Fair Oaks Health & Rehabilitation: Injection Safety Failure - VA
The complaint inspection at Fair Oaks Health & Rehabilitation, located at 12475 Lee Jackson Memorial Highway, identified a breakdown in the facility's own medication administration process. Inspectors reviewed the facility's Injectable Medication policy, which states that medications will be administered in a safe and effective manner and that staff must check the order on the Medication Administration Record to confirm an injection is currently ordered and due before giving it. That step was not consistently followed.
The violation affected some residents, in the language inspectors use to indicate more than one person was exposed to the lapse. CMS classified the level of harm as minimal harm or potential for actual harm, the lower end of the harm scale but not the bottom.
The regional director of clinical operations, identified in inspection records as ASM #3, was notified of the findings before inspectors left the building. No further information was provided to inspectors prior to their exit.
Injectable medications carry risks that oral drugs do not. Once a needle delivers a drug into the body, there is no retrieving it. An injection given without a current order, or given when a dose is not yet due, can mean a resident receives the wrong drug, a double dose, or a medication that a physician has already discontinued. The inspection report does not describe what specific medications were involved or what, if anything, happened to the residents who received them.
Fair Oaks Health & Rehabilitation is a for-profit skilled nursing facility. The October inspection was triggered by a complaint, meaning someone, whether a resident, a family member, or a staff member, contacted regulators before inspectors arrived.
The facility's own written policy existed precisely to prevent this. "Medications will be administered in a safe and effective manner," it reads. "Check the order on the Medication Administration Record to see that an injection is currently ordered and due." The gap between what the policy required and what inspectors found is what produced the citation.
What the inspection record does not say is whether the facility had identified the problem itself before the complaint was filed, whether any resident experienced an adverse reaction, or whether the staff members involved received additional training or discipline. The plan of correction, if one was submitted, was not included in the materials reviewed.
For the residents whose injections were given without a verified order, the question of what drug was in the syringe, and whether it should have been, remains unanswered in the public record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair Oaks Health & Rehabilitation from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
FAIR OAKS HEALTH & REHABILITATION in FAIRFAX, VA was cited for violations during a health inspection on October 8, 2025.
That step was not consistently followed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.