Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairfax Behavioral Health & Memory Care Community during CMS and state inspections, most recent first.
Failure to Monitor and Respond to Resident Decline: A resident with stroke, CHF, hemiplegia, DM2, and severe cognitive impairment showed poor intake and abnormal behavior earlier in the day, but staff did not promptly document, assess, or escalate the change in condition. By evening, the resident was lethargic, unresponsive, and sent to the ER with abnormal VS and elevated blood sugar; the EMT reported the resident was alone in the room and had likely been unresponsive for hours.
A resident who was cognitively intact but required substantial/maximal assistance and two-person help for toileting and transfers sustained two separate left arm fractures when staff did not follow the care plan or facility transfer policy. On one occasion, a CMA used a one-person transfer to the bathroom despite the resident stating they needed two-person assistance, and the resident fell and fractured the left arm. On another occasion, two CNAs transferred the resident to a shower chair by lifting under the arms instead of using a gait belt or approved technique, and a pop was heard in the resident’s shoulder, followed by confirmation of a left humerus fracture. The DON later stated staff were to use gait belts and not lift residents under their arms.
A resident with dementia and impaired mobility, identified as at risk for falls, experienced multiple witnessed and unwitnessed falls over time, including events causing skin tears, facial laceration, bruising, and swelling. Although some fall-related interventions such as non-slip socks, proper fitting shoes, staff presence, frequent toileting, distraction with snacks, and use of a specialized chair were documented in incident notes or described by staff, these interventions were not incorporated into the resident’s care plan after an earlier post-fall entry. Staff reported relying on the EHR, room postings, charts, or verbal instructions to know interventions, while the DON acknowledged that care plans were supposed to be updated after each fall but that the subsequent interventions were not added and were only reflected in progress notes that CNAs could not access.
A resident with severe cognitive impairment, dementia, anxiety, a history of wandering, and an identified elopement risk was able to leave the facility and was later found at a nearby park despite existing care plan interventions and staff presence. The resident required hands-on assistance for ambulation and was frequently observed walking the halls with a CNA, who attempted but was unable to consistently redirect the resident to sit. Staff and the DON reported that the resident was supposed to have 1:1 supervision during waking hours, that only staff knew the exit door code, and that staff were instructed to check exit doors and keep residents engaged, yet the resident still eloped from the building, indicating a failure to provide adequate supervision to prevent elopement.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A resident with diabetes and a below-the-knee amputation did not receive prescribed wound care for a toe, as the order was entered incorrectly and the treatment was not completed. The resident confirmed no treatment was being done, and both the ADON and DON acknowledged the lapse.
The facility did not ensure that food served was hot and palatable, as observed during a test tray review where meals were found to be inadequately heated and poorly prepared. Two residents with intact cognition reported dissatisfaction with the temperature and taste of the food, and similar concerns were raised during a resident council meeting. The dietary manager acknowledged attempts to serve hot, appealing meals.
A dietary aide was seen washing dishes without a beard guard, and a bulk sugar container with a broken lid was found in the kitchen. The dietary manager confirmed that staff should use hair restraints and that the container lid should have been replaced. Meals from this kitchen were served to 48 residents.
The facility did not follow the posted menu for two meal services, serving meals that did not include the required bread and providing a pureed meal that did not match the planned menu. Staff confirmed that bread was omitted and that frozen pureed items were used instead of pureeing the prepared meal.
A resident prescribed haloperidol for delusional and anxiety disorders did not have required side effect monitoring documented on the treatment administration record, despite facility policy and care plan directives. The DON confirmed that monitoring should occur every shift and be recorded, but no such documentation was found.
The facility did not transmit MDS assessment data to the State within the required 14-day period for four residents. The ADON/MDS coordinator, who had recently taken over responsibility for MDS assessments, reported being behind in completing and submitting the assessments on time, resulting in late transmissions.
A resident with an indwelling urinary catheter for urinary retention did not have the catheter use addressed in their care plan, despite facility policy and staff acknowledgment that it should have been included. The omission was confirmed through record review and staff interviews.
A resident with diabetes and a foot ulcer received wound care from an ADON who did not wear a gown, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. No signage indicated EBP was in place, and both the ADON and acting DON were unaware or did not follow EBP requirements for wound care, as confirmed by observation and interviews.
