PHOENIX OF FAIRLAWN
For profit - Limited Liability company
80 Beds
Independent
Data: November 2025
Trust Grade
63/100
#320 of 913 in OH
Photo by Phoenix of Fairlawn (formerly known as Windsong)
Photo by Phoenix of Fairlawn (formerly known as Windsong)
Photo by Phoenix of Fairlawn (formerly known as Windsong)
1 / 10 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Phoenix of Fairlawn has a Trust Grade of C+, which means it is considered decent and slightly above average compared to other nursing homes. It ranks #320 out of 913 facilities in Ohio, placing it in the top half, and #13 out of 42 in Summit County, indicating that there are only a dozen options in the area. However, the trend is worsening, with issues increasing from 1 in 2024 to 13 in 2025, suggesting ongoing problems. Staffing is a concern, with only average ratings and less registered nurse coverage than 92% of state facilities, although the turnover rate is slightly below the state average at 47%. Specific incidents include a serious failure to prevent falls for residents, resulting in hospitalizations, and concerns about maintaining a clean kitchen environment, which could affect residents' health. Overall, while there are some strengths, such as good quality measures, families should weigh these issues carefully.
- Trust Score
- C+
- In Ohio
- #320/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $4,922 in fines. Lower than most Ohio facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 35%
Needs review
1 → 13 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 13 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 47%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Federal Fines: $4,922
Below median ($33,413)
Minor penalties assessed
The Ugly 31 deficiencies on record
1 actual harm
Apr 2025
13 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were transported in the facility in a dignified and respectful manner. This affected one (#37) of one residents reviewed for respect and dignity. The facility census was 55.
Findings Include:
Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses that included cocaine abuse, sepsis, and atrial fibrillation.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and required assistance of one staff person for completing his activities of daily living including bathing.
Observation of Resident #37 on 04/21/25 at 11:44 A.M. revealed Resident #37 was sitting on a shower chair being pulled by Certified Nurse Aide (CNA) #608 to his room. Resident #37 was observed to be wearing no clothing except for a thin hospital gown with a package of deodorant and an adult incontinence brief sitting in his lap. The gown was not tied around the resident's waist and his buttocks was exposed to the air.
Interview with Registered Nurse (RN) #579 verified Resident #37's gown was not tied and his buttocks was easily visible to anyone walking down the hall and an adult incontinence brief and package of deodorant was sitting in his lap while being transported down the hall in his shower chair.
Review of the undated policy titled, Residents Rights and Facility Responsibilities, revealed it is the facility's policy to abide by all residents, and to communicate these rights and to residents and their designated representatives in a language that they can understand.
This deficiency represents non-compliance investigated under Complaint Number OH00163638 and Complaint Number OH00159640.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interviews, the facility failed to provide the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interviews, the facility failed to provide the resident or resident representatives with the name and telephone number of the appeal agency. This affected two (#5 and #8) of three residents reviewed for beneficiary notices. The facility census was 55.
Findings include:
1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE].
Review of a NOMNC letter revealed skilled services ended on 04/14/25. The letter did not contain the name or the telephone number of the Quality Improvement Organization (QIO) for appeal purposes.
2. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE].
Review of a NOMNC letter revealed skilled services ended on 03/15/25. The letter did not contain the name or the telephone number of the QIO for appeal purposes.
Interview on 04/28/25 at 11:20 A.M. with Chief Clinical Officer (CCO) #509, during review of Resident #5 and Resident #8's NOMNC letters, confirmed the QIO information was not present. CCO #509 reported the Business Office Manager talked with the residents and or family and completed the forms.
Interview on 04/28/25 at 1:17 P.M. with Business Office Manager (BOM) #513 revealed she received the corrected form from the Administrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and staff interview, the facility failed to ensure a resident was properly a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and staff interview, the facility failed to ensure a resident was properly assessed for use of a restraint. This affected one (#18) of three residents reviewed for restraints. The census was 55.
Findings included:
Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included sepsis, Alzheimer's disease, dementia, diabetes, hypertension, and depression.
Review of the plan of care dated 11/29/24 revealed Resident #18 had the potential for pressure ulcer development related to a skin tear to the right fifth digit. Interventions included garden gloves at all times except while sleeping with instructions to remove at night for washing and to check skin integrity dated 04/17/25.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #18 had severely impaired cognition.
Review of the progress note dated 04/09/25 at 12:35 P.M. revealed the nurse discussed options with the legal representative to prevent further skin breakdown from Resident #18 from chewing on her fingers. The physician ordered the antianxiety medication Ativan 0.5 milligrams (mg) as needed every eight hours to prevent anxious chewing.
