Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Gardens Of Fairfax Health Care Center during CMS and state inspections, most recent first.
A cognitively intact, oxygen‑dependent resident with ESRD, paraplegia, and chronic respiratory failure was sent to dialysis with a portable oxygen tank that was not full. After dialysis, while waiting in the lobby for transportation, the tank from the facility became empty, and the resident became distressed until dialysis staff placed the resident on their oxygen concentrator. Dialysis staff repeatedly attempted to reach facility staff for a replacement tank, but the facility LPN stated they could not bring oxygen in time, and the transport company would not wait and had no portable oxygen. With the dialysis center closing and no portable oxygen available, the facility nurse instructed dialysis staff to call 911, and EMS transported the resident to the ED solely because the resident had run out of oxygen. EMS and dialysis staff reported this was a recurring issue, with the resident often arriving with insufficient oxygen to last through the return trip, and the facility’s oxygen policy did not address oxygen management for outside appointments.
Meal service was delayed when staff lacked a communication method between the servery and main kitchen, had to send aides back and forth for meatloaf, plates, bowls, and alternate entrees, and ran out of the main entree before all residents were served. Lunch started in the kitchen, but the dining room did not receive the first plate until much later, and two residents were served hamburgers instead of meatloaf because the entree was unavailable. The DM confirmed there were no plates or bowls at the start of service and that prep sheets were based on the wrong census.
Failure to Report Allegation of Missing Funds to State Agency: A resident with CVA, hemiplegia, vascular dementia, and moderate cognitive impairment reported that his debit card and $8,000 were missing after staff could not use his card to order food. Police were called, the bank reviewed the account and determined the card had been compromised, but the Administrator did not report the allegation to the State Agency because she believed it was identity theft and not abuse. Facility policy required allegations of misappropriation or resident property to be reported immediately.
Failure to Provide Needed ADL Assistance: Three residents who were dependent on staff did not consistently receive needed ADL care. One resident with cognitive impairment and dependence for bathing and grooming had visible facial hair despite a care plan for shaving assistance. Another resident with CVA, dementia, and total grooming needs had an unshaved beard and records showing missed or incomplete shaving attempts. A third resident with dementia and dependence for ADLs was found with a urine odor nearby, reported staff did not check on him or help with toileting and dressing, and was left waiting for help to get up and dressed before breakfast.
A resident with ESRD receiving hemodialysis through a tunneled dialysis catheter was not documented as being immediately assessed when returning from dialysis for access-site bleeding or other complications. The care plan called for routine catheter monitoring, but the record showed only shift-based checks with no times, and staff stated they relied on the dialysis center’s post-treatment vitals rather than completing an immediate facility assessment on return.
A resident with atrial fibrillation, schizophrenia, and type 2 DM had pharmacist medication regimen reviews that recommended VALs and LFTs, and the physician agreed with both recommendations. VALs were drawn, but LFTs were not completed until months later, and the physician order record did not show current, completed, or discontinued LFT orders. The DON confirmed the findings.
A resident with severe cognitive impairment and multiple medical conditions, identified as an elopement risk and equipped with a wanderguard, was found missing and later located at a local hospital. Despite facility policy requiring immediate reporting of such incidents, the Administrator did not report the elopement to the State Agency, citing lack of knowledge about the reporting requirement and process.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unsupervised by following a visitor onto the elevator and out the front door. Despite interventions such as a Wanderguard and regular safety checks, staff did not detect the resident's absence until after she had exited the building and checked herself into a nearby hospital emergency department.
Failure to Ensure Adequate Portable Oxygen for Oxygen‑Dependent Resident During Dialysis Transport
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate oxygen for a resident who was oxygen‑dependent during outside dialysis appointments. The resident had multiple diagnoses including end stage renal disease, paraplegia, acute and chronic respiratory failure with hypoxia, hypertension, type 2 diabetes, and psychosis, and used continuous oxygen via nasal cannula. Physician orders included dialysis three times weekly and continuous oxygen at five liters per minute via nasal cannula. The resident’s care plan identified the need for oxygen related to chronic respiratory disease and directed staff to observe for signs and symptoms of dyspnea. The facility’s oxygen administration policy addressed oxygen use under physician orders but did not address oxygen management for residents during appointments outside the facility. On the day of the incident, the resident completed dialysis treatment in the early afternoon and was placed back on the portable oxygen tank supplied by the facility while waiting in the dialysis center lobby for transportation back to the facility. Dialysis staff reported that the portable oxygen tank from the facility was not full and that the resident frequently arrived with insufficient oxygen to last through the return trip, often running out while waiting for transportation. On this occasion, while waiting in the lobby, the resident’s portable tank became empty, and he began complaining that he was not getting oxygen, became upset, crying, and exhibited distress such as huffing and puffing. Dialysis staff confirmed the tank from the nursing home was empty and placed the resident on the dialysis center’s oxygen concentrator, which improved his condition. Dialysis staff made multiple attempts to contact the facility to obtain a replacement oxygen tank. After several unanswered calls, they reached an LPN at the facility and explained that the resident’s tank was empty and he required oxygen. According to dialysis and EMS documentation, the facility nurse stated there was no way to bring a replacement tank in time, and transportation staff were unwilling to wait and did not have portable oxygen available. The dialysis center had only one E‑tank with the crash cart and otherwise used plug‑in concentrators, so they could not provide portable oxygen for transport. Following back‑and‑forth