Health inspection·October 23, 2019

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based 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. Finding include: Observation on 10/20/19 at 4:45 P.M. revealed no residents were in the second-floor dining room. On 10/20/19 at 4:48 P.M. Resident #9 was heard asking Nurse Manager #49 why the dining room wasn't open today. Nurse Manager #49 stated that residents were going to eat in their rooms that evening. Interview on 10/22/19 at 9:57 A.M. with Dietary Supervisor #3 and Dietary Manager #16 revealed the dietary department had a list of which residents had chosen to usually ate in the second-floor dining room. The list included 21 residents (Residents #1, #8, #9, #10, #15, #27, #31, #39, #47, #48, #50, #53, #56, #57, #59, #60, #63, #64, #65, #66 and #67). The food for the second-floor residents was brought up in a steam table (equipment used to keep bulk food hot), and residents were served in the dining room from the pantry. When nursing was short-staffed, they notified dietary to assemble all residents' meals on trays for delivery to resident rooms. Residents were not brought to the dining room. Then kitchen then ran a tray-line for all the resident trays and sent them upstairs on the food carts to be served in the rooms. Interview on 10/23/19 at 11:21 A.M. with Licensed Practical Nurse (LPN) #78 revealed when nursing was short-staffed, the residents ate in their rooms because it was hard to get them up and ready to go to the dining room on time. Page 1 of 20 366106 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: 1. Record review of Resident #69 revealed she was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. She had not returned to the facility as of the time of the survey. The record review revealed no evidence the Ombudsman or representative had received written notice of the transfer or the rights to an appeal or bed-hold. Interview with Licensed Social Worker (LSW) #10 on 10/22/19 at 1:37 P.M. revealed when residents are hospitalized , their responsible parties were informed via telephone. The facility only notified the Ombudsman of hospital transfers if they were not anticipating the resident would return. Interview with LSW #10 on 10/22/19 at 4:17 P.M. confirmed the Ombudsman was not informed and no written notice of discharge justification and rights was given related to the transfer of Resident #69 to the hospital on [DATE]. 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, cellulitis of right lower limb, arthritis and fibromyalgia. On 07/08/19 Resident #28 was transferred to the hospital. The resident returned to the facility on [DATE]. The record review revealed no evidence the Ombudsman or representative had received written notice of the transfer or the rights to an appeal or bed-hold. Interview with LSW #10 on 10/22/19 at 1:37 P.M. revealed when residents are hospitalized , their responsible parties were informed via telephone. The facility only notified the Ombudsman of hospital transfers if they were not anticipating the resident would return. Interview with LSW #10 on 10/22/19 at 4:21 P.M. confirmed the Ombudsman was not informed and no written notice of discharge justification and rights was given related to the transfer of Resident #28 to the hospital on [DATE]. 366106 Page 2 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including dysphagia, diabetes mellitus, facial weakness and cerebral infarction. Review of the MDS 3.0 assessment dated [DATE] indicated the resident was rarely understood and eating was coded as the activity did not occur. Review of resident #26's medical record revealed physician's orders, medication administration records (MAR) and treatment administration records (TAR) for October 2019 revealed Resident #26 received nothing by mouth. The resident received enteral feeding (nutrition taken through a tube that goes directly into the stomach or small intestine) from 9:00 A.M. to 9:00 P.M. daily. Interview on 10/23/19 at 10:09 A.M. with MDS Nurse #54 confirmed Resident #26's received enteral feedings during the assessment period for the MDS dated [DATE], and documentation should have stated total dependence with one person assist for eating. 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, cellulitis of right lower limb, arthritis and fibromyalgia. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 was coded as having received an antipsychotic medication, and on a separate question was coded antipsychotic medication was not received. Review of the physician orders revealed Resident #28 was receiving Risperdal, an antipsychotic, as of 07/13/19. Interview on 10/23/19 at 2:38 P.M. with MDS Nurse #54 confirmed Resident #28 received an antipsychotic medication during the assessment reference period for the MDS dated [DATE]. 3. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, cerebral infarction, dysphasia and aphasia. The quarterly MDS 3.0 assessment dated [DATE] revealed the resident required extensive assistance for bed mobility, transfers, walking in his room, dressing, toilet use and personal hygiene. Restraints were coded as not used. The staff assessed the resident as severely cognitively impaired. The quarterly MDS 3.0 assessment dated [DATE] indicated restraints were used daily. Interview on 10/22/19 at 2:55 P.M. with State Tested Nurse Aide (STNA) #12 revealed Resident #48 did not have a restraint, he had never had a restraint. 366106 Page 3 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0641 Level of Harm - Minimal harm or potential for actual harm Interview on 10/22/19 at 3:15 P.M. with MDS Nurse #54 confirmed there was an MDS error. Resident #48 never had a restraint. Interview on 10/23/19 10/23/19 at 9:19 A.M. with STNA #1 revealed Resident #48 had never had a restraint. She had not seen a restraint used in the three years she had worked at the facility. Residents Affected - Few 366106 Page 4 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the medical record revealed Resident #19 was readmitted to the facility on [DATE] with diagnoses including epilepsy, stage five kidney disease, protein malnutrition, diabetes mellitus, enterocolitis due to clostridium difficile (C-diff). Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Interview on 10/23/19 at 10:09 A.M. with MDS Nurse #54 verified the baseline care plan was not completed and stated that baseline care plans are not completed. Review of the undated facility's policy entitled Advance Care Planning/Baseline Care Plan revealed that upon admission the resident and/or the responsible party shall be informed that the care plan discussions are available. 366106 Page 5 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, cellulitis of right lower limb, arthritis and fibromyalgia. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required limited assistance for bed mobility. Transfers, locomotion, eating and toilet use were coded as only occurred once or twice. Dressing and personal hygiene were coded as not assessed. The Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. Two care plans relative to nutrition were the only care plans in the electronic medical record. Interview on 10/23/19 at 9:55 A.M. with MDS Nurse #54 verified there were no active nursing care plans in the electronic medical record, there were only the two nutrition care plans. Interview on 10/23/19 at 2:53 P.M. with MDS Nurse #54 verified Residents #28's care plans were canceled as of 07/23/19 and had not been reactivated. They had now been reactivated. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, major depressive disorder, diabetes and vascular dementia with behavioral disturbances. The annual MDS 3.0 assessment dated [DATE] revealed the resident was totally dependent on staff for bed mobility, transfers and toileting. He required limited assistance for locomotion on the unit and supervision for locomotion off unit and eating. The resident was receiving off-site dialysis. There was no care plan developed or implemented relative to dialysis. Interview on 10/23/19 at 3:12 P.M. the Director of Nursing (DON) verified there was no dialysis care plan developed for Resident #33 3. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including dementia with behavior disturbance, chronic obstructive pulmonary disease and diabetes mellitus. Review of Resident #40's MDS 3.0 assessment dated [DATE] indicated the resident was rarely understood and received antipsychotic medications. Review of the October 2019 physician's orders revealed an order for Zyprexa (an antipsychotic medication) for the diagnosis of dementia. 366106 Page 6 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the care plan for Resident #40 revealed there were no interventions for behaviors or antipsychotic medications. Interview on 10/23/19 at 10:12 A.M. with Licensed Practical Nurse (LPN) #78 verified there were no care plans for Resident #40 in regard to behaviors or antipsychotic medications. Residents Affected - Few Review of the policy dated 12/1/17 entitled, Psychoactive Medications revealed that nursing will monitor psychotropic drug use. 366106 Page 7 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, cellulitis of right lower limb, arthritis and fibromyalgia. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required limited assistance for bed mobility. Transfers, locomotion, eating and toilet use were coded as only occurred once or twice. Dressing and personal hygiene were coded as not assessed. The Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. A review of the Task Sheet for Showers/Bathing for 09/24/19 through 10/22/19 revealed only two showers were completed, on 9/27/19 and on 10/1/19, in the thirty-day report period. A review of the Showers Sheets for 09/24/19 through 10/22/19 revealed one Shower Sheet completed for 10/22/19. Interview on 10/20/19 at 10:31 A.M. with Resident #28 revealed her showers were supposed to be on Tuesdays and Fridays, but she did not always receive them. Interview on 10/23/19 at 3:34 P.M. with Licensed Practical Nurse (LPN) #78 verified the shower/bathing information was the only documentation available. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including lymphedema, venous insufficiency, chronic kidney disease, peripheral vascular disease, vascular dementia and major depressive disorder. The annual MDS 3.0 assessment dated [DATE] revealed the resident required the extensive assistance of one person for bed mobility and toilet use. Supervision was required for walking, dressing and eating. Staff assessed the resident as severely cognitively impaired. A care plan relative to ADL revealed the resident required one-person assistance bathing/showering on shower days, Tuesday and Friday and as necessary. A review of the Task Sheet for Showers/Bathing for 09/24/19 through 10/22/19 revealed a shower was completed once, 10/04/19, in the thirty-day report period. A review of the Showers Sheets for 09/24/19 through 10/22/19 revealed one Shower Sheet completed for 09/24/19. Interview on 10/23/19 at 3:34 P.M. with LPN #78 verified the shower/bathing information was the only documentation available. 366106 Page 8 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some Findings include: Observation of the first floor of the facility, containing 25 residents, (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) on 10/20/19 at 8:20 A.M. revealed no nurses engaged in any direct resident care. Interviews with State-Tested Nursing Aides (STNA) #53 and #71 on 10/20/19 at 8:23 A.M. revealed there was no nurse currently taking care of residents on the first floor. The night-shift nurse had departed, and the day-shift nurse had not yet arrived. Interview with STNA #53 on 10/20/19 at 10:16 A.M. revealed there was still no nurse assigned to provide care on the first floor. Observation on 10/20/19 at 11:03 A.M. revealed Registered Nurse (RN) #49 entered a first-floor resident's rooms with pain medications. Interview with RN #49 on 10/20/19 at 11:11 A.M. revealed she was a nurse manager, and had not assumed any care for residents on the first floor beyond administering one resident's pain medication. She confirmed that morning medications were generally passed between 8:00 A.M. and 10:00 A.M. and confirmed that all first-floor residents' medications scheduled for this timeframe were now late. Interview with the Director of Nursing (DON) on 10/20/19 at 11:45 A.M. confirmed no nurse was assigned to cover residents on the first floor. The facility had a call-off, and they had been trying all morning to call in staff to cover the first floor. Licensed Practical Nurse (LPN) #63 had been the night nurse on the first floor and had worked a double-shift. Interview with RN #22 on 10/20/19 at 12:56 P.M. revealed she arrived at the facility at roughly 12:00 P.M. and was assigned to care for the residents on the first floor. She was called at around 11:00 A.M. to come in to work. She received a report for the assignment from RN #205. Interview with RN #22 on 10/20/19 at 3:22 P.M. revealed the morning-scheduled medications for the first floor had still not been administered. Interview with the DON on 10/20/19 at 3:47 P.M. confirmed morning medications were not passed for the first floor. She said facility staff called the Medical Director and he said not to pass them. Interview with the Medical Director on 10/23/19 at 8:49 A.M. revealed that on 10/20/19, RN #22 called to inform him of the situation on the first floor of the facility. The Medical Director said he instructed RN #22 to administer the morning medications, monitor the