Health inspection·September 24, 2025

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 interview, record review, and facility policy review, the facility failed to ensure an elopement was reported to the State Agency. This affected one resident (#50) of three residents reviewed for elopement. The facility census was 47.Findings include:Review of the medical record for Resident #50 revealed an admission date of 05/14/24 and a discharge date of 09/16/25. Diagnoses included emphysema, malignant neoplasm of the cecum, malignant neoplasm of the upper left female breast, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. Review of the Minimum Data Set (MDS) (modified) annual assessment, dated 06/12/25, revealed Resident #50 had severely impaired cognition. The resident was independent for mobility, transfers, toileting, ambulation, upper and lower body dressing, and donning and doffing footwear. Resident #50 had no episodes of recorded wandering. Review of mood revealed she had total severity score of 13, indicating moderate depression. Review of the care plan dated 06/12/25 revealed Resident #50 was at risk for elopement as she had exit-seeking behaviors and unaware of safety needs. Interventions included a wanderguard to the right ankle and chair, redirect as needed, and follow the facility elopement policy and procedures. Review of Resident #50's physician orders revealed an order dated 07/15/25 for Resident #50 to have a wanderguard (a wearable bracelet-like device used to monitor and prevent residents at risk for wandering from leaving designated areas. It is part of a larger system which includes sensors on doors which alarm and lock the doors when a resident approaches a monitored exit) on at all times to the right ankle and an additional order to check the placement and function of the wanderguard device every shift. Review of Resident #50's Treatment Administration Record (TAR) dated 07/15/25 through 09/22/25 revealed the resident's wander guard was documented as being on at all times to the right ankle and placement and function was documented as checked daily on both day and night shifts. Review of Resident #50's elopement risk assessment dated [DATE] revealed she was an elopement risk and scored a 4.0 as she had a history of eloping and had a lack of awareness of safety needs. Listed interventions in place were the wanderguard and safety checks. Review of Resident #50's nurse progress note dated 09/14/25 at 2:30 P.M. authored by Licensed Practical Nurse (LPN) #120 revealed the nurse was alerted by Certified Nursing Assistant (CAN) #151 that Resident #50 was missing. LPN #120 and other staff began looking for Resident #50 checking all rooms and bathrooms, checking the whole facility and outside. During the search for Resident #50, the resident's daughter and the hospital administrator called the facility and stated Resident #50 was at a local hospital emergency department (ED). The facility Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) was notified. Review of the State Agency's Certification and Licensure System (CALS) revealed no facility self-reported incident (SRI) had been submitted regarding Resident #50's elopement. An interview on 09/22/25 at 2:50 P.M. with the Administrator revealed she did not know she needed to report an elopement to the State Agency and was unaware where on the computer she was to report the Page 1 of 6 366106 366106 09/24/2025 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0609 Level of Harm - Minimal harm or potential for actual harm incident. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property. Additionally, the facility should immediately report all allegations to the Administrator and to the Ohio Department of Health. Residents Affected - Few 366106 Page 2 of 6 366106 09/24/2025 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Minimal harm or potential for actual harm 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLAINCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the closed medical record, interview, review of the facility's investigation, interviews with facility staff, and review of the facility policy on elopement, facility failed to ensure staff provided adequate supervision to prevent Resident #50 from leaving the facility unsupervised. This affected one resident (#50) of three residents reviewed for elopement and supervision. The facility census was 47. Findings include: Review of the closed medical record for Resident #50 revealed an admission date of 05/14/24 and a discharge date of 09/16/25. Diagnoses included emphysema, malignant neoplasm of the cecum, malignant neoplasm of the upper left female breast, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. Review