communication between dialysis staff and the facility nurse, and with the dialysis center closing and transportation leaving, the decision was made, with the facility nurse’s agreement, to call 911 and send the resident to the emergency department solely because he had run out of oxygen and no replacement tank was provided. EMS documentation and the resident’s own statements indicated that this was not the first time he had been sent out from the facility with a partially filled oxygen tank and had run out of oxygen while away from the facility. The EMS run sheet documented that EMS arrived to find the resident in the dialysis lobby on supplemental oxygen from the dialysis center’s concentrator, with oxygen saturation at 97% on oxygen. EMS noted that the resident was oxygen‑dependent at three liters per minute and that his portable tank from the facility had run out while he was waiting for his ride. EMS contacted the facility en route and were told again that staff had instructed dialysis to call 911 because the resident could not stay at the dialysis center and transportation would not wait. The emergency department after‑visit summary recorded that the resident was seen for running out of oxygen and that no emergency medical condition was identified at that time. In a later telephone interview, the resident reported that while at the facility he repeatedly ran out of oxygen because he was given “half‑tanks,” and he described being very upset when he ran out of oxygen at dialysis and transportation refused to take him without oxygen.
Meal Service Delays and Insufficient Entree Availability
Penalty
Summary
The facility failed to maintain effective communication and meal service processes to ensure timely service and adequate portions of the main entree were available during lunch service. On observation, lunch began in the main kitchen at 11:55 A.M. for residents eating in their rooms, with meatloaf, corn, and mashed potatoes on the menu. Three insulated carts were delivered, and dietary staff moved trays to the second-floor servery at 12:34 P.M., where food temperatures were taken. A large spill of creamed corn required cleanup before service could continue, and the dietary staff member in the servery had forgotten the tray of meatloaf in the main kitchen. There was no communication method such as a walkie talkie or phone between the servery and the main kitchen, so a dietary aide had to go back and forth to retrieve the meatloaf, plates, bowls, and later hamburgers for alternate requests. Meal service was further delayed because there were not enough plates or bowls available in the servery at the start of lunch, and the staff member in the servery ran out of the main entree before all residents were served. The lunch meal was not completed until 1:42 P.M. Two residents were served hamburgers as a substitute because no meatloaf was available for them. The Dietary Manager stated the process for serving room trays and dining room meals had been revised several times, confirmed there was no method to clean and sanitize dishes in the second-floor servery, confirmed there were no plates or bowls available at the start of lunch, and confirmed there was no current communication method between the servery and the main kitchen. She also stated the staff member used preparation sheets from the wrong census, which did not account for the increased census.
Failure to Report Allegation of Missing Funds to State Agency
Penalty
Summary
The facility failed to ensure Resident #49’s allegation of missing funds was reported to the State Agency. Resident #49 was admitted with diagnoses including cerebral infarction due to embolism of the left vertebral artery, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and vascular dementia. His care plan and MDS reflected that he required maximal assistance with ADLs, total care for grooming, and had moderate cognitive impairment with dependence for toileting hygiene, bathing, and dressing. On 01/29/26, Resident #49 told staff to use his debit card to order food and was told staff could not use it. Later that night, he told staff someone stole his card and his money, stating that $8,000.00 was missing. He requested police involvement, and the police came to the facility and interviewed him. The next day, Resident #49 continued to report that $8,000.00 was missing from his bank card, and police advised him to contact his bank and opened a theft report. A follow-up note documented that Resident #49 later stated he was not accusing staff or the facility of taking his money and believed his bank account was compromised. The bank reviewed his account activity, determined he never had a balance of $8,000.00, locked his debit card, and advised that a replacement card would be issued. During interview, the Administrator stated she did not report the incident to the State Agency because she believed it was identity theft and not abuse, and she did not think an SRI was needed because she knew what happened. The facility policy required all allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to be immediately reported to the Administrator and the State Agency.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff received appropriate assistance with activities of daily living, including bathing, shaving, dressing, and incontinence care. This affected three residents reviewed for ADL assistance. The report states the facility did not implement its bathing policy, which was intended to provide cleanliness, comfort, and a sense of well-being. One resident had diagnoses including metabolic encephalopathy, diabetes mellitus, COPD, and altered mental status, and was assessed as having moderate cognitive impairment and dependence on staff for bathing and personal hygiene. Although the care plan included assistance with bathing, grooming, nail care, shaving, and hair care, bathing records showed showers twice weekly and the last documented shaving assistance was weeks earlier. Surveyors observed facial hair growth on the resident’s chin on two occasions, and a CNA confirmed the resident had facial hair and agreed to shaving assistance. A second resident with CVA-related hemiplegia, vascular dementia, and moderate cognitive impairment was care planned for total grooming care, including shaving. Records showed a refusal to be shaved on one shower date and no evidence of shaving or an additional attempt on another date. Surveyors observed a scruffy beard about three-quarters of an inch long, and the resident stated he wanted his beard shaved but no one had shaved or offered to shave it. Staff interviews indicated shaving and other care were sometimes missed depending on the aide or because the unit was busy. A third resident with dementia and dependence for ADLs was observed seated in a wheelchair with a strong urine odor nearby, stated staff did not check on him or help him with toileting and dressing, and was later found trying to dress while undressed from the waist down after requesting help to get up and dressed before breakfast.
