The Gardens of Fairfax Health Care Center

Inspectors wroteBased on closed record review, review of dialysis center documentation, review of an Emergency Medical Services (EMS) run sheet, interview and review of the facility policy, the facility failed to provide adequate amounts of oxygen to ensure safe breathing. This affected one resident (Resident #60) of one resident requiring oxygen on outside appointments. Facility census was 58.

Inspectors wroteBased on observation, interview, review of meal times, and review of the dining room checklist, the facility failed to maintain effective communication and processes to ensure a timely meal service and ensure adequate portions of the main entree were available. This had the potential to effect all residents receiving meals from the kitchen. The facility identified one Resident (#7) as receiving nothing by mouth (NPO) who did not receive meals from the facility kitchen. The facility census was 61.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure Resident #49's allegation of missing funds was reported to the State Agency. This affected one resident (Resident #49) out of three residents reviewed for misappropriation. The facility census was 61.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, the facility failed to ensure residents who were dependent on care received the appropriate assistance. This affected three Residents (#5, #21, and #49) of four residents reviewed for activities of daily living (ADL) assistance. The facility census was 61.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure Resident #60's dialysis access site was immediately monitored upon her return to the facility from dialysis for bleeding and other complications. This affected one resident (#60) out of two residents reviewed for dialysis. The facility census was 61.

Inspectors wroteBased on resident record review and staff interview, the facility failed to ensure pharmacy recommendations approved by the physician were implemented in a timely manner. This affected one resident (#4) of five residents reviewed for pharmacy reviews. The facility census was 61.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an elopement was reported to the State Agency. This affected one resident (#50) of three residents reviewed for elopement. The facility census was 47.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLAINCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the closed medical record, interview, review of the facility's investigation, interviews with facility staff, and review of the facility policy on elopement, facility failed to ensure staff provided adequate supervision to prevent Resident #50 from leaving the facility unsupervised. This affected one resident (#50) of three residents reviewed for elopement and supervision. The facility census was 47.

Inspectors wroteBased on observation, medical record review, review of a facility Self-Reported Incident (SRI), staff statements, local police incident report, National Centers for Environmental Information, the [NAME] Cleveland Ohio Neighborhood Guide, the facility's Elopement policy and procedure and interviews, the facility failed to provide adequate supervision to Resident #1, who was assessed to be cognitively impaired and at risk for elopement, to prevent the resident from exiting the facility without staff knowledge. This resulted in Immediate Jeopardy and the likelihood for serious harm, injury, or death on 03/16/24 between 3:30 P.M. and 4:10 P.M. when Resident #1 exited the facility without staff knowledge. [...]

Inspectors wroteBased on interview and review of medical record, Self-Reported Incident report/investigation, and the facility's abuse policy and procedure the facility failed to implement their abuse policy and procedure related to an injury of unknown origin. This affected one (Resident #14) of seven residents reviewed for abuse and neglect.

Inspectors wroteBased on observation, interview, medical record review, Self-Reported Incident report/investigation review and abuse policy and procedure review, the facility failed to thoroughly investigate an allegation of physical abuse. This affected one (Resident #14) of seven residents reviewed.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to provide feeding assistance in a timely manner for dependent residents. This affected one (Resident #14) of seven residents reviewed. The census was 44.

Inspectors wroteBased on record review and interview the facility failed to develop a person-centered baseline care plan for one resident (#48) of two residents reviewed for baseline care plans. The facility census was 47.

Inspectors wroteBased on record review and interview the facility failed to develop a person-centered care plan for one resident (#9) of two residents reviewed for comprehensive person-centered care plans. The facility census was 47.

