents at risk of their rights to have their medical needs met . Findings include:A record review of Resident #1's face sheet, dated 07/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses which included unspecified dementia (memory loss), major depressive disorder (sadness), diabetes (too much sugar in the blood) and hypertension (high blood pressure). A record review of Resident #1's Quarterly MDS assessment, dated 06/23/2025, reflected the resident had a BIMS score of 8, which indicated moderate cognitive impairment. A record review of Resident #1's progress note, dated 07/17/2025 written by LVN A at 10:39 AM, reflected Patient c/o increased pain to her lower back. UA was obtained early this AM and sent to the lab R/T malodorous (smelling very unpleasant) urine. Patient lower pubic area is distended and firm to palpitation. IN and OUT cath performed using sterile supplies and sterile technique. Once urine returned a small amount of blood returned an no more urine noted. Bladder appears to be having spasms during procedure. Cath. Removed and MD was contacted. Patient stated that she wants to go to ER at this time. She remains Afebrile (free from fever) and has received PRN medications for pain. MD gave verbal order for Rocephin 1GM now, and he will come visit patient and check bladder for retention. LVN A, charge nurse contacted RP for patient. She is aware of plan of care at this time and agrees. Care ongoing. During an interview with Resident #1's RP on 07/26/2025 at 10:35 AM, the RP stated LVN A did not send Resident # 1 to the hospital on [DATE], when Resident # 1 requested to go to the hospital when she had experienced pain in the lower back. Resident #1's RP stated LVN A did collect a sample of urine and Resident #1 received pain medication, but the LVN A should had sent Resident #1 out to the hospital when she requested to go. The RP stated when LVN A did not send Resident #1 out to the hospital per her request her medical needs would not have been addressed. The RP stated Resident #1 was no longer at the facility as she transferred her to another facility on 07/22/2025. During an interview with LVN A on 07/26/2025 at 1:27 PM, LVN A stated on 07/17/2025, can't recall the time around 11:00 AM to 12:00 PM, she went in to check on Resident # 1 and she told her that her lower back was hurting, and she wanted to go to the hospital. LVN A asked Resident #1 if she could help her with anything before sending her out and she said okay and she was fine. LVN A stated she assessed Resident #1 and she did not fail to send Resident #1 out to the hospital because she wanted to see what she could do before Resident # 1 would be sent out. LVN A stated she knew it was expected to send Residents Affected - Few (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 3 Event ID: 676123 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 07/28/2025 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)