of the Minimum Data Set (MDS) (modified) annual assessment, dated 06/12/25, revealed Resident #50 had severely impaired cognition. The resident was independent for mobility, transfers, toileting, ambulation, upper and lower body dressing, and donning and doffing footwear. Resident #50 had no episodes of recorded wandering. Review of mood revealed she had total severity score of 13, indicating moderate depression. Review of the care plan dated 06/12/25 revealed Resident #50 was at risk for elopement as she had exit-seeking behaviors and unaware of safety needs. Interventions included a wanderguard to the right ankle and chair, redirect as needed, and follow the facility elopement policy and procedures. Review of Resident #50's physician orders revealed an order dated 07/15/25 for Resident #50 to have a wanderguard (a wearable bracelet-like device used to monitor and prevent residents at risk for wandering from leaving designated areas. It is part of a larger system which includes sensors on doors which alarm and lock the doors when a resident approaches a monitored exit) on at all times to the right ankle and an additional order to check the placement and function of the wanderguard device every shift. Review of Resident #50's Treatment Administration Record (TAR) dated 07/15/25 through 09/22/25 revealed the resident's wander guard was documented as being on at all times to the right ankle and placement and function was documented as checked daily on both day and night shifts. Review of Resident #50's elopement risk assessment dated [DATE] revealed she was an elopement risk and scored a 4.0 as she had a history of eloping and had a lack of awareness of safety needs. Listed interventions in place were the wanderguard and safety checks. Review of Resident #50's nurse progress note dated 09/14/25 at 2:30 P.M. authored by Licensed Practical Nurse (LPN) #120 revealed the nurse was alerted by Certified Nursing Assistant (CAN) #151 that Resident #50 was missing. LPN #120 and other staff began looking for Resident #50 checking all rooms and bathrooms, checking the whole facility and outside. During the search for Resident #50, the resident's daughter and the hospital administrator called the facility and stated Resident #50 was at a local hospital emergency department (ED). The facility Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) was notified. Review of a witness statement dated 09/14/25 authored by CNA #151 revealed she was not assigned to Resident #50 but observed the resident in her wheelchair, rolling back and forth down the hallway, as she normally did. Later that morning, Resident #50 laid back down. When lunchtime came around, Resident #50 was informed it was time for lunch and stated she was not hungry. CNA #151 told her she would check back. About 1:45 P.M., she went to ask Resident #50 if she wanted to come down for church services and that's when she reported to the nurse that Resident #50 was not in her room. Review of a witness statement dated 09/14/25 authored by LPN #120 revealed she was assigned to Resident #50. Around noon, while administering a tube feeding to Resident #50's roommate, she observed Resident #50 lying in bed. After caring for the roommate, LPN #120 proceeded 366106 Page 3 of 6 366106 09/24/2025 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with passing scheduled medications and completing skilled charting at the nurse's station. Approximately 1:25 P.M., LPN #120 went on lunch break. Upon returning, a (unnamed) CNA informed her that another resident required her assistance and she provided that care. Shortly thereafter, a (unnamed) CNA informed her Resident #50 was not in her room. LPN #120 stated she immediately stopped what she was doing and initiated the facility's elopement policy. While conducting a search for Resident #50 and attempting to contact her family, the hospital called informing Resident #50 was in the emergency room (ER) requesting to be seen. LPN #120 explained to hospital staff that she did not send her and would go across the street to the ER and follow up with the resident. In addition, several attempts were made to contact Resident #50's daughter with no response. Review of a witness statement dated 09/14/25 from CNA #132 revealed he was alerted by another CNA that Resident #50 was not in her room. The nurse in charge gave instructions for the search and the elopement protocol was followed. CNA #132 searched the exterior part of the building. While doing so, he received a call instructing him to head across the street to a local hospital ER. Once there, he spoke with the security guard, who informed him that Resident #50 checked herself into the hospital. CNA #132 was escorted to her room where he