Inspectors wroteBased on record review, facility policy review, personnel file review and interview, the facility failed to implement the screening component of their abuse policy and procedure to ensure all potential new hires were checked against the state Nurse Aide Registry (NAR) to ensure no employee had findings concerning abuse, neglect, exploitation or misappropriation of residents' property. The facility also retained staff after 30 days when background check results were not received. This affected six out of 14 employees whose personnel files were reviewed and had the potential to affect all 45 residents in the facility. Findings Include: Review of 14 personnel records on 05/10/23 starting at 12:29 P.M. with Human Resource Coordinator (HRC) #202 revealed the following concerns: a. Review of State Tested Nursing Assistant (STNA) #218's personnel file revealed a re-hire date of 04/11/23. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered Nurse (RN) was on-site eight hours a day, seven days a week as required. This had the potential to affect all 45 residents in the facility. Findings Include: 1. Review of posted staffing sheets from 04/01/23 to 05/06/23 revealed a RN was not in the facility on 04/01/23, 04/02/23, 04/03/23, 04/06/23, 04/07/23, 04/08/23, 04/09/23, 04/10/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/17/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/27/23, 04/28/23, 04/29/23 and 05/06/23. Interview on 05/09/23 at 9:14 A.M. with Scheduler #220 verified the identified dates did not meet the required eight hours of RN coverage as required. 2. Review of the staffing schedules for 04/30/23 to 05/06/23 with Scheduler #220 on 05/09/23 at 12:05 P.M. revealed the facility did not have an RN onsite on any shift on 05/06/23. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served at safe and appetizing temperatures. This affected 44 residents receiving food from the kitchen. Resident #25 was ordered nothing-by-mouth. The facility census was 45. Findings Include: Review of the Fall/Winter Week Two menu for Monday corresponding to 05/08/23 revealed the meal to be served for lunch included Salisbury steak, garlic mashed potatoes, stewed tomatoes, wheat bread, margarine, coconut cream pie and beverage of choice. Observation on 05/08/23 at 11:37 A.M. revealed [NAME] #209 was taking temperatures for lunch tray service with the facility's self-calibrating electronic thermometer. Food temperatures obtained were as follows: sour cream (on ice) 33.5 degrees Fahrenheit (F); Salisbury steak, 203 degrees F; baked potato, 191 degrees F; stewed tomatoes, 173 degrees F; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a clean and sanitary kitchen. This affected 44 residents receiving food from the kitchen. Resident #25 was ordered nothing-by-mouth. The facility census was 45. Findings Include: Observation of the kitchen on 05/07/23 from 8:54 A.M. to 9:45 A.M. with [NAME] #209 revealed the following concerns: • The walk-in cooler lacked an internal thermometer. On the shelves, two bags of shredded mozzarella cheese, a lemon meringue pie and a strawberry cream pie did not have dates on them. • On the bread cart, four loaves of bread had a use by date of 04/24/23 and two loaves of bread had a use by date of 05/02/23. Buns and wraps were present but also undated. • On a pull cart, three packs of ham were undated. • In the freezer, a bag of unidentifiable meat was not dated and had a lot of ice buildup. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a clean and sanitary laundry service, privacy curtains were changed when visibly dirty, a comprehensive legionella program, and yearly screening for tuberculosis. This affected all 45 residents residing at the facility. Findings Include: 1. Observation on 05/10/23 at 10:29 A.M. with Building Manager #226 revealed in the soiled area of the laundry processing area there were two large washing machines and one smaller washing machine. The smaller washing machine had clothing inside. An attempt to open the door of the smaller washing machine revealed it would not open. The tops of both large washers had sticky liquid spills, and dust. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement a comprehensive antibiotic stewardship program. This had the potential to affect all 45 residents residing at the facility including Residents (#9, #15, #23, #27, #39 and #40) who received antibiotics between March 2023 and May 2023. Findings Include: Interview on 05/09/23 at 9:24 A.M. with the Director of Nursing (DON) revealed the facility kept a log of resident infections in a notebook which was tracked by type of organism, type of antibiotic used and mapped by room to identify potential patterns. If a physician ordered an antibiotic prior to obtaining culture and sensitivity results, the nurse wrote a progress note that McGreer's criteria (antibiotic surveillance definitions specific for benchmarking appropriate antibiotic usage) had not been met and the physician was notified. [...]

