Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, cognitive impairment, and documented need for a two-person assist with transfers was transferred by a single CNA, contrary to the resident’s care plan and Kardex. The CNA reported not calling for help because she believed the resident was a one-person assist and proceeded to move the resident from bed to wheelchair alone; the resident fell during repositioning in the chair and was found on the floor with a head laceration. EMS transported the resident to the ER, where imaging revealed large bilateral subdural hematomas and scattered SAH, and the resident later died from the head injury.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy and a resident’s care plan by not wearing required gowns during a high-contact care activity. A resident with end stage renal disease, chronic kidney disease, and dependence on hemodialysis, with an AV fistula and an order for EBP every shift, had an EBP sign on the door indicating that gowns were required for high-contact activities such as transferring. Two CNAs were observed transferring the resident from a geri-chair to a bed while wearing gloves but no gowns; one CNA stated he usually wears a gown and the other said she was just helping, and an LPN confirmed gowns should have been used. Review of the facility’s EBP policy showed that gowns are required for high-contact care activities, including transferring, for residents meeting EBP criteria.
Surveyors identified multiple deficiencies in food storage, handling, and hygiene, including failure to discard expired perishable items, improper cleaning of food pans, leaving unused food in an out-of-order refrigerator, inadequate temperature control in refrigeration units, and dietary staff not wearing required beard restraints.
Facility staff failed to notify the ombudsman of transfer or discharge for two residents and did not provide the receiving hospital with proper documentation or bed hold information for another resident. These deficiencies were confirmed through staff interviews and record reviews, with facility policies requiring such notifications and documentation not being followed.
Facility administration failed to comply with professional standards by not paying a contracted staffing agency for temporary healthcare personnel, resulting in a lawsuit and an outstanding balance exceeding $1.1 million. Despite repeated invoices and demands for payment, the facility did not provide a policy for accounts payable or resolve the issue prior to survey exit.
A resident with a history of chronic conditions and severe pain did not receive scheduled Gabapentin for three days after admission due to delays in obtaining the prescription and medication from the pharmacy. Documentation showed missed doses, ongoing pain, and communication issues between nursing staff and the pharmacy, with staff unable to recall specific details about medication administration.
A resident with hypertension and other medical conditions did not receive Amlodipine and Propranolol as ordered due to a nurse's decision to hold the medications based on a blood pressure reading, without provider notification. The facility's care plan required administering medications as ordered, but the nurse acted on judgment without consulting the physician.
A resident with multiple health conditions, including renal disease and dysphagia, did not receive a scheduled bolus tube feeding due to a delay in implementing a new feeding order. The resident's family requested immediate feeding, and the on-call provider agreed to start the feeds that night. The issue was discussed with facility leadership, but no additional information was provided to the surveyor.
A resident with pneumonia and a history of cancer was not administered the prescribed antibiotic Levofloxacin on three occasions due to medication availability issues. Despite the medication being available in the facility's in-house supply, it was not administered as ordered, and the nurse did not accept a delivery from the pharmacy.
Failure to Follow Two-Person Transfer Requirement Resulting in Fatal Fall
Penalty
Summary
Facility staff failed to ensure appropriate interventions were implemented for resident safety when a resident who required a two-person assist for transfers was transferred by a single CNA. The resident had multiple diagnoses, including metabolic encephalopathy, type 2 diabetes mellitus with diabetic kidney disease, congestive heart failure, unspecified dementia, end stage renal disease, unspecified lack of coordination, and muscle weakness. The most recent MDS showed a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s comprehensive person-centered care plan identified a need for assistance with activities of daily living due to chronic disease and specified a two-person assist for transfers. On the day of the incident, the resident was scheduled for dialysis. According to RN interview, the RN assigned to the resident stated that the resident was a two-person assist for transfers and that she had instructed CNA #1 to get assistance to transfer the resident. Shortly thereafter, CNA #1 reported to the RN that the resident was on the floor. The RN went to the room and found the resident lying supine on the floor, bleeding from a laceration to the right eyebrow, and assessed the resident’s vital signs while the nursing supervisor called 911. A progress note documented that the resident fell during transfer from bed to chair with CNA assistance while preparing to go for dialysis. In a witness statement obtained by phone, CNA #1 reported that she had not worked with the resident before but knew how to check transfer status in the Kardex. She stated she did not call for help because she was told the resident was a one-person assist and did not need further assistance. CNA #1 described transferring the resident from the edge of the bed to a wheelchair using a one-person technique and reported that the resident fell when she was repositioning the resident in the chair. The facility’s synopsis of events and final report stated that the resident was listed as a two-person assist, that CNA #1 had access to the resident’s transfer status and had signed off on the Kardex acknowledging awareness of the transfer status, and that despite this, the CNA transferred the resident alone. The incident was categorized as an allegation of neglect, and the facility substantiated that the resident fell during an improperly performed transfer. Following the fall, EMS transported the resident to the emergency department. The ER report documented that the resident fell while being moved out of bed, fell from about three feet, and struck the right side of the head, with vomiting noted en route. CT imaging showed a large acute right-sided subdural hemorrhage with mass effect and midline shift, a smaller acute left-sided subdural hematoma, and scattered subarachnoid hemorrhage. Hospital neurosurgery notes indicated the resident presented with a large right subdural hematoma in the setting of a fall from bed at the skilled nursing facility with head strike, and that the resident was actively dying from the significant head injury. The facility’s synopsis of events recorded that the resident sustained a subarachnoid hemorrhage and subsequently died at the hospital.
