THE GARDENS OF FAIRFAX HEALTH CARE CENTER Inspection Report, Violations & Safety Grade (CLEVELAND, Ohio)

9014 CEDAR AVE, CLEVELAND, Ohio 44106

Phone: 2167951363

CMS Overall:2/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

66.5

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Cuyahoga

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall2/5

Health2/5

Staffing1/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	Ohio Avg	Difference
RN Hours per Resident per Day	0.38	0.64	-0.26
Total Nurse Hours per Resident per Day	3.62	3.71	-0.09
CMS Staffing Rating	1/5	2.4/5	-
Nursing Staff Turnover	66.0%	49%	-

Health Citation History

47 health citations on record

Date	Category	Description	Severity
2026-03-09	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2026-02-12	Nutrition and Dietary Deficiencies	Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.	F – Moderate Harm Potential
2026-02-12	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2026-02-12	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2026-02-12	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential
2026-02-12	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2025-09-24	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2025-09-24	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2024-03-29	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	J – Immediate Jeopardy
2024-03-29	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	D – Moderate Harm Potential
2024-03-29	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2024-03-29	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2023-12-06	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2023-12-06	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2023-05-16	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	F – Moderate Harm Potential
2023-05-16	Nursing and Physician Services Deficiencies	Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.	F – Moderate Harm Potential
2023-05-16	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	F – Moderate Harm Potential
2023-05-16	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-05-16	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2023-05-16	Infection Control Deficiencies	Implement a program that monitors antibiotic use.	F – Moderate Harm Potential
2023-05-16	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2023-05-16	Pharmacy Service Deficiencies	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	E – Moderate Harm Potential
2023-05-16	Nutrition and Dietary Deficiencies	Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.	E – Moderate Harm Potential
2023-05-16	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2023-05-16	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2023-05-16	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2023-05-16	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2023-05-16	Quality of Life and Care Deficiencies	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	D – Moderate Harm Potential
2023-05-16	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2023-05-16	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential
2023-05-16	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2023-05-16	Administration Deficiencies	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	C – Minimal Harm Potential
2023-05-16	Administration Deficiencies	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.	C – Minimal Harm Potential
2019-10-23	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	F – Moderate Harm Potential
2019-10-23	Administration Deficiencies	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	F – Moderate Harm Potential
2019-10-23	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2019-10-23	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	E – Moderate Harm Potential
2019-10-23	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2019-10-23	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2019-10-23	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	D – Moderate Harm Potential
2019-10-23	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2019-10-23	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2019-10-23	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2019-10-23	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2019-10-23	Pharmacy Service Deficiencies	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	D – Moderate Harm Potential
2019-10-23	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	D – Moderate Harm Potential
2019-10-23	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	C – Minimal Harm Potential

Fire Safety Citation History

39 fire safety citations on record

Date	Category	Description	Severity
2026-02-12	Smoke Deficiencies	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	F – Moderate Harm Potential
2026-02-12	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	F – Moderate Harm Potential
2026-02-12	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2026-02-12	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	F – Moderate Harm Potential
2026-02-12	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	F – Moderate Harm Potential
2026-02-12	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2023-05-16	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	F – Moderate Harm Potential
2023-05-16	Smoke Deficiencies	Provide properly protected cooking facilities.	F – Moderate Harm Potential
2023-05-16	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2023-05-16	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2023-05-16	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	F – Moderate Harm Potential
2023-05-16	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	F – Moderate Harm Potential
2023-05-16	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2023-05-16	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	F – Moderate Harm Potential
2023-05-16	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2023-05-16	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the use of electrical equipment.	F – Moderate Harm Potential
2023-05-16	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2023-05-16	Egress Deficiencies	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	E – Moderate Harm Potential
2019-10-23	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2019-10-23	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	F – Moderate Harm Potential
2019-10-23	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2019-10-23	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2019-10-23	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2019-10-23	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2019-10-23	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	E – Moderate Harm Potential
2019-10-23	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	E – Moderate Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Address patient/client population and determine types of services needed.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Include a process for Emergency Preparedness collaboration.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Establish procedures for tracking staff and patients during an emergency.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Establish policies and procedures for volunteers.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Create arrangements with other facilities to receive patients.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Establish roles under a Waiver declared by secretary.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	List the names and contact information of those in the facility.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Provide emergency officials' contact information.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Establish methods for sharing information.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Provide a means of sharing information on occupancy/needs.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Provide family notifications of emergency plan.	C – Minimal Harm Potential
2019-10-23	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	C – Minimal Harm Potential

Total Penalties & Fines

$85,538

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2024-03-29	Fine	$10,039	-
2024-02-20	Fine	$4,938	-
2024-02-12	Fine	$4,938	-
2024-01-22	Fine	$14,814	-
2024-01-08	Fine	$4,938	-
2024-01-02	Fine	$4,587	-
2023-12-11	Fine	$13,762	-
2023-11-20	Fine	$4,587	-
2023-11-13	Fine	$4,587	-
2023-11-06	Fine	$4,587	-
2023-10-30	Fine	$4,587	-
2023-10-23	Fine	$4,587	-
2023-10-17	Fine	$4,587	-

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the CLEVELAND area at no cost.

Find Safe, Vetted Facilities Near CLEVELAND
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the CLEVELAND area at no cost.

Find Safe, Vetted Facilities Near CLEVELAND
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.