Inspectors wroteBased on record review, observation and interview the facility failed to provide nail care for residents unable to carry out activities of daily living (ADLs) without assistance. This affected three (Residents #2, #8, and #26) of four residents reviewed for ADLs. Findings Include: 1. Review of the medical record for Resident #8 revealed an admission date of 06/04/21. Diagnoses included type II diabetes, heart disease, chronic kidney disease, blindness of one eye, and glaucoma. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/23, revealed Resident #8 had impaired cognition and required extensive assistance with bed mobility, limited assistance with transfers, total dependence for dressing and personal hygiene. Review of the plan of care dated 05/03/23 revealed Resident #8 had a self-care performance deficit related to blindness. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure monitoring for medication effects and potential adverse consequences was completed for residents who were receiving psychotropic medications. This affected four residents (#2, #8, #11 and #41) out of five residents reviewed for unnecessary medications. The facility census was 45 residents. Findings Include: 1. Review of Resident #11's medical record revealed an admission date of 11/25/20 and diagnoses including type two diabetes, schizophrenia, anemia, hypertension and hypertension. Review of Resident #11's plan of care dated 11/25/20 revealed she used lexapro and trazodone. Interventions listed included: administer antidepressant medications as ordered by physician. [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure pureed foods were prepared in a manner that preserved nutritional value. This affected five residents (Residents #6, #15, #16, #24 and #34) receiving a pureed diet. The facility census was 45. Findings Include: Review of the Fall/Winter Week Two menu for Monday corresponding to 05/08/23 revealed the meal to be served for lunch included Salisbury steak, garlic mashed potatoes, stewed tomatoes, wheat bread, margarine, coconut cream pie and beverage of choice. Observation on 05/08/23 starting at 10:56 A.M. with [NAME] #209 revealed she was making pureed stewed tomatoes for the lunch meal. [NAME] #209 indicated she needed six purees but would make seven portions. [NAME] #209 then stated she needed four purees so would make five portions. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible for residents. This affected one resident (Resident #46) of two residents (Resident #12 and #46) reviewed for call light placement. Findings Include: Review of the medical record for Resident #46 revealed an admission date of 12/17/22. Diagnoses included but were not limited to cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery, type II diabetes mellitus and adult failure to thrive. Review of the 04/08/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #46 revealed a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. [...]

Inspectors wroteBased on record review, self-reported incident (SRI) review, policy review and interview, the facility failed to report an allegation of potential abuse related to an injury of unknown origin as required. This affected one resident (Resident #29) of four residents (Residents #26, #29, #35, and #147) reviewed for abuse. The facility census was 45. Findings Include: Review of the medical record for Resident #29 revealed an admission date of 09/02/22. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, adult failure to thrive and osteoarthritis. Review of 02/22/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #29 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated severe cognitive impairment. [...]

Inspectors wroteBased on record review, self-reported incident (SRI) review, policy review and interview, the facility failed to conduct a thorough investigation related to and injury of unknown origin for Resident #29 and an allegation of alleged sexual abuse for Resident #35. This affected two (Resident #29 and #35) of four residents (#26, #29, #35 and #147) reviewed for abuse. Findings Include: 1. Review of the medical record for Resident #29 revealed an admission date of [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, adult failure to thrive and osteoarthritis. Review of the [DATE] quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #29 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated severe cognitive impairment. [...]

Inspectors wroteBased on record review and interview the facility failed to develop a baseline care plan. This affected one resident (Resident #148) of three residents reviewed for new admissions. Findings Include: Review of the medical record for Resident #148 revealed an admission date of 05/02/23. Diagnoses included heart disease, gout, osteoarthritis, repeated falls, and retention of urine. Review of the baseline assessment, dated 05/02/23 revealed Resident #148 experienced confusion, had a history of falls, an unsteady gait, poor balance, and was impulsive. Resident #148 used a walker. Review of the baseline care plan dated 05/03/23 revealed information regarding nutritional risk. The care plan did not include information regarding falls, unsteady gait, confusion, impulsiveness or urinary retention. Interview on 05/09/23 at 1:13 P.M. [...]