Failure to Immediately Monitor Dialysis Access After Return From Treatment
Penalty
Summary
The facility failed to ensure a resident with ESRD and dependence on renal dialysis had her dialysis access site immediately monitored when she returned from dialysis for bleeding and other complications. Resident #60 was cognitively intact, used a wheelchair, and received hemodialysis three times weekly through a right upper chest tunneled dialysis catheter. Her care plan directed dialysis treatments on Tuesdays, Thursdays, and Saturdays and included monitoring the dialysis catheter every shift, but there was no documented intervention to immediately assess the access site when she returned from dialysis. Review of the resident’s records from 01/12/26 through 02/04/26 did not show evidence that she was monitored immediately after returning from dialysis, including assessment of the access site. The MAR/TAR showed the catheter was checked every shift with check marks and no times documented, indicating the checks could have occurred at any point during the day or night shift. During interviews, the LPN stated post-dialysis vital signs and the access port did not need to be checked at the facility because they were done at the dialysis center, while the DON later confirmed the resident’s catheter was checked twice a day but not immediately upon return from dialysis and that the twice-daily checks could occur hours later.
Delayed Implementation of Physician-Approved Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations approved by the physician were implemented in a timely manner for Resident #4. The resident was admitted with diagnoses of atrial fibrillation, schizophrenia, and type 2 diabetes mellitus with hyperglycemia. The consultant pharmacist completed medication regimen reviews and, on two occasions, documented recommendations for laboratory testing, including Valproic Acid Level (VALs) and Liver Function Tests (LFTs), and the physician signed both recommendations as agreed. Review of the laboratory records showed that VALs were drawn, but LFTs were not drawn until approximately four months after the first request and two months after the second request. The physician orders reviewed did not show any current, completed, or discontinued orders for LFT laboratory draws. During interview, the DON confirmed and verified these findings.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report an elopement incident involving a resident to the State Agency as required. The resident, who had diagnoses including emphysema, malignant neoplasms, a history of TIA, and severely impaired cognition, was identified as being at risk for elopement due to exit-seeking behaviors and lack of awareness of safety needs. Interventions in place included a wanderguard device and regular safety checks, which were documented as being performed. Despite these measures, the resident was found missing, and staff initiated a search throughout the facility and outside. During the search, it was discovered that the resident was at a local hospital emergency department, as reported by the resident's daughter and the hospital administrator. The facility's Administrator, DON, and ADON were notified of the incident. However, a review of the State Agency's Certification and Licensure System revealed that no self-reported incident had been submitted regarding the elopement. In an interview, the Administrator stated she was unaware of the requirement to report elopements to the State Agency and did not know how to submit such a report. Facility policy required immediate reporting of all allegations of abuse, neglect, or exploitation to the Administrator and the Ohio Department of Health, but this protocol was not followed in this case.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to prevent a resident with severely impaired cognition and a known risk for elopement from leaving the facility unsupervised. The resident had diagnoses including emphysema, malignant neoplasms, a history of TIA, and cerebral infarction without residual deficits. The care plan identified the resident as an elopement risk due to exit-seeking behaviors and lack of awareness of safety needs, with interventions including a Wanderguard device and regular safety checks. Despite these measures, the resident was able to exit the facility undetected. On the day of the incident, multiple staff members observed the resident in various locations throughout the morning and at lunchtime. The resident was last seen in the dining room and later in her room, but was not directly supervised at all times. Staff became aware of the resident's absence when a CNA attempted to bring her to an activity and found her missing. A search was initiated, and it was discovered that the resident had left the facility by following a visiting family member onto the elevator and out the front door. Video surveillance confirmed that the resident exited the building behind the visitor, who was unaware of the resident's risk and did not notice her leaving. The facility's elopement policy was reportedly followed after the resident was found missing, but the event was not reported to the State Agency. The incident highlighted a lapse in supervision and monitoring, as the resident was able to leave the premises without staff detection, despite being identified as an elopement risk and having interventions in place. The resident was later found safe at a nearby hospital emergency department, having checked herself in without injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crawford Manor Healthcare Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Singleton Health Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Judson Park | 0.9 mi | ★★★★★ | 0 | 0 |
| University Manor Health & Reha | 0.9 mi | ★★★★★ | 0 | 0 |
| Cityview Healthcare And Rehabilitation | 1.1 mi | ★★★★★ | 9 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.