Fairfield Nursing & Rehabilitation Center

Based on interviews and record reviews, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed.The facility failed to follow up on concerns and requests expressed in resident council meetings from July 2025 through November 2025. This failure placed residents at risk of not having their preferences honored.Review of Resident Council minutes from 07/05/2025 to 12/09/2025 reflected the following Resident council grievances did not have a facility's responses: *7/05/ 2025 minutes reflected: Nursing review concerns: When getting showers, beds still not getting stripped. When answering call lights aides come & leave without helping, not putting call lights in reach.It was reported residents did not receive scheduled showers. Staff completed showers at their convenience, and residents had to ask for showers. Fresh water not provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure Dietary Aide A wore proper hair restraint when holding clean plates in the dishwashing room.2. The facility failed to ensure the Dietary Manager wore a beard guard when standing next to the food prep table. 3. The facility failed to ensure Dietary Aide A sanitized his hands prior to donning gloves after touching his clothes.Findings include: Observations on 12/16/2025 at 9:05 AM, Dietary Aide A was wearing a baseball cap when he was holding clean plates in the dishwasher room in the kitchen. He had approximately 12 inches of hair in a ponytail not covered by the baseball cap. Interview on 12/16/2025 at 9:09 AM, Dietary Aide A stated he was informed by the Dietary Manager to cover his ponytail with a hair net. He stated he forgot, and he was expected to have all of his hair covered when in the kitchen. Dietary Aide A stated there was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for complete and accurate records. The facility failed to ensure Resident #1's weight was documented in PCC for July 2025. This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs. 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 had 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure all allegations of abuse are reported immediately, but not later than 2 hours after the allegation is made, to the Administrator of the facility and to HHSC for one (Resident #4) of five residents reviewed for abuse. The facility staff failed to immediately report an allegation of abuse to the Administrator and to HHSC as required when Resident #4 was struck in the face by Resident #3 on 08/20/2024 at 8:30 p.m This failure could place residents at risk for unreported allegations of abuse. Findings included: Record review of the facility EHR reflected nurses note dated 08/20/24 at 8:30p.m. stated that Resident #3 struck Resident #4 in the face at 8:30 p.m. on 08/20/24. The facility staff was present in the area and intervened. The residents were separated and assessed for injuries. Resident #3 was placed on 1:1 supervision by staff. Resident #4 was monitored as part of the assessment. The facility Administrator was not made aware of the incident until a 6:45 a.m. on 08/21/2024. The report was made at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 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 disease and infection for 1 (Residents #1) of 3 residents reviewed for infection control in that: 1. CNA A failed to change their soiled gloves and wash hands during incontinent care for Resident #1. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #1's EHR on 09/24/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Polyarthritis (arthritis that affects all joints),and mixed incontinence (both urine and bowel incontinence). Review of Resident #1's quarterly MDS assessment, dated 7/02/24, reflected a BIMS score of 9, indicating the resident was moderately impaired cognitively, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints, not required to treat the resident's symptoms, for 1 of 9 residents (Resident #1) reviewed for physical restraints. The facility failed to ensure RP #2 was educated on physical restraint policy and refrained from having tied Resident #1's right hand/wrist to her bed's assist bar with a blanket. This failure placed residents at risk of physical harm, psychosocial harm, and having their needs gone unmet. Findings included: Record review of Resident #1's AR, dated 8/14/2024, reflected an [AGE] year-old female admitted to the facility on [DATE]. She was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life,) Cerebral infarction (which was a pathologic process that resulted in necrotic tissue in the brain, caused by disrupted oxygen and blood supply,) and Bullous Pemphigoid (which was a rare skin condition that caused blisters on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, for 1 of 9 residents (Resident #1) reviewed for reporting abuse allegations. The facility failed to report an incident involving the use of a restraint on Resident #1 by RP #2, that occurred on 8/3/2024 at 8:35 PM, until 8/5/2024 to Health and Human Service. This failure placed residents at risk of physical harm, psychosocial harm, lack of regulatory oversite, and having their needs gone unmet. Findings included: Record review of Resident #1's AR, dated 8/14/2024, reflected an [AGE] year-old female admitted to the facility on [DATE]. She was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life,) Cerebral infarction (which was a pathologic process that resulted in necrotic tissue in the brain, caused by disrupted oxygen and blood supply,) and Bullous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 3 medication carts (nurse cart hall 300) and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 7 of 9 months (October 2022, February 2023, March 2023, April 2023, May 2023, June 2023, and July 2023) reviewed for pharmacy services. 1. The facility failed to remove expired insulin from the nurse medication cart on hall 300 for Resident #36. 2. The facility failed to remove expired medications from the nurse medication cart on hall 300 for Resident #64. 3. The facility failed have a licensed pharmacist and two witnesses initial the attached pages of the controlled medication destruction inventory sheets. These failures could place residents who receive medications at risk of not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.