The facility failed to provide a safe and comfortable environment due to the lack of hot running water in rooms on the 100 hall. A resident with arthritis reported pain from washing hands in cold water, and two other residents confirmed the absence of hot water for over a month. The maintenance supervisor stated the issue is due to a broken hot water tank, which will not be replaced until a government grant is received.
A resident with dementia was observed by staff inappropriately touching another resident, also with dementia, in their room. The residents were immediately separated, and an assessment showed no signs of trauma. The incident was reported to the physician, family, and police.
A resident with a history of aggressive behavior verbally and physically threatened another resident in the dining room, resulting in an abusive interaction. Despite staff training on abuse identification and reporting, the incident was not initially recognized as abuse until later acknowledged by the ADON.
A resident with vascular dementia and leg amputations was left unclothed in their room and had an uncovered catheter bag in public areas, despite the facility having dignity covers. The resident was unable to reposition themselves or call for help, and staff failed to ensure their dignity was maintained. An LPN acknowledged the availability of dignity covers, and the DON confirmed the importance of respecting resident rights.
The facility did not provide three residents the opportunity to develop or refuse an advance directive as part of their admission process. An LPN confirmed that one resident's advance directive was signed late, and two others were not documented as having been offered the opportunity. The DON stated that advance directives should be completed during admission.
The facility failed to ensure interdisciplinary team participation in care planning for several residents. The MDS Coordinator did not invite other care team members to meetings, and there was no documentation of these meetings. The DON acknowledged the meetings should have been documented and that the physician was only informed of issues as required.
The facility failed to educate residents on the risks and benefits of bed rails, obtain informed consent, inspect bed frames and rails, and attempt alternatives before use. Two residents with dementia and amputations were affected, with no documentation of necessary assessments or attempts at alternative measures. The DON confirmed the lack of documentation and alternative interventions.
The facility failed to maintain registered nurse coverage for eight hours daily, as required. PBJ reports and staffing schedules revealed missing RN hours on several dates across two quarters. Interviews indicated a lack of awareness and communication among staff, with the DON unaware of the issue and an LPN responsible for staffing unable to fill gaps effectively.
The facility experienced delays in administering medications to residents due to sudden staffing shortages. On two consecutive days, a significant number of residents received their morning medications hours later than scheduled. The issue arose when two CMAs quit unexpectedly, leaving the facility short-staffed, and administrative nurses were unavailable due to emergencies. The DON acknowledged the situation and confirmed that medications should have been administered on time.
A facility failed to provide a written notice of discharge to a resident and did not notify the ombudsman when the resident was discharged to a hospital. The DON admitted to not giving a notice of transfer and not reporting the discharges to the ombudsman. A resident was discharged four times to a hospital for medical reasons, but the required notifications were not made.
A resident with vascular dementia and leg amputations developed a pressure wound on the coccyx, which was not accurately documented in the MDS quarterly assessment. The MDS Coordinator admitted to the error, and the DON acknowledged the lack of peer review among MDS nurses, leading to the inaccurate assessment.
A resident with vascular dementia and recent leg amputation developed a new pressure ulcer, but the facility failed to perform a significant change assessment within the required timeframe. The MDS Coordinator admitted the oversight, noting the part-time nurse responsible for assessments was unsupervised. The DON acknowledged the need for timely and accurate assessments.
The facility did not have policies and procedures for obtaining feedback from staff, residents, and resident representatives. A review of QAPI and QAA records showed no documentation of a feedback program. The Administrator confirmed the absence of such a program, despite having a grievance process for residents.
A facility failed to maintain a functioning call light system for a resident with multiple diagnoses, including vascular dementia. The resident's call light was out of reach and not ringing at the front desk. Despite the facility's policy to provide alternative alert methods, no immediate intervention was implemented. The issue was identified on June 3, 2024, but a hand bell was only provided after the malfunction was discovered.
