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Complaint Investigation

The Gardens Of Fairfax Health Care Center

Inspection Date: September 24, 2025
Total Violations 2
Facility ID 366106
Location CLEVELAND, OH
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Inspection Findings

F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Gardens of Fairfax Health Care Center

9014 Cedar Ave Cleveland, OH 44106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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📋 Inspection Summary

THE GARDENS OF FAIRFAX HEALTH CARE CENTER in CLEVELAND, OH inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CLEVELAND, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE GARDENS OF FAIRFAX HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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