residents, and create an incident report. He denied ever giving RN #22 instructions to hold the morning medications for her residents, and stated he did not speak to the DON that day. 366106 Page 9 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0684 Level of Harm - Minimal harm or potential for actual harm Interview with RN #22 on 10/23/19 at 9:21 A.M. revealed she called the Medical Director on 10/20/19, and he gave her instructions to ensure residents received their needed care. The Medical Director did not instruct her not to give morning medications, however she did not give any morning medication due to the need to assess the first-floor residents for urgent needs, monitor their vitals, and determine if any urgent action was needed to ensure resident safety. Residents Affected - Some Interview with RN #49 on 10/23/19 at 9:55 A.M. revealed she did not receive any report from the night shift nurse on the morning of 10/20/19. She did not pass any medications except pain medications for one resident and did not give any other resident care. Review of the punch card times for LPN #63 on the night of 10/19/19 revealed he was assigned to staff the first floor, and clocked-out on 10/20/19 at 7:38 A.M. This deficiency substantiates Master Complaint Number OH00107633 and Complaint Number OH00107620. 366106 Page 10 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Observation of Resident #26 on 10/20/19 at 10:18 A.M. revealed he had tube feed running into a gastric tube at 75 milliliters (ml) per hour. The feed bag was unlabeled and contained no information about the formula being fed, the date and time hung, the rate it was to run, and the time it was to come down. The feed bag was almost empty. The resident was not interviewable. Observation of Resident #26 on 10/20/19 at 10:37 A.M. and 10:59 A.M. revealed his tube feed bag was empty. The tube feed administration pump read feed error and was stopped. Tube feed formula was still visible in the tubing entering the resident's gastric tube. Interview with Registered Nurse (RN) #49 on 10/20/19 at 11:11 A.M. confirmed the above observations regarding Resident #26, and she said his tube-feed should have come down at 9:00 A.M. Observation of Resident #26 on 10/20/19 at 11:32 A.M. and 12:30 P.M. revealed the status of his tube feed pump and tubing to be unchanged from the observation at 10:59 A.M. Observation on 10/20/19 at 12:32 P.M. revealed RN #22 entered with Resident #26 at this time, disconnected and flushed the resident's enteral tube, and administered the scheduled tube feed bolus. Record review of Resident #26 revealed he was admitted to the facility on [DATE] and had diagnoses including dysphagia, cerebral infarction, hemiplegia and diabetes mellitus type 2. He had an active physician's order dated 10/29/18 for a tube feed of Diabetisource (a tube-feed brand) to run at 75 ml per hour continuously every night from 9:00 P.M. to 9:00 A.M. Review of the facility's tube feed policy, dated 07/03/07, revealed feeding tubes were to be flushed after feeding to maintain patency and provide hydration. 366106 Page 11 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. In addition, the facility did not staff sufficiently to ensure residents had the option of eating in the dining room, affecting the twenty-one residents who usually eat in the second-floor dining room [ROOM NUMBER] residents (Residents #1, #8, #9, #10, #15, #27, #31, #39, #47, #48, #50, #53, #56, #57, #59, #60, #63, #64, #65, #66 and #67). The facility census was 64. Findings include: 1. Observation of the first floor of the facility, containing 25 residents, (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) on 10/20/19 at 8:20 A.M. revealed no nurses engaged in any direct resident care. Interviews with State-Tested Nursing Aides (STNA) #53 and #71 on 10/20/19 at 8:23 A.M. revealed there was no nurse currently taking care of residents on the first floor. The night-shift nurse had departed, and the day-shift nurse had not yet arrived. Interview with STNA #53 on 10/20/19 at 10:16 A.M. revealed there was still no nurse assigned to give care on the first floor. Observation on 10/20/19 at 11:03 A.M. revealed Registered Nurse (RN) #49 entered a first-floor resident's rooms with pain medications. Interview with RN #49 on 10/20/19 at 11:11 A.M. revealed she was a nurse manager and had not assumed any care for residents on the first floor beyond administering one resident's pain medication. She confirmed that morning medications were generally passed between 8:00 