Failure to Monitor and Respond to Resident Decline
Penalty
Summary
The facility failed to access, monitor, and intervene for a change in condition for one resident who had diagnoses including stroke, CHF, hemiplegia, and diabetes mellitus type II. The resident’s quarterly assessment showed severe cognitive impairment, unclear speech, and a need for substantial assistance with all ADLs. The record contained no nurse progress notes for several days before the incident, and the resident’s treatment record showed a finger stick blood sugar of 209 in the morning, with blood pressure and pulse documented later that day as 130/84 and 93 beats per minute. By the evening, the resident was found lethargic and not responding to verbal or tactile stimuli, with a blood sugar of 334, blood pressure of 108/57, and pulse of 111, and was sent to the ER. Family members stated they were told the resident had been admitted to the hospital with a UTI after being found unresponsive, and one family member said they were informed the resident had not been checked on in four hours and no one knew how long the resident had been unresponsive. The EMT stated that when they arrived shortly after 8:00 p.m., the resident was lying flat on their back, alone in the room, barely breathing, and white as a ghost, and that staff at the nurse’s station said the resident had been like that since at least 4:00 p.m. Staff interviews showed the resident’s decline was observed earlier in the day, including poor intake, gagging, and not responding appropriately, but the concerns were not promptly documented or escalated. A CNA said they notified an LPN that the resident was not eating, and another staff member said they asked an LPN to go check on the resident. The ADON stated documentation should have been completed about the resident’s decline and that an assessment should have been conducted right after the change in condition was identified. An LPN stated they did not feel the assessment needed to be documented and did not feel the condition warranted a physician call because they did not identify a change in condition, while another LPN stated they did not know the concerns had been raised earlier and did not feel the situation was dire enough to have someone sit with the resident.
Unsafe Transfer Techniques Resulting in Repeated Arm Fractures
Penalty
Summary
The facility failed to ensure safe transfer techniques were used for a cognitively intact resident who required substantial/maximal assistance and two-person help for toileting and incontinence care, resulting in two separate left arm fractures. The resident’s care plan, dated 10/02/25, specified moderate to maximum assistance of two staff for toileting and incontinent care. On 11/30/25, a CMA used a one-person transfer to assist the resident to the bathroom; the resident began to fall and used their left hand to break the fall, after having told the CMA they needed two-person assistance. The resident was subsequently found to have an acute distal left arm fracture on x-ray and was sent to the hospital for stabilization. The CMA later stated they did not know the resident was a two-person transfer. On 01/09/26, two CNAs transferred the same resident to a shower chair by placing their arms under the resident’s arms, rather than using a gait belt or other approved technique. Both CNAs and an LPN reported that during this transfer they heard a pop in the resident’s left shoulder. A mobile x-ray on 01/10/26 showed an acute distal fracture of the left humerus, and the resident was again sent to the hospital for stabilization. The resident later stated they broke their left arm when two aides transferred them under their armpits to get into a shower chair. The DON stated staff were expected to use gait belts and not lift residents under their arms, indicating that the transfer methods used with this resident were inconsistent with facility policy and the resident’s care plan.
Failure to Update Fall Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s fall care plan after multiple falls, despite a policy requiring that interventions be reflected in the care plan and updated with revised or additional interventions. The resident, admitted with non-Alzheimer’s dementia and identified as at risk for falls due to weakness, impaired mobility, abnormal gait, and balance, initially had a care plan dated 08/20/25 with a post-fall intervention added on 11/02/25 for frequent checks while in their room. After that date, the care plan contained no additional interventions, even though the resident experienced numerous subsequent falls. Incident notes documented a witnessed fall without injury on 12/26/25 with interventions of non-slip socks and proper fitting shoes, an unwitnessed fall with a right elbow skin tear on 01/01/26 with no interventions documented, and another unwitnessed fall on 01/18/26 with no injuries or interventions documented. Further documentation showed the resident was seen in the emergency department on 01/20/26 for a fall resulting in a facial laceration repaired with tissue glue, facial bruising, and a knee injury, followed by monitoring for bruising and swelling to the right eye on 01/21/26. Additional unwitnessed falls occurred on 01/22/26, 01/24/26, and three times on 01/28/26, with no injuries or interventions documented for several of these events. On 01/29/26, the resident had two unwitnessed falls; one had non-slip socks as an intervention and the other resulted in a right elbow skin tear and bruising with an intervention to start Buspar for agitation. Observations showed the resident was unsteady, required hands-on assistance to walk, and was frequently ambulating in the halls with a CNA. Staff interviews revealed that CNAs and an LPN described various fall interventions (such as constant staff presence, snacks for distraction, frequent toileting, non-slip socks, and use of a specialized chair) and stated they relied on the electronic health record, room postings, charts, or verbal communication to know interventions. The DON stated care plans were to be updated after every fall but acknowledged that interventions after 11/02/25 were not on the care plan and that CNAs could not see progress notes where interventions were documented.