observed her. He called her name, and she responded and recognized him. Hospital personnel informed him they reached out to her daughter to come and pick her up. CNA #132 immediately left the hospital, returned to the facility, and reported to the charge nurse. Prior to this, the last time he saw Resident #50 was at lunchtime, at approximately 12:30 P.M. He was not assigned to care for Resident #50 that day. Review of the witness statement dated 09/14/25, authored by Registered Nurse (RN) #137 revealed on 09/14/25, she observed Resident #50 in the morning after she finished her breakfast. At that time, RN #137 encouraged her to get dressed as she was still wearing her nightgown. Resident #50 was pleasant, agreed and proceeded to her room. Later that day, around lunchtime, RN #137 noticed Resident #50 in the common area with other residents. No distress was noted. RN #137 was not assigned to Resident #50 but was responsible for the 300 hall during her shift. At approximately 2:15 P.M., RN #137 was notified by a nurse aid that Resident #50 was not in her room. At that time, the elopement protocol was followed. RN #137 spoke with the family member in an attempt to provide details regarding the situation; however, she was unable to do so because the family member hung up during the conversation. Review of the witness statement dated 09/14/25 from CNA #118 revealed she was not assigned to Resident #50 however, she did observe her at lunchtime in the main dining room. During her shift, she was assigned to a separate hall and provided care for those residents. When informed by the nurse of a missing resident, she began looking for Resident #50. Review of the witness statement dated 09/14/25 from CNA #129 revealed she was assigned to Resident #50 and assisted her with morning care. Resident #50 was pleasant, and they had a good conversation. During lunch time, Resident #50 was encouraged to finish eating her food. After that, CNA #129 proceeded to provide resident care in another room. An interview on 09/22/25 at 3:56 P.M. with the DON verified Resident #50 had gotten out of the facility undetected after the resident followed the family member onto the elevator and out the front door of the facility. Review of the video surveillance footage from 09/14/25, viewed on 09/23/25 at 9:10 A.M., revealed Resident #50 was on the first floor exiting the double doors behind a family member who allowed Resident #50 on the coded elevator. The family member was seen exiting the double doors and turning left. She did not look behind her. Resident #50 was observed exiting the double doors and going to the right. Review of the facility investigation dated 09/14/25 and timed 2:15 P.M. revealed at approximately 1:45 P.M., CNA #151 notified RN #137 that Resident #50 was missing. The missing resident procedure was initiated, and staff began searching the facility. At approximately 1:54 P.M., RN #137 received a call from the hospital, located across the street from 366106 Page 4 of 6 366106 09/24/2025 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility, that Resident #50 had walked to and checked herself into the emergency department. Notifications were completed, Resident #50 was noted to be uninjured, and Resident #50's daughter requested the emergency department aid in finding placement in an alternate nursing facility. The facility investigation concluded that Resident #50 had followed another resident's visiting family member onto the elevator and out the front door of the facility. The investigation noted that initial audits, education, and ongoing monitoring were implemented following the incident. Interviews conducted on 09/22/25 at 2:50 P.M. with the Administrator confirmed Resident #50 eloped from the facility on the afternoon of 09/14/25. The Administrator reported the facility policy on elopement was followed but the event was not reported to the State Agency. The Administrator confirmed following the elopement occurrence, the elopement was investigated and corrective action was implemented. Review of the facility policy titled Elopement and Unsafe Wandering, with a revision date of 04/28/21, revealed elopement was defined as a resident leaving the premises or a safe area without authorization and/or necessary supervision to do so. The policy noted the facility will assess the resident's risk to elope and will implement measures to protect the resident when the resident is no longer able to make sound decisions. The deficient practice was corrected on 09/15/25 when the facility implemented the following corrective actions: On 09/14/25 at approximately 1:45 P.M., facility staff completed a facility head count immediately with all other residents accounted for. On 09/14/25 