A.M. and 10:00 A.M. and confirmed that all first-floor residents' medications scheduled for this timeframe were now late. Interview with the Director of Nursing (DON) on 10/20/19 at 11:45 A.M. confirmed no nurse was assigned to cover residents on the first floor. The facility had a call-off, and they had been trying all morning to call in staff to cover the first floor. Licensed Practical Nurse (LPN) #63 had been the night nurse on the first floor and had worked a double-shift. Interview with RN #22 on 10/20/19 at 12:56 P.M. revealed she arrived at the facility at roughly 12:00 P.M. and was assigned to care for the residents on the first floor. She was called at around 11:00 A.M. to come in to work. She received a report for the assignment from RN #205. Interview with RN #22 on 10/20/19 at 3:22 P.M. revealed the morning-scheduled medications for the first floor had still not been administered. Interview with the DON on 10/20/19 at 3:47 P.M. confirmed morning medications were not passed for 366106 Page 12 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0725 the first floor. She said facility staff called the Medical Director, and he said not to pass them. Level of Harm - Minimal harm or potential for actual harm Interview with the Medical Director on 10/23/19 at 8:49 A.M. revealed that on 10/20/19, RN #22 called to inform him of the situation on the first floor of the facility. The Medical Director said he instructed RN #22 to administer the morning medications, monitor the residents, and create an incident report. He denied ever giving RN #22 instructions to hold the morning medications for her residents, and said he did not speak to the DON that day. Residents Affected - Many Interview with RN #22 on 10/23/19 at 9:21 A.M. revealed she called the Medical Director on 10/20/19 and he gave her instructions to ensure residents received their needed care. The Medical Director did not instruct her not to give morning medications, however she did not give any morning medication due to the need to assess the first-floor residents for urgent needs, monitor their vitals, and determine if any urgent action was needed to ensure resident safety. Interview with RN #49 on 10/23/19 at 9:55 A.M. revealed she did not receive any report from the night shift nurse on the morning of 10/20/19. She did not pass any medications except pain medications for one resident and did not give any other resident care. Completion of the staffing grid (a tool used to determine compliance with minimum licensure staffing levels) from 10/14/19 to 10/20/19 revealed the facility was below the minimum staffing requirements on 10/14/19, 10/15/19, 10/16/19, and 10/20/19. Review of the punch card times for LPN #63 on the night of 10/19/19 revealed he was assigned to staff the first floor and clocked-out on 10/20/19 at 7:38 A.M. 2. Observation of Resident #26 (a resident on the first floor) on 10/20/19 at 10:18 A.M. revealed he had tube feed running into a gastric tube at 75 milliliters (ml) per hour. The feed bag was unlabeled and contained no information about the formula being fed, the date and time hung, the rate it was to run, and the time it was to come down. The feed bag was almost empty. The resident was not interviewable. Observation of Resident #26 on 10/20/19 at 10:37 A.M. and 10:59 A.M. revealed his tube feed bag was empty. The tube feed administration pump read feed error and was stopped. Tube feed formula was still visible in the tubing entering the resident's gastric tube. Interview with RN #49 on 10/20/19 at 11:11 A.M. confirmed the above observations regarding Resident #26, and she said his tube-feed should have come down at 9:00 A.M. Observation of Resident #26 on 10/20/19 at 11:32 A.M. and 12:30 P.M. revealed the status of his tube feed pump and tubing to be unchanged from the observation at 10:59 A.M. Observation on 10/20/19 at 12:32 P.M. revealed RN #22 entered with Resident #26 at this time, disconnected and flushed the resident's enteral tube, and administered the scheduled tube feed bolus. Record review of Resident #26 revealed he was admitted to the facility on [DATE] and had diagnoses including dysphagia, cerebral infarction, hemiplegia and diabetes mellitus type 2. He had an active physcian's order dated 10/29/18 for a tube feed of Diabetisource (a tube-feed brand) to run at 75 ml per hour continuously every night from 9:00 P.M. to 9:00 A.M. 366106 Page 13 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility's tube feed policy dated 07/03/07 revealed feeding tubes were to be flushed after feeding to maintain patency and provide hydration. 