Failure to Adequately Supervise High-Risk Resident to Prevent Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for one resident identified as an elopement risk. The resident had non-Alzheimer's dementia, delirium due to a psychological condition, anxiety disorder, a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive dysfunction, and a documented history of wandering. The care plan, initiated prior to the incident, identified the resident as an elopement risk with interventions including structured activities and diversions. Despite these identified risks and care plan interventions, the resident was able to leave the facility and was later found at a nearby park approximately 50 yards from the facility's back door, on the other side of a small hill. At the time of the elopement, eight direct care staff were on duty. Following the elopement, documentation and staff interviews showed that the resident was to have one-on-one supervision with staff during waking hours, and staff described interventions such as remaining with the resident, providing snacks, treats, and fidget items, and using distraction with activities and toileting. Observations on multiple days showed the resident walking up and down the halls with a CNA, unsteady on their feet and requiring hands-on assistance, and staff attempting to redirect the resident to sit in a chair without success. The facility’s elopement prevention policy stated it was the policy to protect residents from elopement, and staff reported that only employees had the door code and that they were educated to check exit doors when near them and keep residents engaged. Despite these measures and the resident’s known elopement risk and cognitive impairment, the resident had previously been able to exit the building and reach the nearby park, demonstrating a failure to provide adequate supervision to prevent elopement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes mellitus type 2 and a below-the-knee amputation, who was assessed as having moderate cognitive impairment. The physician's order directed that the resident's left great toe be cleansed with normal saline, patted dry, Betadine applied every shift, and left open to air twice daily for wound care. Review of the Treatment Administration Record (TAR) for July 2025 showed no documentation of wound care for the left great toe as of mid-month. The resident confirmed that no treatment was being performed on the toe, and facility staff, including the ADON and DON, acknowledged that the wound care order had been entered incorrectly and the treatment was not being completed as ordered.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food served from the kitchen was palatable and at an appetizing temperature for its residents. During a test tray observation, the food was found to be not hot, with the meatloaf described as dry and bland, mixed vegetables as soggy, potatoes as not well seasoned, and the brownie as undercooked; bread was also missing from the meal. Two residents with intact cognition reported that the food was not hot when served in their rooms and sometimes did not taste appealing, with one stating the food was not good. Additionally, concerns about food temperature and palatability were raised by multiple residents during a resident council meeting. The dietary manager acknowledged efforts to serve hot, palatable food.
Failure to Ensure Proper Food Storage and Staff Hygiene in Kitchen
Penalty
Summary
During a kitchen inspection, a dietary aide was observed washing dishes without wearing a beard guard, which is required as a hair restraint in food preparation areas. Additionally, a bulk sugar container with a broken lid was found in the kitchen. The dietary manager confirmed that staff are expected to wear hair restraints and that the broken lid should have been replaced. The administrator reported that 48 residents received meals prepared in this kitchen. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Follow Posted Menu for Regular and Pureed Meals
Penalty
Summary
The facility failed to follow the posted menu for two observed meal services, affecting all 48 residents who received meals from the kitchen. During observation, the regular meal served included meatloaf, mixed vegetables, au gratin potatoes, and a brownie, but no bread was provided, despite the menu specifying 'bread of choice.' For the pureed diet, the meal included pureed meatloaf, pureed corn, pureed bowtie pasta, and banana pudding, which did not match the menu that called for a vegetable blend and bread. Staff interviews confirmed that bread was forgotten during lunch service and that the pureed meal did not follow the planned menu, as frozen pureed items were used instead of pureeing the prepared meal.
