Health inspection·April 20, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure all incidents of potential abuse were reported timely to the State agency as required. This affected one resident (#50) of three reviewed. The facility census was 43. Findings include: Review of Resident #50's closed medical records revealed an initial admission date of 01/27/23 with a readmission date of 04/12/23 and a discharge date of 04/15/23. Diagnoses included stroke with left sided weakness and aphasia (difficulty speaking). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition and required extensive assistance with bed mobility, transfers, toileting and personal hygiene. Resident #50 was incontinent of bowel and bladder. Review of the care plan dated 03/14/23 revealed Resident #50 had impaired cognition and interventions included to offer simple choices, maintain eye contact while speaking and repeat communications as needed. Resident #50 had self care deficits related to stroke and interventions included provide assistance as needed. Review of progress note dated 04/05/23 revealed Resident #50 had complaints of abdominal fullness with an elevated heart rate. The physician ordered Resident #50 be sent to the hospital for evaluation and treatment. Review of progress note dated 04/15/23 revealed Resident #50 was sent to the hospital for abdominal discomfort. Interview on 04/20/23 at 9:55 A.M. with the Administrator revealed on 04/19/22 the Ombudsman arrived at the facility and informed him and the Licensed Social Worker (LSW) of Resident #50 testing positive for a sexual transmitted disease (STD). The Administrator stated he had not been aware of the concern previously. The Administrator stated the facility had not reported Resident #50's STD as a possible sexual abuse occurring in the facility to the State Agency but an investigation would be initiated. Interview on 04/20/23 at 10:05 A.M. with LSW #205 revealed at approximately 12:30 P.M. on 04/19/23 the Ombudsman arrived at the facility and stated Resident #50 had tested positive for an STD. LSW #205 stated she was not aware of the concern previously and stated there had been no other concerns Page 1 of 2 366106 366106 04/20/2023 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0609 related to abuse. Level of Harm - Minimal harm or potential for actual harm Review of the facility's abuse policy and procedure with a revision date of 09/29/22 revealed the policy did not indicate the time frame for reporting allegations of abuse. Residents Affected - Few Interview on 04/20/23 at 2:55 P.M. with the Administrator confirmed the facility's policy did not contain information regarding a time frame on reporting abuse. The Administrator was unable to state the time frame for reporting abuse. This deficiency represents non-compliance investigated under Complaint Numbers OH00142167 and OH00142181. 366106 Page 2 of 2