3. Observation on 10/20/19 at 4:45 P.M. revealed no residents were in the second-floor dining room. On 10/20/19 at 4:48 P.M. Resident #9 was heard asking Nurse Manager #49 why the dining room wasn't open today. Nurse Manager #49 stated that residents were going to eat in their rooms that evening. Interview on 10/22/19 at 9:57 A.M. with Dietary Supervisor #3 and Dietary Manager #16 revealed the dietary department had a list of which residents had chosen to usually ate in the second-floor dining room. The list included 21 residents (Residents #1, #8, #9, #10, #15, #27, #31, #39, #47, #48, #50, #53, #56, #57, #59, #60, #63, #64, #65, #66 and #67). The food for the second-floor residents was brought up in a steam table (equipment used to keep bulk food hot), and residents were served in the dining room from the pantry. When nursing was short-staffed, they notified dietary to assemble all residents' meals on trays for delivery to resident rooms. Residents were not brought to the dining room. Then kitchen then ran a tray-line for all the resident trays and sent them upstairs on the food carts to be served in the rooms. Interview on 10/23/19 at 11:21 A.M. with Licensed Practical Nurse (LPN) #78 revealed when nursing was short-staffed, the residents ate in their rooms because it was hard to get them up and ready to go to the dining room on time. This deficiency substantiates Master Complaint Number OH00107633 and Complaint Number OH00107620. 366106 Page 14 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Many Findings include: Observation upon entry into the facility on [DATE] at 8:00 A.M. revealed the direct-care staffing information posted by the facility was dated 10/18/19. Interview with the Director of Nursing (DON) on 10/20/19 at 11:45 A.M. confirmed the posted staff schedule was from 10/18/19. This is an example of continued noncompliance from the survey completed on 10/08/19. 366106 Page 15 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Review of Resident #61's medical record, physician's orders, medication administration records (MAR) and treatment administration records (TAR) for September and October 2019 revealed Resident #61 received Haldol Solution (antipsychotic) intramuscularly one hour in the morning prior to dialysis on Tuesdays, Thursdays and Saturdays. Review of the nurses' notes revealed no documentation regarding what behaviors Resident #61 was exhibiting which required the administration of Haldol. Review of the physician's orders revealed the Haldol dose was originally ordered on 03/23/19 and decreased on 03/26/19. Interview with the Licensed Practical Nurse (LPN) #78 on 10/23/19 at 10:12 A.M. verified that Resident #61 was receiving Haldol, and there was no supporting diagnosis for an antipsychotic medication. Review of the policy dated 12/01/17 entitled, Psychoactive Medications, revealed that the facility supports the use of psychologic medications that are therapeutic and enabling for residents suffering from a mental illness. 366106 Page 16 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Many Findings include: Review of the QAA committee process revealed the medical director was not included in the QAA meetings. Interview with the Medical Director on 10/23/19 at 8:49 A.M. revealed that he had been the medical director of the facility since 04/2019 and had never participated in or been invited to a QAA meeting at the facility. 366106 Page 17 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Many Findings include: 1. Review of the medical record revealed Resident #19 was readmitted to the facility on [DATE] with epilepsy, stage five kidney disease, protein malnutrition, diabetes mellitus, enterocolitis due to clostridium difficile (C-diff). Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact and was always incontinent of bowel. On 10/21/19 at 7:40 A.M., tour of the laundry and interview with Laundry Aide #6 revealed that he did not know which linens were from isolation rooms because they were not separated, and he washed everything together at the same time. The Administrator was in the laundry room during the interview and told Laundry Aide #6 that linens from isolation rooms should be washed separately. Review of the facility's policy dated 01/11/16 entitled, Infection Control revealed that personal protective equipment (PPE) should be worn when entering an isolation room and laundry should be separated. 