Failure to Document Psychotropic Medication Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that side effect monitoring was completed and documented for a resident who was receiving psychotropic medication. According to facility policy, nursing staff are required to document the resident's response to antipsychotic medications and any side effects, including extrapyramidal symptoms or sedation, every shift. Record review showed that a resident with diagnoses of delusional disorder and unspecified anxiety disorder, and with intact cognition, was prescribed haloperidol daily. The resident's care plan specified monitoring for medication side effects every shift. However, review of the treatment administration records for two months did not show any documentation of side effect monitoring. The Director of Nursing confirmed that such monitoring should be documented in the treatment administration record and acknowledged that if it was not documented, it was not done.
Failure to Timely Transmit MDS Assessment Data
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the State within 14 days after completion for four residents. According to the facility's policy, all MDS assessments must be completed accurately and submitted electronically to the Quality Improvement and Evaluation System (QIES) within mandated timelines. Record review showed that for four sampled residents, the assessments were completed but not transmitted within the required 14-day period. Batch transmittal forms confirmed that the submission dates for these assessments exceeded the 14-day window. The Assistant Director of Nursing (ADON)/MDS coordinator reported that they had recently assumed responsibility for MDS assessments and, despite assistance, were still behind in completing and submitting the assessments on time.
Failure to Address Indwelling Urinary Catheter in Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing the use of an indwelling urinary catheter for one resident, despite having a policy requiring individualized care plans for each resident. Record review showed that the resident had diagnoses including unspecified retention of urine and dementia, and a physician's order documented the presence of a size 16 French indwelling urinary catheter. However, the resident's care plan did not include any information regarding the catheter. Interviews with the ADON and acting DON confirmed that catheter use should have been addressed in the care plan, and they were unable to explain why it was omitted.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During a wound care observation, the Assistant Director of Nursing (ADON) was seen providing wound care to a resident with a history of diabetes mellitus and a foot ulcer without wearing a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy. There was no signage indicating that the resident was on EBP, despite the policy mandating the use of personal protective equipment (PPE) for residents colonized or infected with multidrug-resistant organisms (MDROs) in accordance with CDC guidance. The resident confirmed that staff did not wear gowns during wound care, and the ADON acknowledged not using EBP during the procedure. Additionally, the acting Director of Nursing (DON) stated they were unaware of the requirement to use EBP during wound care.
Facility Fails to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the lack of hot running water in the rooms on the 100 hall. Observations and interviews revealed that residents have been without hot water for over a month due to a broken hot water tank. Resident #4, who suffers from arthritis, reported experiencing pain when washing hands in cold water. The maintenance supervisor confirmed the issue and stated that the hot water tank would not be replaced until a government grant is received in March. Resident #5 and Resident #6 also confirmed the absence of hot water in their rooms since their arrival and for over a month, respectively, expressing the inconvenience it causes for daily activities like washing hands and face.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents with dementia. One resident, with a BIMS score of 11, was observed by staff with their hand on the pubic area of another resident, who had a BIMS score of 5. This incident occurred in the resident's room, and the two residents were immediately separated following the observation. A head-to-toe assessment was conducted on the affected resident, revealing no signs of trauma or injury. The incident was reported to the physician, family, and local police department.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. Resident #3, who has diagnoses including diabetes mellitus and hypertension, was observed in the dining room shouting obscenities and threatening Resident #8, who has diagnoses including schizophrenia and convulsions, with bodily harm. Resident #3 propelled their wheelchair into Resident #8's leg, causing a physical altercation. A nurse's note documented the incident, and RN #2 acknowledged that such behavior is common for Resident #3 and agreed that the interaction was abusive. The Assistant Director of Nursing (ADON) confirmed that staff receive training on identifying and reporting abuse, and acknowledged that the incident met the definition of abuse.
