Health inspection·March 29, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed an admission date of 04/01/22. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Resident #14 was receiving hospice services. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/24, revealed Resident #14 had impaired cognition. Review of progress note dated 02/24/24 timed 8:00 A.M. authored by Licensed Practical Nurse (LPN) #106 revealed State Tested Nurse Assistant (STNA) #105 observed Resident #14 had a black eye. LPN #106 entered Resident #14's room and observed the eye. Resident #14 told LPN #14 that it happened at night. When LPN #106 asked if the injury occurred as a result of an accident or if it was purposeful, Resident #14 responded by shrugging his shoulders. Receptionist #112 told LPN #106 that Resident #14's eye did not look like that the day before. STNA #105 and Receptionist #112 asked Resident #14 again if someone had hit him, Resident #14 shook his head indicating yes. The Administrator was notified. Review of Self-Reported Incident number 244523 dated 02/24/24 timed 10:55 A.M. revealed an injury of unknown origin was reported by LPN #106 (an agency nurse). LPN #106 immediately contacted the Administrator. LPN #106 had interviewed Resident #14 and identified STNA #101 as a potential perpetrator and STNA #101 was immediately suspended. The Director of Nursing (DON) was notified on 02/25/24 at 10:30 A.M. Resident #14 was out of the building for a dialysis treatment when the DON arrived at the facility. Resident #14 was assessed and interviewed by the DON on 02/25/24. The facility conclusion indicated Resident #14 had a burst blood vessel in the right eye and the dark discoloration beneath the eye was not bruising but a common side effect from receiving an iron tablet daily for iron deficiency anemia which was present beneath both eyes. Review of the facility investigation revealed statements from STNA #101, Receptionist #112, Resident #14, and the administrator. Interview on 03/26/24 at 9:57 A.M. with the DON revealed she did not interview any residents who received care from STNA #101 on 02/24/24. The DON did not obtain statements from any other staff than Page 1 of 11 366106 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0607 Level of Harm - Minimal harm or potential for actual harm those listed above and indicated the progress note LPN #106 authored dated 02/24/24 timed 8:00 A.M. served as her statement. Review of the facility policy Abuse, Neglect, and Misappropriation, dated 2023 revealed the actions the facility would take when abuse was alleged including the following. Residents Affected - Few 1. Thoroughly investigate suspicious bruising of residents, and any other occurrences, injuries, patterns and/or trends that resemble abuse. 2. Thoroughly investigate any evidence of suspected abuse, neglect, or misappropriation of property. 3. Use video, photographs, witness statements, staffing patterns, interviews with residents, staff, and visitors to investigate allegations of abuse or neglect. 366106 Page 2 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed an admission date of 04/01/22. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Resident #14 was receiving hospice services. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/24, revealed Resident #14 had impaired cognition. Review of progress note dated 02/24/24 timed 8:00 A.M. authored by Licensed Practical Nurse (LPN) #106 revealed State Tested Nurse Assistant (STNA) #105 observed Resident #14 had a black eye. LPN #106 entered Resident #14's room and observed the eye. Resident #14 told LPN #14 that it happened at night. When LPN #106 asked if the injury occurred as a result of an accident or if it was purposeful, Resident #14 responded by shrugging his shoulders. Receptionist #112 told LPN #106 that Resident #14's eye did not look like that the day before. STNA #105 and Receptionist #112 asked Resident #14 again if someone had hit him, Resident #14 shook his head indicating yes. The Administrator was notified. Review of Self-Reported Incident number 244523 dated 02/24/24 timed 10:55 A.M. revealed an injury of unknown origin was reported by LPN #106 (an agency nurse). LPN #106 immediately contacted the Administrator. LPN #106 had interviewed Resident #14 and identified STNA #101 as a potential perpetrator and STNA #101 was immediately suspended. The Director of Nursing (DON) was notified on 02/25/24 at 10:30 A.M. Resident #14 was out of the building for a dialysis treatment when the DON arrived at the facility. Resident #14 was assessed and interviewed by the DON on 02/25/24. The facility conclusion indicated Resident #14 had a burst blood vessel in the right eye and the dark discoloration beneath the eye was not bruising but a common side effect from receiving an iron tablet daily for iron deficiency anemia which was present beneath both eyes. Review of Receptionist #112's statement dated 02/24/24 timed 10:45 A.M. revealed the receptionist was assisting Resident #14 in his wheelchair to the door to leave for dialysis. Receptionist #112 indicated she observed Resident #14 had a black eye that was not there the night before. The receptionist asked if someone had hit him in the eye, Resident #14 nodded his head yes. The receptionist told Resident #14 she was going to report the incident, and Resident #14 started saying no no. Review of an STNA #101's