Inspectors wroteBased on record review and interview the facility failed to provide Resident #8's restorative nursing program for ambulation and lower extremity exercises as ordered by the physician and as recommended upon discharge from physical therapy. This affected one (Resident #8) of two residents reviewed for physical therapy. Finding Include: Review of the medical record for Resident #8 revealed an admission date of 06/04/21. Diagnoses included type II diabetes, heart disease, chronic kidney disease, blindness of one eye, and glaucoma. Review of the quarterly Minimum Data Set 3.0 assessment, dated 03/31/22, revealed Resident #8 had impaired cognition and required extensive assistance from staff for bed mobility, transfers and ambulation. Review of the plan of care dated 05/03/23 revealed Resident #8 had a self-care performance deficit related to blindness. [...]

Inspectors wroteBased on interview, record review and policy review, the facility failed to provide appropriate catheter care and monitoring. This affected one resident (Resident #44) of one resident reviewed for catheter care. The facility census was 45 residents. Findings Include: Review of Resident #44's medical record revealed an admission date of 08/02/22 and diagnoses including acute kidney failure, chronic obstructive pulmonary disease, osteoarthritis, adult failure to thrive and gout. Review of Resident #44's bowel and bladder program screener dated 08/02/22 revealed a score of 19 indicating Resident #44 was a good candidate for retraining. Review of Resident #44's hospital paperwork revealed a urinary catheter was placed prior to his readmission to the facility on [DATE]. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to obtain dialysis orders and ensure the dialysis care plan included individualized interventions which accurately reflected the care needs of the resident. This affected one of one resident (Resident #12) reviewed for dialysis. The facility identified two residents (Residents #2 and #12) receiving dialysis. Findings Include: Review of the medical record for Resident #12 revealed an admission date of 07/13/19. Diagnoses included but were not limited to dementia, end stage renal disease and chronic combined systolic (congestive) and diastolic heart failure. Review of the 03/14/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #12 revealed a Brief Interview of Mental Status (BIMS) score of 09 which indicated Resident #12 was moderately cognitively impaired. [...]

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure pharmacy medication recommendations were timely addressed and followed up upon. This affected one resident (Resident #41) of five residents reviewed for unnecessary medications. The facility census was 45 residents. Findings Include: Review of Resident #41's medical record revealed an admission date of 05/05/21 and diagnoses including bipolar disorder, current episode manic severe with psychotic features, unspecified dementia, unspecified severity without behavioral disturbance, major depressive disorder, insomnia, history of COVID-19 and other specified mental disorders due to known physiological condition. Review of Resident #41's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 was cognitively impaired and received antipsychotics and antidepressants. [...]

Inspectors wroteBased on interview, record review and review of the Payroll Based Journal (PBJ) staffing data report, the facility failed to ensure consistent submission of information as required. This had the potential to affect all 45 residents in the facility. Findings Include: Review of the facility's Payroll Based Journal (PBJ) staffing data report for Quarter Three of 2022 (covering 04/01/22 to 06/30/22) revealed no staffing data was submitted by the facility for the quarter. Review of facility documentation for submission of PBJ data revealed the last data the facility submitted was on 05/12/22 for the dates 01/01/22 to 03/31/22. No more recent submission information was available for review. Interview on 05/08/23 at 4:26 P.M. with Human Resource Coordinator (HRC) #202 verified the facility last submitted PBJ data on 05/12/22. [...]