Failure to Maintain Resident Dignity in Dressing and Catheter Management
Penalty
Summary
The facility failed to uphold the dignity of a resident who required assistance with dressing and catheter management. The resident, who had vascular dementia and amputations of both legs, was observed lying nude from the waist down in their room after returning from the hospital. They were unable to reposition themselves or reach the call light for assistance, indicating a lack of staff attention to their needs. The resident expressed dissatisfaction with being left unclothed, although they could not recall the duration of this state. Additionally, the resident's catheter bag was repeatedly observed uncovered in public spaces, such as the dining room and hallway, despite the facility having dignity covers available. The catheter bag was noted to be partially or fully filled with urine during these observations. An LPN acknowledged the availability of dignity covers and stated they would instruct aides to use them. The DON later confirmed that all resident rights should be respected, and the resident should not have been left unclothed or with an uncovered catheter bag.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to provide residents the opportunity to develop or refuse the creation of an advance directive for three out of five residents reviewed. The facility's policy on residents' rights regarding advance directives was not dated but stated that every competent person has the right to determine their health care decisions, including life-sustaining treatment and organ donation. Resident #15's advance directive form was signed only after the survey began, despite being admitted earlier. For Residents #21 and #36, there was no documentation indicating they were offered the opportunity to develop an advance directive, although the facility had a document for this purpose during the admission process. The Director of Nursing stated that advance directives should be completed thoroughly during or before admission.
Failure to Ensure Interdisciplinary Team Participation in Care Planning
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in the planning process of resident care plans for six residents. The facility's policy stated that the comprehensive care plan should be developed by an IDT, including the attending physician, registered nurse, nurse aide, dietary staff representative, the resident and/or resident representative, and any other healthcare professional as identified by the resident's needs. However, a review of resident records found no documentation related to interdisciplinary team care plan meetings for the six residents reviewed. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the care plan meetings were not conducted as per the facility's policy. The MDS Coordinator admitted to not inviting other care team members to the care plan meetings and had no recollection of contacting the medical director regarding the results of the meetings. The DON stated that they believed the social services director attended the meetings, but acknowledged that the meetings should have been documented and that the physician was only informed of issues as required. The lack of documentation and participation of the required IDT members led to the deficiency identified during the survey.
Failure to Educate and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were educated on the risks and benefits of using bed rails, obtain informed consent, inspect bed frames and bed rails prior to their application, and attempt alternatives to bed rails before their use. Specifically, two residents, one with vascular dementia and amputations of both legs, and another with dementia, were not provided with education or informed consent regarding the use of bed rails. Additionally, there was no documentation of bed frame and bed rail inspections or attempts to use alternative measures before resorting to bed rails. The Director of Nursing (DON) acknowledged the lack of documentation and stated that no alternative interventions to bed rails had been attempted for the residents in question. The facility's policy on the use of bed rails was undated and did not provide clear guidance on the necessary steps to ensure resident safety and informed consent. Observations confirmed that positioning bars and full bed rails were in use without the required assessments and documentation.
Failure to Maintain Registered Nurse Coverage
Penalty
Summary
The facility failed to maintain registered nurses on duty for eight hours each day, seven days a week, as required. This deficiency was identified through a review of the facility's Payroll Based Journal (PBJ) reports and staffing schedules for the first and second quarters of 2024. The PBJ reports documented missing registered nurse hours on several dates, including specific days in November and December 2023, as well as January and February 2024. The facility's staffing schedules corroborated these findings, showing no registered nurses were documented as having worked on the identified dates. Interviews with facility staff revealed a lack of awareness and communication regarding the staffing deficiencies. The Director of Nursing (DON) was unaware of any dates without registered nurse coverage, relying on an LPN responsible for staffing to fill any gaps. The LPN described a process for finding replacements, which included contacting on-call staff, those willing to work overtime, staffing agencies, and an on-call person. However, this process failed to ensure registered nurse coverage on the identified dates. The Human Resources representative confirmed the accuracy of the PBJ reports, indicating that the facility's staffing records were consistent with the reported deficiencies.
Medication Administration Delays Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure medications were administered within the ordered time frame, as evidenced by a review of medication administration records and staff interviews. On two consecutive days, a significant number of residents did not receive their morning medications at the scheduled time of 7:00 a.m. Instead, these medications were administered after 12:00 p.m. Specifically, on the first day, 23 out of 48 residents were affected, and on the second day, 13 out of 49 residents experienced delays. The facility's Time of Administration policy outlines specific time frames for medication administration, which were not adhered to during this period. The delay in medication administration was attributed to staffing issues, as two Certified Medication Aides (CMAs) quit suddenly, leaving the facility short-staffed. Normally, two CMAs would pass medications, but due to the sudden resignations, only one CMA was available. Additionally, administrative nurses who could have assisted were unavailable due to emergencies. The Director of Nursing (DON) acknowledged the staffing challenges and confirmed that the medications should have been administered on time, despite the unforeseen circumstances.