Failure to Use Required PPE During Enhanced Barrier Precautions Transfer
Penalty
Summary
Facility staff failed to maintain the infection prevention and control program for one resident on Enhanced Barrier Precautions (EBP) by not using all required personal protective equipment (PPE) during a high-contact care activity. Resident #7 had diagnoses including end stage renal disease, type 2 diabetes with chronic kidney disease, and dependence on renal dialysis, and was cognitively intact with a BIMS score of 15/15. The resident had a medical provider order for Enhanced Barrier Precautions every shift related to hemodialysis and an AV fistula in the right forearm, and the comprehensive care plan included a focus on EBP with interventions specifying appropriate PPE per policy and isolation precautions per order. On the survey date, an EBP sign was posted on the resident’s door stating that a gown was required during high-contact patient care activities such as transferring. The surveyor observed two CNAs transferring Resident #7 from a geri-chair to the bed while wearing gloves but not gowns. When questioned, one CNA stated he usually wears a gown, and the other CNA stated she was just helping with the transfer. The LPN who reviewed the EBP sign agreed that gowns should have been donned for this activity. The facility’s EBP policy, effective 3/26/24, required the use of gowns by staff during high-contact care activities, including transferring, for patients who meet EBP criteria, such as those with indwelling medical devices. These observations and document reviews showed that staff did not follow the facility’s EBP policy and the resident’s care plan regarding required PPE.
Deficient Food Storage, Handling, and Hygiene Practices in Kitchen
Penalty
Summary
Facility staff failed to store and handle food in accordance with professional standards for food service safety. Surveyors observed multiple issues in the kitchen, including the presence of perishable food items past their best-by dates, such as wilted cilantro and expired sparkling cider, which were not discarded promptly. Food preparation pans were found with visible, crusty residues in the clean dish area, indicating they were not properly cleaned before being stored. Additionally, unused food items from previous meals, such as trays of peaches, salads, and pudding, were left in a refrigerator that had been out of order for a month, and these items were not discarded until prompted by surveyors. Some of these food items were uncovered and improperly stored. Temperature control and food storage practices were also deficient. One refrigerator was observed at 50 degrees with no food inside, while another freezer containing ice cream cups lacked a thermometer and had a case of strawberry ice cream that was soft, melted, and separated, despite temperature logs indicating a safe temperature earlier that day. A large bag of diced chicken in the walk-in freezer was found to be soft and not fully frozen. Furthermore, several male dietary aides were observed working without beard restraints, contrary to professional standards for food safety and hygiene. These deficiencies were observed and discussed with facility leadership during the survey.
Failure to Notify Ombudsman and Provide Required Transfer Documentation
Penalty
Summary
Facility staff failed to provide required notifications and documentation related to resident transfers and discharges for three residents. In two cases, staff did not notify the local long-term care ombudsman of a resident's transfer or discharge. One resident, who was cognitively intact and discharged home with home health services after an insurance cut, had filed an appeal for discharge, but there was no evidence that the ombudsman was notified of the planned discharge. Another resident, also cognitively intact, was transferred to the hospital, and review of facility records confirmed that the ombudsman was not notified of this transfer/discharge. Additionally, for a third resident who was transferred to the hospital for acute symptoms including chest pain, shortness of breath, and dizziness, the facility failed to provide the receiving hospital with proper documentation at the time of transfer. This resident, who had mild cognitive impairment, was also not given information about the facility's bed hold policy prior to discharge. Interviews with facility staff and review of records confirmed that there was no evidence of the required documentation being provided to the hospital or the resident. Facility policies reviewed by surveyors indicated that staff were required to notify the ombudsman and provide proper documentation during transfers and discharges, but these procedures were not followed in the cases identified. The deficiencies were confirmed through staff interviews, clinical record reviews, and examination of facility documentation, with no further information provided by the facility prior to the survey exit.
