Health inspection·December 6, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based 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. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 10/28/23. Medical diagnoses included hypertension, chronic atrial fibrillation, dementia, encephalopathy, gastro-esophageal reflux disease, and pressure ulcer of sacral region. Review of the physician orders for Resident #48 revealed an order dated 11/01/23 that stated to cleanse right lateral calf wound with normal saline, pat dry, apply oil emulsion gauze and cover with abdominal pad and wrap with Kerlix gauze every night shift every Monday, Wednesday, and Friday and as needed. Further review of the physician orders revealed an order dated 11/01/23 that stated to cleanse sacral wound with normal saline, pat dry, pack wound with Vashe moistened gauze and cover with foam every night shift. Review of Resident #48's care plan dated 11/01/23 revealed no care plan for wound care or skin integrity. Interview on 12/05/23 at 3:02 P.M. with Licensed Practical Nurse (LPN) #335 confirmed Resident #48's baseline care plan did not include wound care or skin integrity. Page 1 of 2 366106 366106 12/06/2023 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. Based 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. Findings include: Review of the medical record for Resident #9 revealed an admission date of 05/11/20. Medical diagnoses included Alzheimer's disease, pulmonary hypertension, moderate protein-calorie malnutrition, chronic kidney disease, and chronic diastolic congestive heart failure. Review of the physician orders for Resident #9 revealed an order dated 05/26/20 for Do Not Resuscitate Comfort Care (DNR-CC). Review of Resident #9's care plan dated 05/11/20 revealed the care plan did not include residents code status wish. Interview on 12/05/23 at 3:02 P.M. with Licensed Practical Nurse (LPN) #335 confirmed Resident #9's comprehensive person-centered care plan did not reflect that Resident #9 had a DNR-CC in effect. 366106 Page 2 of 2