Inspectors wroteBased on interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to provide mandatory staff training on the facility's QAPI program. This had the potential to affect all 45 residents residing in the facility. Findings Include: Review of the facility's QAPI program for 2022 and 2023 revealed initiatives that included: Resident tuberculosis base line testing and documentation, COVID vaccine documentation, and code status posting policy upon admission. There was no evidence of mandatory staff training on the facility's QAPI program initiatives that included the goals and various elements of the program, how the facility intended to implement the program, and how to communicate concerns or opportunities for improvement. Interview on 05/15/23 at 12:27 P.M. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the facility was staffed sufficiently to ensure all residents had assigned nursing coverage at all times. The facility was also not staffed sufficiently to ensure timely and appropriate fulfillment of physician's orders. This affected the 25 residents residing on the first floor (Resident #37, #6, #22, #43, #12, #58, #61, #41, #65, #20, #16, #168, #54, #44, #45, #7, #23, #25, #46, #49, #36, #55, #26, #18, and #13). The facility also did not staff sufficiently to meet minimum staffing needs required by the state of Ohio, affecting all residents in the facility. [...]

Inspectors wroteBased on interview and review of Quality Assessment and Assurance (QAA) process, the facility did ensure the medical director participated in the QAA committee. This had the potential to affect all 64 residents in the facility.

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to ensure infection control practices were followed for isolation precautions for one resident (Resident #19) with clostridium difficile (C-diff), cleaning of glucometers for two residents (Residents #20 and #5) and failed to have Legionella and Tuberculosis assessments. This had the potential to affect all 64 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide residents with their choice of eating in the dining room for meals. This affected the twenty-one residents who usually eat in the second-floor dining room (Residents #1, #8, #9, #10, #15, #27, #31, #39, #47, #48, #50, #53, #56, #57, #59, #60, #63, #64, #65, #66 and #67). The census was 64.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #8 and Resident #28 received the assistance they needed to receive regular showers. This affected two residents of 22 residents assessed for activities of daily living (ADL). The facility census was 64.

Inspectors wroteBased on observation and interview, the facility failed to ensure the first floor was staffed sufficiently to ensure timely fulfillment of physician's orders and management of resident care needs. This affected the 25 residents residing on the first floor (Residents #37, #6, #22, #43, #12, #58, #61, #41, #65, #20, #16, #168, #54, #44, #45, #7, #23, #25, #46, #49, #36, #55, #26, #18, and #13). The facility census was 64.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Ombudsman and resident representatives were notified in writing of hospital transfers and rights. This affected two (Resident #28 and #69) of three residents reviewed for hospitalization and discharge. The facility census was 64.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessment was coded accurately for Residents #26, #28, and #48. This affected three of 22 resident's reviewed for MDS 3.0 assessment accuracy. The facility census was 64.

Inspectors wroteBased on record review, review of facility policy and staff interview, the facility failed to ensure baseline care plans were completed in 48 hours and a copy was provided to the resident. This affected one (Resident #19) of one resident reviewed for baseline care plans. The facility census was 64.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure comprehensive care plans were reactivated for Resident #28 after readmission, were developed related to dialysis for Resident #33 and were developed for antipsychotic medications and behaviors for Resident #40. This affected three residents of 22 residents reviewed for care plans. The facility census was 64.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure tube feed was given according to physician's orders and quality standards of care. This affected one (Resident #26) of two residents at the facility who receive tube feeds (Resident #10 and #26). The facility census was 64.

Inspectors wroteBased on medical record review and staff interview, the facility failed to indicate why the administration of an as needed antipsychotic medication was necessary for one resident (Resident #61) of five residents reviewed for unnecessary medication use. The facility census was 64. Findings Include: Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes mellitus, Alzheimer's disease and dependence on renal dialysis. Review of Resident #61's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was rarely understood and received antipsychotic medications three days of the seven-day during the assessment reference period. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was enough personal protective equipment (PPE) for staff to wear during care with residents on isolation precautions. This affected one resident (Resident #19) and had the potential to affect all 64 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post up-to-date staffing information in public areas. This had the potential to affect all 64 residents living at the facility at the time of the survey.