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Deficiency Records for Fairfax Behavioral Health and Memory Care Community
A list of the most recent deficiencies for Fairfax Behavioral Health and Memory Care Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Fairfax Behavioral Health and Memory Care Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-06 | 2024-09-05 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-06-17 | 2024-08-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-17 | 2024-08-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-06-17 | 2024-08-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-17 | 2024-08-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-06-17 | 2024-08-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-17 | 2024-08-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-07 | 2024-08-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-06-07 | 2024-08-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-06-07 | 2024-08-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-06-07 | 2024-08-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-06-07 | 2024-08-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-07 | 2024-08-02 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-06-07 | 2024-08-02 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-06-07 | 2024-08-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-07 | 2024-08-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-06-07 | 2024-08-02 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-06-07 | 2024-08-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-09 | 2023-10-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-09 | 2023-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-09 | 2023-09-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-09 | 2023-09-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-09 | 2023-09-13 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-09 | 2023-08-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-11 | 2023-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-11 | 2023-06-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-11 | 2023-06-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-11 | 2023-06-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-11 | 2023-06-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-11 | 2023-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-11 | 2023-06-15 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-05-11 | 2023-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-27 | 2023-01-20 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-10-27 | 2023-01-20 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-27 | 2022-12-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-27 | 2022-12-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-27 | 2022-12-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-27 | 2022-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-27 | 2022-12-08 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-29 | 2019-12-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-29 | 2019-12-20 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-29 | 2019-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-29 | 2019-12-20 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-10-29 | 2019-12-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-29 | 2019-12-20 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-10-29 | 2019-12-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-22 | 2019-11-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-22 | 2019-11-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-22 | 2019-11-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-22 | 2019-11-05 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-10-22 | 2019-11-05 | N |
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