2. On 10/21/19 at 7:50 A.M. interview with Housekeeper #41 revealed that State Tested Nursing Assistants (STNA) collect the linens. When she cleaned the room, she wears PPE, and items used for cleaning of the rooms are discarded in the room i.e.: towels, mop heads. She stated that she used the same disinfectant and glass cleaner in isolation rooms that she used in all the rooms. Review of the manufacture's Neutra-Stat disinfectant cleaner instructions revealed that the chemical was not effective against C-diff bacteria. 3. Observation and interview on 10/21/19 at 07:59 A.M. with STNA #27 revealed that she was observed coming out of Resident #19's room without wearing any PPE on of any kind. Resident #19 had C-diff. Interview of STNA #27 on 10/21/19 at 8:00 A.M. revealed that there was no disposable gowns or masks in the PPE container hanging on the door. STNA #27 stated that the linen was put in a separate container and was double bagged. The first bag was dissolvable, and the clear bag went around it. She went to get a gown to go back into the room, and there were no disposable gowns available in the building. Review of the facility's policy dated 01/11/16 entitled, Infection Control revealed that PPE should be worn when entering an isolation room, and laundry should be separated. 4. Observation of a blood glucose check by Registered Nurse (RN) #22 for Resident #20 on 10/20/19 at 3:09 P.M. revealed that after the procedure, RN #22 cleaned the glucometer (brand-name [NAME] Smart Meter) off only with a Webcol-brand alcohol swab before putting it away. 366106 Page 18 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview with RN #22 at the time of the above observation revealed she used disinfectant wipes to clean the glucometer between residents when they were available and when not, she used alcohol swabs. Observation of a blood glucose check by Licensed Practical Nurse (LPN) #78 for Resident #5 at 8:14 A.M. on 10/21/19 revealed that after the procedure, LPN #78 cleaned the glucometer (brand-name [NAME] Smart Meter) off only with a Webcol-brand alcohol swab before putting it away. Interview with LPN #78 immediately following the above observation revealed she was allowed to use either alcohol swabs or sanitizing wipes to clean the glucometer between use. Interview with the Director of Nursing (DON) on 10/22/19 at 3:21 PM revealed staff members were allowed to use either sanitizing wipes or alcohol swabs when cleaning glucometers. Review of the [NAME] Smart Meter user manual revealed both its cleaning and disinfection procedure included the use of a germicidal wipe when cleaning or sanitizing the device. The instructions did not indicate an alcohol swab served as an acceptable substitute for a germicidal wipe. Interview with the DON on 10/23/19 at 9:58 A.M. confirmed the above findings. 5. Interview on 10/22/19 at 2:03 P.M. with Maintenance Director #19 revealed that he did not have a Legionella assessment and did no testing for Legionella. He stated that the former DON had all that paperwork, but he can't find any documentation. 6. Interview on 10/23/19 at 10:30 A.M. with the DON revealed that she didn't have a Tuberculosis assessment. She produced policies in regard to newly admitted residents and newly employed staff testing. 366106 Page 19 of 20 366106 10/23/2019 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based 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. Findings include: Observation and interview on 10/21/19 at 07:59 A.M. with State Tested Nurse Aide (STNA) #27 revealed that she was observed coming out of Resident #19's room without wearing any PPE on of any kind. Resident #19 had a diagnosis of clostridium difficile (C-diff). Interview of STNA #27 on 10/21/19 at 8:00 A.M. revealed there were no disposable gowns or masks in the PPE container hanging on the door. STNA #27 stated that the linen was put in a separate container and was double bagged. The first bag was dissolvable, and the clear bag went around it. She went to get a gown to go back into the room, and there were no disposable gowns available in the building. Observation and interview with Director of Nursing (DON) on 10/21/19 at 8:05 A.M. revealed that the DON currently does the ordering for nursing and took this surveyor to the central supply room. There were no disposable gowns in the facility. The DON stated that she would get them in right away. Review of the facility's policy dated 01/11/16 entitled, Infection Control revealed that PPE should be worn when entering an isolation room and laundry should be separated. 366106 Page 20 of 20