Failure to Notify Resident and Ombudsman of Hospital Discharge
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident and did not notify the ombudsman office when the resident was discharged to a hospital. This deficiency was identified for one of the two residents reviewed for discharges and hospitalizations. The facility's policy and procedure for transfer and discharge required notification to the resident, their representative, and the ombudsman, with documentation of the reason for transfer or discharge in the resident's medical record. However, the Director of Nursing (DON) admitted that they had not given a notice of transfer to the resident when discharged to a hospital and had not reported the discharges to the ombudsman office. Resident #12 was discharged from the facility four times since admission, with progress notes documenting transfers to a hospital for medical reasons on specific dates.
Inaccurate MDS Assessment of Pressure Wound
Penalty
Summary
The facility failed to accurately assess and code a pressure wound in Section M of a Minimum Data Set (MDS) quarterly assessment for a resident. The resident, who had vascular dementia and amputations of both legs, developed a new wound on the coccyx, which was documented in progress notes as increasing in size and later as an open area upon return from the hospital. However, the quarterly MDS assessment inaccurately documented that the resident had no pressure ulcers, despite the presence of an open wound observed during wound care. The MDS Coordinator admitted to the error, stating they were focused on the resident's surgical wounds rather than the pressure wound when completing the assessment. The Director of Nursing (DON) acknowledged that they were responsible for checking the MDS nurses' work but noted that the two MDS nurses did not review each other's assessments. The expectation was for all assessments to be accurate and timely, which was not met in this instance.
Failure to Conduct Significant Change Assessment
Penalty
Summary
The facility failed to conduct a significant change assessment for a resident following the development of a new pressure ulcer and a partial leg amputation. The resident, who had vascular dementia and had undergone an above-the-knee amputation, developed a wound on the coccyx. Despite these significant changes in the resident's condition, the facility did not perform the required assessment within the 14-day period as stipulated by their policy. The MDS Coordinator acknowledged that a significant change assessment should have been conducted due to the amputation and the new pressure wound. However, it was revealed that the part-time nurse responsible for MDS assessments was not supervised, which contributed to the oversight. The Director of Nursing stated that they were responsible for checking the work of the MDS nurses and agreed that the assessments should have been completed accurately and timely.
Lack of Feedback Program and Policies
Penalty
Summary
The facility failed to establish policies and procedures for obtaining and using feedback from staff, residents, and resident representatives. A review of the facility's Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) records revealed no documentation of a program to gather feedback from these groups. During an interview, the Administrator acknowledged that while there was a grievance process for residents, there was no formal feedback program or associated policies and procedures in place.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system for one of the residents, identified as Resident #47, who was part of a sample of 12 residents reviewed for this issue. Resident #47 had multiple diagnoses, including vascular dementia, atherosclerotic heart disease, and bipolar disorder. The resident's care plan, revised in April 2024, specified that the call light should be kept within reach and marked with bright tape. However, during an observation on June 3, 2024, the call light was found to be out of reach, attached to a privacy curtain, while the resident was seated in a wheelchair. Additionally, the resident was unable to confirm if the call light was functioning properly. The Director of Nursing (DON) confirmed that the call light for Resident #47 was not ringing at the front desk and admitted that no alternative intervention had been implemented at that time. The facility's policy stated that in the event of a call light malfunction, alternative methods such as a bell or buzzer should be provided, and maintenance should be notified immediately. However, the Administrator acknowledged that although they were informed of the issue on June 3, 2024, and maintenance had looked into it, a part needed to be ordered. A hand bell was provided to the resident only after the malfunction was discovered, indicating a delay in implementing the alternative alert method as per the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairfax
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southern Oaks Care Center | 17 mi | ★★★★★ | 9 | 0 |
| Bradbury Commons | 20.9 mi | ★★★★★ | 0 | 0 |
| Shawn Manor Nursing Home | 22 mi | ★★★★★ | 0 | 0 |
| Cleveland Care And Rehab Center | 22.1 mi | ★★★★★ | 4 | 0 |
| Ponca City Nursing & Rehabilitation Center | 23.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.