Fairfax Behavioral Health & Memory Care Community

In the surveyor’s words

From the most serious findings on record at Fairfax Behavioral Health & Memory Care Community, in the surveyor’s own words.

• Actual harm, isolatedF684Feb 5, 2026

  Based on observation, record review, and interview, the facility failed to ensure staff transferred a resident in a safe manner to prevent injury for 1 (#6) of 2 sampled residents reviewed for safe transfers.The DON identified 48 residents resided in the facility. Findings:On 02/03/26 at 1:14 p.m., Resident #6 was observed sitting in a wheelchair in their room with their left arm wrapped in an ace wrap and secured in an immobilized arm sling.A facility policy titled Policy and Procedure Resident Transfer and Safe Patient Handling, dated 11/01/23, read in part, It is the policy to ensure all resident transfers are performed using proper body mechanics, approved transfer techniques, and appropriate equipment in order to prevent injury to residents and staff and to promote resident dignity… […]

• Actual harm, isolatedF600Jul 21, 2025

  Based on observation, record review, and interview, the facility failed to prevent resident-to-resident abuse for 2 (#33 and #45) of 4 sampled residents reviewed for abuse, which resulted in Resident #45 being hospitalized . The administrator reported four incidents of resident-to-resident abuse in the past 90 days. Findings: An undated policy titled Abuse By A Resident To Other Residents, read in part, In the case of abuse from one resident to another resident, any employee observing the abuse, shall immediately intervene in an effort to protect the resident. If there is an actual physical altercation, the employee shall immediately gain the assistance of another employee to assist in separating the residents involved by moving one resident away from the other. […]

• No harm, potential for more than minimal, widespreadF812May 11, 2023

  Based on observation, record review, and interview the facility failed to ensure: a. foods were labeled and dated, and disposed of according to policy, and b. kitchen equipment, sinks and refrigerators were cleaned and free from food debris and grime. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: An undated, Food Storage, Preparation and Distribution policy, read in parts, .Leftovers food items will be labeled, dated and stored under refrigeration .non-potentially hazardous leftovers will be used or disposed of within 48 hours .Leftover foods will be stored in covered containers or wrapped securely. […]

• No harm, potential for more than minimal, widespreadF880May 11, 2023

  Based on observation and interview, the facility failed to ensure there was a system in place to monitor for Legionella and other waterborne diseases. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: An undated Water Management Program policy, read in part, .The facility can control the growth and spread of water-borne pathogens through a water management program . On 05/11/23 at 8:30 a.m., the medication storage room was observed. The double sink was observed to be used, the water was observed to back up from the other side of the drain. LPN #1 was asked how long had the sink not been draining. They stated, since the maintenance man had quit. They were asked how long was that. They stated about one to two weeks ago. […]

• No harm, potential for more than minimal, patternF684Jul 21, 2025

  Based on record review and interview, the facility failed to follow physician orders for 1 (#4) of 13 sampled residents whose orders were reviewed.The administrator identified 48 residents resided in the facility. Findings: An admission assessment, dated 05/08/25, showed Resident #4 had diagnoses which include diabetes mellitus type 2 and acquired absence of right leg below the knee. The assessment showed Resident #4 had a BIMS score of 9, which indicated a moderate impairment of cognitive ability. A physician's order, dated 07/05/25, showed to cleanse the left great toe with normal saline, pat dry, apply Betadine (antiseptic) every shift and leave open to air two times a day for wound care.The TAR for July 2025 did not show any wound care completed for the left great toe as of 07/17/25. […]