A list of the most recent deficiencies for Fairfax Health Care Center. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-06 | 2024-01-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-06 | 2024-01-04 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-08 | 2023-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-08 | 2023-09-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-20 | 2023-09-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-16 | 2023-09-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-16 | 2023-09-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-16 | 2023-09-14 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-16 | 2023-09-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-16 | 2023-09-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-16 | 2023-09-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-16 | 2023-09-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-16 | 2023-09-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-16 | 2023-09-14 | 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 | 2023-05-16 | 2023-09-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-16 | 2023-09-14 | 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 | 2023-05-16 | 2023-09-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-16 | 2023-09-14 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-05-16 | 2023-09-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-16 | 2023-09-14 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-05-16 | 2023-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-16 | 2023-09-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-16 | 2023-09-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-08 | 2023-09-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-08 | 2023-07-20 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-05-16 | 2023-06-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-29 | 2023-01-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-29 | 2023-01-06 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-10-21 | 2023-01-06 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-21 | 2023-01-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-10-21 | 2023-01-06 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-10-21 | 2023-01-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-31 | 2022-02-25 | Y |
| 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 | 2022-01-31 | 2022-02-25 | Y |
| 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 | 2021-08-30 | 2021-10-12 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-30 | 2021-10-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-26 | 2021-10-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-23 | 2020-03-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-23 | 2020-03-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-23 | 2020-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-23 | 2020-03-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-21 | 2020-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2020-03-07 | 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 | 2019-10-21 | 2020-02-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-21 | 2020-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2020-02-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2020-02-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-21 | 2020-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2020-02-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-23 | 2020-02-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-23 | 2020-02-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-23 | 2020-02-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-23 | 2020-02-12 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-10-23 | 2020-02-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-23 | 2020-02-12 | 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 | 2019-10-23 | 2020-02-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-23 | 2020-02-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-23 | 2020-02-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Establish methods for sharing information. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-21 | 2019-12-31 | N |
| Post nurse staffing information every day. | Health | 2019-10-23 | 2019-11-22 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-09-13 | 2018-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-14 | 2018-10-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-14 | 2018-10-12 | N |
