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Inspection visit

Inspection

Fairfax Behavioral Health & Memory Care CommunityCMS #37546716 citations on this visit
16 citations recorded

Citations

16 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0727GeneralS&S Epotential for harm

    F727 - Except when waived under paragraph (f) or (g) of this section, the

    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.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0851GeneralS&S Epotential for harm

    F851 - Mandatory submission of staffing information based on payroll data in a

    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0759GeneralS&S Epotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0625GeneralS&S Dpotential for harm

    F625 - Transfer and discharge-

    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.

  • 0684GeneralS&S Epotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0758GeneralS&S Epotential for harm

    F758 - Medication Errors

    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.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0004GeneralS&S Fpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0036GeneralS&S Fpotential for harm

    Establish emergency prep training and testing.

  • 0291GeneralS&S Fpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0321GeneralS&S Epotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0347GeneralS&S Cno actual harm

    Properly provide smoke detection systems in areas open to corridors.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0741GeneralS&S Cno actual harm

    F741 - The facility must have sufficient staff who provide direct services to

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

FAQ · About this visit

Common questions about this visit

What happened during the May 11, 2023 survey of Fairfax Behavioral Health & Memory Care Community?

This was a inspection survey of Fairfax Behavioral Health & Memory Care Community on May 11, 2023. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Fairfax Behavioral Health & Memory Care Community on May 11, 2023?

Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full tim..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.