untimed statement dated 02/24/24 revealed STNA #101 had worked the night before and repositioned Resident #14 several times while the resident was in bed. STNA #101 denied observing swelling or discoloration on his face. Review of Resident #14's statement dated 02/25/24 timed 12:56 P.M. revealed when the DON asked Resident #14 what happened. Resident #14 curled his hand into a fist and directed his fist toward his eye. The DON asked Resident #14 was someone helping you at the time, Resident #14 responded yeah. The DON asked Resident #14 if it was a staff member, Resident #14 responded yeah. The DON asked if it was a male or female, Resident #14 responded female. The DON asked if the female was short or tall, 366106 Page 3 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #14 put his hand out to indicate the staff was short. The DON asked Resident #14 again about the staff being a male or female, Resident #14 responded a lady. The DON asked if it happened at night, Resident #14 responded yes. Resident #14 demonstrated poor eye contact during the interview and presented with a flat affect, no smiling nor grimacing were observed. Review of the Administrator's untimed statement dated 02/26/24 revealed STNA #101 stated Resident #14 was fidgety and placed himself upside down in bed three times. STNA #101 stated LPN #106 assisted each time the resident needed repositioned. STNA #101 stated Resident #14 threw himself on the floor and seemed very confused. STNA#101 mentioned that she had not noticed a problem with Resident #14's eye, but in her opinion, Resident #14 eyes were dark frequently and his face was swollen due to needing dialysis. STNA #101 denied having any accidents or confrontations with Resident #14. Interview on 03/26/24 at 9:57 A.M. with the DON revealed she did not interview any residents who received care from STNA #101 on 02/24/24. The DON did not obtain statements from any other staff than those listed above and indicated the progress LPN #106 authored served as her statement. Observation of Resident #14 on 03/26/24 at 11:00 A.M. revealed Resident #14 was lying in bed fully clothed. An attempt to interview Resident #14 was unsuccessful; he was unable/unwilling to answer questions. Observation revealed the skin beneath both eyes was darkened. Review of the timecard report dated 02/18/24 through 03/02/24 revealed STNA #101 did not work on 02/24/24, 02/25/24 due to scheduled time off. STNA #101 returned to work on 02/26/24 after meeting with the Administrator. Interview on 03/26/24 at 4:24 P.M. with Receptionist #112 revealed she thought Resident #14 had a black eye, but she was mistaken. Receptionist #112 stated the resident had a history of having a swollen face. Receptionist #112 stated when she told Resident #14 she was going to report the incident he began to back pedal stating no no. Receptionist #112 confirmed the statement she had written on 02/24/24. Review of the facility policy Abuse, Neglect, and Misappropriation, dated 2023 revealed the actions the facility would take when abuse was alleged included the following. 1. Will thoroughly investigate suspicious bruising of residents, and any other occurrences, injuries, patterns and/or trends that resemble abuse. 2. Will thoroughly investigate any evidence of suspected abuse, neglect, or misappropriation of property. 3. Will use video, photographs, witness statements, staffing patterns, interviews with residents, staff, and visitors to investigate allegations of abuse or neglect. 366106 Page 4 of 11 366106 03/29/2024 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 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. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed an admission date of 04/01/22. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Resident #14 was receiving hospice services. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/24, revealed Resident #14 had impaired cognition and required supervision or hands on assistance for eating. Review of the plans of care revealed no plan related to nutrition or assistance needed for eating. Review of the nutritional assessment dated [DATE] revealed Resident #14 received a liberal renal pureed diet with nectar thickened liquid. Resident #14 required supervision, set-up, and assistance with eating. Resident #14 was at risk for altered laboratory results, fluid imbalance related to end stage renal disease, diabetes, and difficulty swallowing as evidenced by the need for a therapeutic mechanical altered foods and fluids. Observation on 03/26/24 at 8:32 A.M. revealed Resident #14 seated in wheelchair in his room eating independently. There was no staff present to provide assistance or verbal cueing. The bowls and cups holding Resident #14's food and beverages were scattered haphazardly on the tray and the bottom of the tray was filled with the beverages that had been spilled. Interview on 03/26/24 at 8:36 A.M. with Registered Nurse (RN) #110 revealed due to call offs administrative staff were assisting residents as needed on the unit but she did not know their current location or who they were assisting. RN #110 said when a resident required supervision and/or hands on assistance staff were to stay with the resident while eating to observe, prompt, guide, and assist with needs. RN #110 stated she was assisting Resident #14 but left to go to another resident's room. RN #110 verified the spilled beverages and haphazard set up the bowls on Resident #14's meal tray. Interview on 03/26/24 at 9:22 A.M. with the Director of Nursing (DON) revealed staff were to stay with Resident #14 during meals to assist and cue as needed. 