Cycle 1
Health 2024-09-26 · Fire 2024-09-26
3 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fairfield, TX
Fairfield Nursing & Rehabilitation Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
420 Moody St, Fairfield, TX
(903) 389-1236
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2006-12-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.60
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,316
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.74
Baseline 18.75% · Performance 21.09% · Measure score 0.74 · Achievement 0.74 · Improvement 0
Healthcare-associated infections
2.31
Baseline 6.13% · Performance 7.14% · Measure score 2.31 · Achievement 2.31 · Improvement 0
Total nurse turnover
0.75
Baseline 38.89% · Performance 60.61% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Adjusted total nurse staffing
1.36
Baseline 3.51 hours · Performance 3.47 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.25% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 4.29% · Lower 95% interval 6.37% |
| Discharge to community | 52.73% |
50.57%
2.2 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 53.19% · Lower 95% interval 42.14% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 47 · Denominator 48 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 2 · Denominator 48 |
| Discharge self-care score | 73.33% |
53.69%
19.6 pts better
|
Numerator 22 · Denominator 30 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 15 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 5.13% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 110 |
| Staff flu vaccination coverage | 11.33% |
42%
30.7 pts worse
|
Numerator 17 · Denominator 150 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 18 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 7.41% |
25.2%
17.8 pts worse
|
Numerator 2 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.1
1.4 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.7% |
3.3%
4.4 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.8% · Q3 10.4% · Q4 5.0% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
18.9%
3.6 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.5% · Q3 14.8% · Q4 16.3% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
10.8%
7 pts worse
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.0% · Q3 19.0% · Q4 14.6% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.7% |
15.4%
0.3 pts worse
|
16.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 27.4% · Q3 9.7% · Q4 16.6% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
16.1%
1.5 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 29.3% · Q3 9.3% · Q4 18.4% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
15.0%
6.4 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 19.4% · Q3 24.7% · Q4 19.0% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.2%
2.3 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.6% · Q3 7.3% · Q4 7.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
12.0%
2.3 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 9.1% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.0% |
25.9%
12.1 pts worse
|
23.9%
14.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.0% · Observed 34.1% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-26 · Fire 2023-07-26
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-06-08 · Fire 2022-06-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-09-26
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-09-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-09-26
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-09-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-25
E · Potential for more than minimal harm
2023-07-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-22
E · Potential for more than minimal harm
2023-07-26
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-05-22
E · Potential for more than minimal harm
2022-06-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-07-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-29
D · Potential for more than minimal harm
2024-09-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-08-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-15
E · Potential for more than minimal harm
2023-07-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-07-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-06-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-26
D · Potential for more than minimal harm
2022-06-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-09
D · Potential for more than minimal harm
2022-06-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-06-27
Penalties and ownership
What sits behind the stars
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Fairfield I Enterprises, LLC
Operational/Managerial Control · Organization
Huggins, Linda
Corporate Officer · Individual
Stratton, Charles
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Fairview Healthcare Residence
Fairfield, TX
2-star overall rating with 2-star inspections with abuse icon flag with $19,412 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Teague Nursing And Rehabilitation
Teague, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Skilled Care of Mexia
Mexia, TX
4-star overall rating with 4-star inspections with $24,634 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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