Fairfax Behavioral Health & Memory Care Community Inspection Report, Violations & Safety Grade (Fairfax, Oklahoma)

282 County Road 6300, Fairfax, Oklahoma 74637

Phone: 9186423234

CMS Overall:1/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

49.2

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Osage

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

Yes

CMS Star Ratings

Overall1/5

Health2/5

Staffing2/5

Quality1/5

Nurse Staffing Check

Metric	This Facility	Oklahoma Avg	Difference
RN Hours per Resident per Day	0.23	0.34	-0.11
Total Nurse Hours per Resident per Day	3.19	3.82	-0.63
CMS Staffing Rating	2/5	2.7/5	-
Nursing Staff Turnover	N/A	55.4%	-

Health Citation History

36 health citations on record

Date	Category	Description	Severity
2026-05-06	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2026-02-05	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	G – Actual Harm
2026-02-05	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2026-02-05	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-07-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	G – Actual Harm
2025-07-21	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2025-07-21	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	E – Moderate Harm Potential
2025-07-21	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2025-07-21	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-07-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	D – Moderate Harm Potential
2025-07-21	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	D – Moderate Harm Potential
2025-07-21	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2025-07-21	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2024-10-16	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	D – Moderate Harm Potential
2024-10-16	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2024-08-06	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2024-06-07	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2024-06-07	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2024-06-07	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2024-06-07	Quality of Life and Care Deficiencies	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.	E – Moderate Harm Potential
2024-06-07	Nursing and Physician Services Deficiencies	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.	E – Moderate Harm Potential
2024-06-07	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2024-06-07	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	D – Moderate Harm Potential
2024-06-07	Resident Assessment and Care Planning Deficiencies	Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	D – Moderate Harm Potential
2024-06-07	Resident Assessment and Care Planning Deficiencies	Assess the resident when there is a significant change in condition	D – Moderate Harm Potential
2024-06-07	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	D – Moderate Harm Potential
2024-06-07	Environmental Deficiencies	Make sure that a working call system is available in each resident's bathroom and bathing area.	D – Moderate Harm Potential
2023-05-11	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-05-11	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2023-05-11	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2023-05-11	Nursing and Physician Services Deficiencies	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.	E – Moderate Harm Potential
2023-05-11	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2023-05-11	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2023-05-11	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2023-05-11	Administration Deficiencies	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	E – Moderate Harm Potential
2023-05-11	Resident Rights Deficiencies	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.	D – Moderate Harm Potential

Fire Safety Citation History

18 fire safety citations on record

Date	Category	Description	Severity
2025-07-21	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2025-07-21	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2025-07-21	Smoke Deficiencies	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	E – Moderate Harm Potential
2025-07-21	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2025-07-21	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	E – Moderate Harm Potential
2024-06-07	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2024-06-07	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2024-06-07	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2024-06-07	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	E – Moderate Harm Potential
2024-06-07	Smoke Deficiencies	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	C – Minimal Harm Potential
2024-06-07	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	C – Minimal Harm Potential
2023-05-11	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	F – Moderate Harm Potential
2023-05-11	Emergency Preparedness Deficiencies	Establish emergency prep training and testing.	F – Moderate Harm Potential
2023-05-11	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	F – Moderate Harm Potential
2023-05-11	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2023-05-11	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-05-11	Smoke Deficiencies	Properly provide smoke detection systems in areas open to corridors.	C – Minimal Harm Potential
2023-05-11	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	C – Minimal Harm Potential

Total Penalties & Fines

$46,436

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-02-05	Fine	$4,186	-
2025-07-21	Fine	$42,250	-

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3-Year Complete Report ($19)

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