366106 Page 5 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 03/16/24 between 3:30 P.M. and 4:10 P.M. when Resident #1 exited the facility without staff knowledge. Resident #1 was wearing a wanderguard bracelet (a device that activates an alarm and locks armed doors when the wearer approaches within a set parameter of the door) that failed to lock the doors or set off an alarm to alert facility staff. Resident #1's whereabouts were unknown until approximately 7:20 P.M. when a family member reported he had been found and was currently at a family member's home. This affected one resident (#1) of seven residents who were identified by the facility as being at risk for elopement. The facility census was 44. On 03/16/24 at 4:50 P.M., the Administrator was notified Immediate Jeopardy began on 03/16/24 at 4:10 P.M. when staff identified Resident #1, who was severely cognitively impaired and at high-risk for elopement, could not be located. Facility staff and the resident's son/power of attorney (POA) were unaware of how Resident #1 exited the facility. The resident traveled to an alleged location 10-15 minutes driving distance away from the facility. Resident #1's son reported the resident traveled on a bus to the alleged location where he was allegedly found by friends/family. At the time of the incident, Resident #1 had a care plan in place for being at high risk for falls, wandering behaviors, and at risk for elopement. The resident was wearing a wanderguard device at the time of the incident, however it was determined to be not functional. The Immediate Jeopardy was removed on 03/27/24 when the facility implemented the following corrective actions: • On 03/16/24 at approximately 9:00 P.M. Resident #1 was returned to the facility by his son. The resident was assessed by Registered Nurse (RN) #110 and was determined not to have any injuries. The resident was placed on hourly checks by staff based following a physician's order. These checks would continue indefinitely. The resident's wanderguard bracelet was changed for a new bracelet that was working properly. • On 03/16/24 by 10:30 P.M., all other residents at risk for elopement (Resident #7, #8, #9, # 10, #12 and #13) had their wanderguard bracelets checked by Social Worker (SW) #111. It was determined all bracelets were working properly. Although the bracelets were functioning properly each bracelet was changed because it was time to change them based on the manufacturer's 90-day recommendation. Moving forward, all wanderguard bracelets would be checked weekly for functionality by the SW #111. A spreadsheet was created to document the weekly monitoring of the wanderguard bracelets. The Administrator would audit the weekly check list once each month for four months and report findings during quality assurance Quality Assurance Performance Improvement (QAPI) meetings. 366106 Page 6 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety On 03/17/24, the Director of Nursing (DON) reviewed the care plans of all residents at risk for elopement, Resident #1, #7, #8, #9, # 10, #12 and #13 to ensure the care plans reflected the current behavior and needs of the residents. Residents Affected - Few • On 03/17/24, the DON reviewed the elopement books posted at each nursing station to ensure that they were up-to-date and reflected those residents at risk for elopement. The DON also reviewed the elopement book and elopement policy with all nurses. • On 03/18/24 at 10:30 A.M., during a stand-up meeting the interdisciplinary team including the Administrator, DON, SW #111, the Minimum Data Set (MDS) Nurse, and Director of Environmental Services performed a root cause analysis. It was determined Resident #1's elopement was caused by a nonperforming wanderguard bracelet. On 03/16/24 Resident #1's wanderguard bracelet was changed upon return to facility, and it was determined the wanderguard bracelets the other residents at risk for elopement were wearing were working as designed. It was verified that all exit alarms were working properly, and they had been previously checked on 03/15/24. The Elopement policy was reviewed and determined to be appropriate with no changes required. • On 03/18/24, the receptionists who monitor the entrance doors received training by the administrator. The training was designed to make monitoring the main entrance doors the number one priority on the list of responsibilities for receptionist. The facility Scheduler/Administrative Assistant #104 was also included in the training to provide backup coverage. SW #111 and the DON would be responsible for monitoring the receptionists' performance and would provide a quarterly performance evaluation. The human resource coordinator would audit the receptionists' performance evaluations quarterly for one year. • On 03/25/24, the DON posted signs at the two entrance doors alerting residents, families, and friends of residents that staff must be notified, and residents must be signed-out before leaving the building. • On 03/27/24, the administrator began training sessions for all staff on all shifts. This training included the use of elopement books, the elopement policy, the