at approximately 1:46 P.M., RN #137 initiated the missing resident procedure, directing staff to search resident rooms, shower rooms, etc. and the perimeter of the facility. On 09/14/25 at approximately 1:54 P.M., RN #137 received a call from the hospital across the street saying that Resident #50 was there and safe. On 09/14/25 at approximately 2:00 P.M., Resident #50's responsible party was notified of the incident. On 09/14/25 at approximately 2:15 P.M., Medical Director #500 was notified. On 09/14/25 at approximately 2:20 P.M., CNA #132 went across the street and verified the presence of Resident #50. Hospital staff confirmed Resident #50 was uninjured, safe and reported her daughter requested hospital assistance with placement to a new facility with a memory care unit. On 09/14/25 at approximately 2:45 P.M. the Administrator and DON interviewed eight staff members and two visitors as part of the investigation into how Resident #50 exited the building. Staff members including CNAs #129, #132 and #151 reported she was last observed in the dining room toward the end of lunchtime at approximately 12:30 P.M. A visiting family member stated during an interview that on 09/14/25 at approximately 1:00 P.M. that Resident #50 entered the elevator with her and exited the elevator on the first floor near the facility entrance. The family member reported she was unaware Resident #50 could not leave the floor and did not witness her exiting the facility. On 09/14/25 at approximately 2:45 P.M. the DON or designee verified all wander guard devices were properly placed and functioning for eight residents. All were placed and functioning properly. On 09/14/25 at approximately 7:50 P.M. the DON or designee contacted all resident representatives (44 in total) to re-educated them on the importance of speaking with staff before permitting residents to use the elevator with them. On 09/14/25 at approximately 8:00 P.M., the Administrator or designee re-educated 60 staff via message system and four staff via phone, on not sharing the facility door or elevator codes with family members or visitors and the appropriate response to alarms and actions to take if a door is found ajar or malfunctioning. All staff were notified. On 09/14/25 at approximately 8:30 P.M., the Administrator and Maintenance Director #230 completed an environmental safety risk assessment. All potential egress points were inspected and confirmed secured with no concerns noted. All doors and sensors were checked with no concerns noted. On 09/14/25 at approximately 9:30 P.M., an outside vendor inspected the front door to ensure proper functioning. No concerns were identified. On 09/14/25 at approximately 10:00 P.M., the DON 366106 Page 5 of 6 366106 09/24/2025 The Gardens of Fairfax Health Care Center 9014 Cedar Ave Cleveland, OH 44106

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or designee completed elopement assessments on all 43 residents and validated appropriate care plans were indicated. On 09/14/25 by 10:00 P.M., the DON or designee re-educated all 64 staff members on identifying signs and symptoms of exit-seeking behaviors. All staff were educated. On 09/15/25, an ad hoc Quality Assurance (QA) committee meeting was held to review the incident investigation, complete root cause analysis, internal action plan and audit plan. Attendees included the Medical Director #500, the Administrator, the DON, Assistant Director of Nursing (ADON) #152, ADON #153, admission Director #250, Medical Record #270, Social Worker #220, Activities Director #290, Human Resources Director #280, Therapy Director #260, Dietary Manager #240, Maintenance Director #230 and Dietician #300. Beginning on 09/15/25, a staff member was assigned to sit at the front desk from 7:00 A.M. to 7:00 P.M. daily to answer calls and monitor the front door. Beginning 09/15/25, elopement drills/audits will be completed by the DON, Administrator or designee weekly for two weeks or until otherwise directed by the QA committee. Beginning 09/15/25, the Maintenance Director #230 or designee will audit the elevator, door alarms and locks five times weekly for two weeks or until otherwise directed by the QA committee. Beginning 09/15/25 the DON or designee will conduct weekly audits on all residents with elopement risk per assessment, checking if the Wanderguard's in place and functioning, five times a week for two weeks or until otherwise directed by the QA committee. Ad hoc QA committee meetings will continue weekly for two weeks to review the effectiveness of the action plan and further needs for audits, changes, or further committee meetings.This deficiency represents non-compliance investigated under Complaint Number 2621167. 366106 Page 6 of 6