Failure to Adhere to Professional Standards in Financial Obligations to Staffing Agency
Penalty
Summary
Facility administration failed to operate and provide services in accordance with accepted professional standards and principles, specifically regarding financial obligations to a contracted staffing agency. The facility entered into a staffing agreement with the agency to provide temporary healthcare personnel, including CNAs, LPNs, and RNs, at agreed-upon hourly rates. The contract stipulated that invoices for staffing services were to be paid upon receipt and not to exceed 45 days, with finance charges applied to overdue balances. A review of facility documents and interviews with the regional vice president of operations revealed that the facility accumulated a significant outstanding balance for services rendered by the staffing agency from May through September. Despite receiving invoices and repeated demands for payment, the facility failed to remit payment for these services, resulting in a past due balance exceeding $911,000, which with interest totaled over $1.1 million. The staffing agency subsequently filed a lawsuit against the facility for non-payment, and the facility was served with a Complaint for Damages. During the survey, the facility was unable to provide a policy for accounts payable when requested by the surveyor. The issue was discussed with facility leadership, including the administrator, DON, and regional consultants, but no further information or documentation was provided to the survey team prior to the survey exit.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer Gabapentin, a medication prescribed for nerve pain, to a resident for three days following their admission. The resident had a history of diabetes, muscle weakness, hypertension, and depression, and was cognitively intact with a BIMS score of 14 out of 15. The resident reported frequent and severe pain, rating it as high as 8 out of 10, which interfered with sleep. The hospital discharge summary included orders for Gabapentin 300 mg every 8 hours and Oxycodone 5 mg as needed for pain. Upon review, Gabapentin was not added to the medication administration record (MAR) until the day after admission, and subsequent doses were missed or coded as not given due to unavailability of the medication. Progress notes indicated ongoing communication issues with the pharmacy regarding the prescription and delivery of Gabapentin, as well as delays in obtaining the necessary scripts. Despite documentation of the resident's pain and non-pharmacological interventions, there was no evidence that the scheduled pain medication was administered as ordered during this period. Interviews with staff revealed a lack of recall regarding the administration of Gabapentin and the issues with medication availability. The DON acknowledged that a four-day delay in obtaining a prescription was not reasonable. Pharmacy records confirmed that the prescription for Gabapentin was not received and processed until several days after admission, resulting in a delay in the resident receiving the ordered medication.
Failure to Administer Blood Pressure Medications as Ordered
Penalty
Summary
The facility staff failed to administer Amlodipine and Propranolol as ordered for a resident diagnosed with Essential Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction, and Chronic Myeloid Leukemia. The resident's care plan included a focus on the risk for cardiac complications secondary to hypertension, with an intervention to administer medications as ordered. However, on the specified date, the medications were not given at 8:00 AM due to a blood pressure reading of 119/61, despite the absence of any provider orders to hold the medications based on blood pressure parameters. The nursing progress notes documented that the medications were held, but there was no evidence of physician notification prior to this decision. The Director of Nursing later confirmed that the nurse held the medication based on nursing judgment without notifying the provider. This incident was discussed with the facility's President of Operations, Administrator, and Director of Nursing, but no further information was provided to the surveyor before the exit conference.
Failure to Administer Ordered Enteral Feeding
Penalty
Summary
The facility staff failed to provide enteral feeding as ordered by the medical provider for a resident diagnosed with multiple conditions, including Acute Kidney Failure, End Stage Renal Disease, Hemiplegia, and Dysphagia following a cerebral infarction. The resident, who was moderately cognitively impaired, had experienced significant weight loss and was on enteral nutrition support. A registered dietitian recommended a specific bolus feeding schedule, which was ordered by the provider but initially lacked the name of the formula. Despite this, the feeding was signed off as administered. However, the order was discontinued and replaced with a new order that was set to begin the following day, leaving the resident without scheduled tube feeding for 24 hours. The resident did not receive the scheduled bolus tube feeding at 5:00 PM on the day of the order change. The resident's family expressed concern and requested the feeding to start as soon as possible. The on-call provider was contacted, and it was noted that the resident was completely NPO and the tube feed orders were set to start the next day. The family requested the feeds to begin that night, and the on-call provider agreed to continue with bolus feeds for that night, with the primary provider to address the orders the following day. The issue of the missed feeding was discussed with facility leadership, but no further information was provided to the surveyor before the exit conference.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of the oral antibiotic Levofloxacin. The resident, who was cognitively intact and had a history of malignant neoplasm of the larynx and dysphagia, was diagnosed with pneumonia and prescribed a seven-day course of Levofloxacin by the physician. However, the medication was not administered on three separate occasions as ordered. Nursing progress notes indicated that the medication was not administered due to it being unavailable or pending from the pharmacy. Despite the facility's in-house medication supply list showing that Levofloxacin was available, the medication was not administered on the specified dates. A pharmacy representative confirmed that a supply of Levofloxacin was delivered to the facility, but the nurse at the time did not accept the delivery and requested its return. Additionally, the Director of Nursing acknowledged that the medication could have been obtained from the in-house supply but did not provide an explanation for why it was not. The issue was discussed with the facility's President of Operations, Administrator, and DON, but no further information was provided before the exit conference.
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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.
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Nursing homes near Fairfax
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Boulevard Post Acute | 3 mi | ★★★★★ | 1 | 0 |
| Fair Oaks Health & Rehabilitation | 3.8 mi | ★★★★★ | 8 | 0 |
| Burke Health & Rehabilitation Center | 4.8 mi | ★★★★★ | 0 | 0 |
| August Healthcare At Iliff | 5.8 mi | ★★★★★ | 4 | 0 |
| August Healthcare At Leewood | 7.2 mi | ★★★★★ | 3 | 1 |
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