wanderguard system, and wandering and exit seeking behaviors. Each training session included an elopement drill. Ongoing training regarding elopement will be completed weekly for four weeks. Review of sign-in sheets dated 03/27/24 revealed 25 staff members across all shifts had attended the training. On-going training would continue for staff as they arrived to work each shift. • 366106 Page 7 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 03/28/24 at 2:00 P.M., a QAPI meeting was held to review the Elopement Abatement Plan. The QAPI members present included the Administrator, DON, Maintenance Director, Administrative Assistant (AA) #104 and SW#111. It was determined no changes were necessary and the QAPI committee would continue to monitor the implementation of the abatement plan to determine if any modification needed each month for four months. Although the Immediate Jeopardy was removed on 03/27/24, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #1 revealed an admission date of 05/05/21 with diagnoses including bipolar disorder, current episode manic severe with psychotic features, unspecified dementia, without behavioral disturbance, and schizophrenia. Review of the resident's plan of care revealed the following plans, dated 05/05/21: Resident #1 was at risk for elopement and wandering aimlessly. Interventions included distracting Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversation, and watching television. Resident #1 had impaired cognitive function/dementia or impaired thought processes related to impaired decision making, psychotropic drug use, short term memory loss. Interventions included cue, reorient, and supervise as needed. Resident #1 was at high risk for falls related to gait/balance problems. Interventions included anticipating and meeting the resident's needs and ensuring the resident wears non-skid socks/shoes when ambulating. On 03/18/24 an intervention was added to monitor Resident #1's location and activity every hour. On 03/25/24 an intervention was added to assess Resident #1 for activity of choice and enable him to engage in that activity when possible. On 03/26/24 an intervention was added to explain to Resident #1 that he must sign out with a staff member or person authorized to remove him from the facility, and to redirect resident from exits. Review of Wandering Risk Scale assessments dated 11/17/23 and 02/16/24 revealed Resident #1 was at risk for wandering. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 02/17/24, revealed Resident #1 was severely-cognitively impaired with a Brief Interview of Mental Status score of three (out of 15). The assessment revealed the resident was independent with walking in his room and on the units. Resident #1 was alert to self only. Review of a nursing progress note dated 03/16/24 timed 10:43 P.M. revealed Resident #1 wandered out of the facility without staff or family knowledge. Resident #1 was oriented to self only. The resident's wanderguard bracelet was replaced, and the resident was moved to the second floor. Resident #1 was placed on one-hour checks per physician orders. Review of the facility SRI report dated 03/16/24 revealed Resident #1 was last observed in the 366106 Page 8 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility on 03/16/24 at approximately 3:30 P.M. Staff noticed Resident#1 missing around 4:10 P.M. when delivering dinner trays. Staff began a search for Resident #1 throughout the facility. The staff notified the Administrator Resident #1 was missing on 03/16/24 at 4:50 P.M. The Administrator assigned staff to search the outside of the facility and surrounding neighborhood. The Administrator notified the police Resident #1 was missing on 03/16/24 at 6:15 P.M. and notified the son/POA at 6:30 P.M. The son/POA suggested some locations the resident might go. The son/POA contacted the facility at 6:45 P.M. stating Resident #1 was found and was with family. The facility offered to pick Resident #1 up to return him to the facility, but the son/POA declined to provide the resident's location. The son/POA returned Resident #1 on 03/16/24 at 9:00 P.M. The SRI report indicated the resident's wanderguard bracelet Resident #1 was wearing did not alarm when he returned to the facility and staff replaced the wanderguard bracelet immediately. Resident #1 returned to the facility without signs/symptoms of stress or injury. Registered Nurse (RN) #110 questioned Resident #1 about his whereabouts and Resident #1 stated his son picked him up and they drove around. The SRI report indicated following the investigation, it was surmised Resident #1 either eloped from the building between 3:30 P.M. and 4:00 P.M. or a family member escorted the resident out without staff knowledge. The facility believed Resident #1 had no money or cognitive ability to negotiate public transportation or make pick-up arrangements. The facility also believed the family entered the facility and escorted Resident #1 out when visitors attending an activity were leaving the facility. The facility receptionist was distracted by all the activity going on and assisting visitors to the door. Review of State Tested Nurse Assistant (STNA) #113's untimed statement dated 03/16/24 revealed STNA #113 last observed Resident #1 on the unit around 3:30 P.M. on 03/16/24. STNA #113 indicated she noticed Resident #1 was missing around 4:00 P.M. and reported it to the