The Gardens of Fairfax Health Care Center

In the surveyor’s words

From the most serious findings on record at The Gardens of Fairfax Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 29, 2024

  Based 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 [DATE] between 3:30 P.M. and 4:10 P.M. when Resident #1 exited the facility without staff knowledge. […]

• No harm, potential for more than minimal, widespreadF800Feb 12, 2026

  Based 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.Findings include: Observations on 02/11/26 of the lunch meal service revealed service began at 11:55 A.M. in the main kitchen area to serve residents who would be eating in their room. The menu included meatloaf, corn, and mashed potatoes. There were three insulated carts delivered. […]

• No harm, potential for more than minimal, widespreadF607May 16, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727May 16, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF804May 16, 2023

  Based 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 Cook #209 was taking temperatures for lunch tray service with the facility's self-calibrating electronic thermometer. […]