nurse. Review of RN #110's statement dated 03/16/24 timed 7:05 P.M. revealed RN #110 observed Resident #1 attending the church service on the second floor. RN #110 stated she was informed later that Resident #1 was missing and she notified the Administrator. Review of AA #104's untimed statement dated 03/16/24 revealed AA #104 asked Resident #1 how he got away from the facility and Resident #1 stated, my son picked me up. Review of a police report revealed an incident date and time of 03/16/24, 6:49 P.M. The incident type was missing person-handicapped. The notification was received via a 911 call. The search was completed at 6:49 P.M. The call comments indicated Resident #1 was last seen around 3:30 P.M. and located at 7:20 P.M. at a family member's home and states he was safe. The family called to notify the facility. Interview on 03/22/24 at 8:32 A.M. with AA #104 revealed Resident #1 told her his son came and got him and they went riding around. AA #104 stated the son told her Resident #1 had a bus pass and took the bus to where the resident was allegedly found. AA #104 further stated the facility did not give out bus passes, Resident #1 had no money, and the nearest bus stop was 15 blocks from the facility. AA #104 said Resident #1's wanderguard was not functioning properly when he returned to the facility. Interview on 03/22/24 at 8:56 A.M. with SW #111 revealed Resident #1's wanderguard was not functioning properly when he returned to the facility. 366106 Page 9 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 03/22/24 at 8:41 A.M. with RN #110 revealed Resident #1's son told RN #110 that Resident #1 walked to a bus stop and took the bus to a family member's house. However, RN #110 said Resident #1 had no money, and the facility did not provide bus passes. RN #1 stated Resident #1 required assistance with dressing and had an unsteady gait. RN #110 stated she felt there was no way Resident #1 could walk 15 blocks to catch a bus or request to exit at a specific destination. Interview on 03/22/24 at 9:29 A.M. with the Administrator revealed staff completed an internal and external search of the property and the surrounding neighborhood when looking for Resident #1. The Administrator said Resident #1's wanderguard bracelet had not functioned properly which allowed exit without alarms sounding. Interview on 03/22/24 at 10:29 A.M. with Receptionist #112 revealed the day Resident #1 eloped was a busy day with two church services and bingo. The last church service ended around 4:15 P.M. and there were many visitors and residents who needed assistance on and off the elevator. Receptionist #112 stated she was distracted and was not always seated at the front desk. Interview on 03/22/24 at 10:51 A.M. with Resident #1's son/POA revealed a family member observed Resident #1 walking on the sidewalk of a street which was approximately ten minutes from the facility. The son/POA also suggested Resident #1 took the bus using a bus pass. The son stated he called the facility to report Resident #1 was with family, but he did not tell the facility where Resident #1 was or who found him. Observations on 03/22/24 at 1:30 P.M. revealed Resident #1 was dressed in street clothes and lying in bed. A follow up interview on 03/22/24 at 2:11 P.M. with SW #111 revealed wanderguard bracelets needed to be replaced every 90 days according to the manufacture's guidelines. Prior to 03/16/24 when Resident #1's wanderguard was replaced upon his return to the facility, his wanderguard bracelet had been changed on 12/15/23 (92 days prior). Interview on 03/22/24 at 3:39 P.M. with STNA #113 revealed when Resident #1 returned to the facility he did not appear anxious or injured. STNA #113 stated Resident #1 was wearing a shirt, pants, shoes, and a jacket. During an interview with Resident #1 on 03/25/24 at 7:44 A.M. he stated he was picked up by his niece, they went to see a movie called Days of Our Lives, and then he went to see his son. After further conversation Resident #1 was asked again what movie they watched and he replied, Days of Our Lives. Interview on 03/25/24 at 8:47 A.M. with the Director of Nursing (DON) revealed Resident #1's family was not contacted on 03/16/24 until 2.5 hours after Resident #1 was identified as missing. The DON indicated the resident's family was not called earlier because staff were busy searching Resident #1. Observations on 03/25/24 at 10:00 A.M. revealed Resident #1 walking down the second-floor hall near the wall; he had a slow shuffling gait. Review of the National Centers for Environmental Information revealed on 03/16/24 the temperature in Cleveland Ohio was 60 degrees Fahrenheit (F). 366106 Page 10 of 11 366106 03/29/2024 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the [NAME] Cleveland Ohio Neighborhood guide dated 2024 revealed the neighborhood in which the facility was located and where Resident #1 was found had a high-crime history. Review of the facility Elopement policy, dated 2022, revealed nursing staff would check placement of wanderguard daily and staff would check the functionality weekly. The policy also stated the administrator, DON and the resident's responsible party would be notified immediately if a resident was not found within 15-30 minutes. This deficiency represents non-compliance investigated under Self-Reported Incident Investigation Control Number OH00152178. 366106 Page 11 of 11