Review of the April 2025 physician's orders revealed Resident #18 had an order to remove gloves, check skin integrity, wash hands with soap, wash the gloves, and hang them to dry dated 04/17/25. Further review of the physician' orders revealed Resident #18 did not have an order for the gloves to be wore to prevent her from chewing on her fingers.
Further review of the medical record revealed no restraint assessment was completed for the use of gardening gloves with hook and loop fasteners (Velcro) to the hands of Resident #18 to prevent her from chewing on her fingers.
Observation on 04/22/25 at 8:12 A.M. revealed Resident #18 had long gardening gloves with Velcro around the wrist area on both her hands. Her fingers were not in the finger holes of the gloves an her hands were balled up in fists inside the gloves preventing her from movement.
On 04/24/25 at 11:17 A.M. an interview with the Director of Nursing (DON) revealed the gloves to the hands of Resident #18 were due to the resident having her own teeth and would chew on her fingers. The DON verified at that time Velcro was around the resident's wrists preventing the resident from removing them herself.
On 04/28/25 at 8:50 A.M. a second interview with the DON revealed the facility attempted skin preparation to harden the skin around Resident #18's nails but she would still bite at them. The DON stated they could not use bandages because the resident would chew on them. The DON verified the physician was aware; however, there was not an order or restraint assessment completed for use of the gloves to prevent biting.
Review of the facility policy titled, Use of Restraints, dated 11/13/23, revealed restraints would only be used for safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints would only be used to treat a resident's medical symptom and never for discipline or staff convenience,or to prevent falls. Prior to placing a restraint there would be a Restorative Enabler Assessment and review to determine the need for restraints.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review (P...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review (PASARR) assessments were updated and accurate. This affected one (#52) of two residents reviewed for PASARR assessments. The facility census was 55.
Findings Include:
Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses that include dementia, schizophrenia, high cholesterol, and retention of urine.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was severely cognitive impaired and required extensive assistance of one staff person for completing his activities of daily living.
Review of the PASARR assessment dated [DATE] revealed the facility did not indicate the resident had a diagnosis of schizophrenia for the the question on the PASARR assessment, Does the individual have a diagnosis(es) of any of the mental disorders listed below?, with a listing of significant mental health diagnoses including schizophrenia to chose from.
Interview with the Director of Nursing (DON) on 04/23/25 at 1:30 P.M. verified Resident #52's PASARR did not address his documented diagnoses of schizophrenia.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of narcotic count sheet, and resident and staff interview, the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of narcotic count sheet, and resident and staff interview, the facility failed to ensure medications were available as ordered to treat pain. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55.
Findings included:
Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, angiodysplasia of the stomach and duodenum with bleeding, urinary tract infections, skin cancer, necrotizing fasciitis, polyneuropathy, mild protein calorie malnutrition, diabetes, chronic kidney, mood disorder, suicidal ideations, chronic obstructive pulmonary disease, chronic pain syndrome, cirrhosis of the liver, hypertension, congestive heart failure, depression, sleep apnea, and anxiety disorder.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had intact cognition and had almost constant pain.
Review of the April 2025 physician's orders revealed Resident #19 had an order for one tablet of the narcotic pain medication hydrocodone-acetaminophen 5-325 milligrams (mg) three times a day for chronic pain.
Review of Resident #19's electronic medication administration record (eMAR) progress note dated 04/20/25 at 10:43 P.M. revealed the facility was waiting on hydrocodone-acetaminophen 5-325 milligrams from the pharmacy.
Review of the narcotic count sheets revealed Resident #19 had a dose of scheduled hydrocodone-acetaminophen 3-325 milligrams on 04/20/25 at 1:03 P.M. and did not have other dose until 04/21/25 at 5:05 A.M. which was 16 hours between doses and it was scheduled every eight hours.
Review of the April 2025 medication administration record revealed Resident #19 had a pain level of eight out of ten on 04/21/25 at 5:05 A.M. after not having her routine pain medication as ordered.
On 04/21/25 at 1:45 P.M. an interview with Resident #19 revealed the nurses do not reorder her pain medication on time and she runs out of it. She stated on 04/18/25 when she got her 2:00 P.M. pain pill she asked the nurse if she would have enough pain pills to get through they weekend because it was Easter weekend. Resident #19 stated the nurse told her there would not be enough pills and she would reorder it, but she never reordered it. Resident #19 stated she ran out on Saturday night and was without her pain pills for almost 17 hours and stated it happened all the time.
On 04/28/25 at 8:58 A.M. an interview with the Director of Nursing (DON) revealed the nurse was unable to pull the hydrocodone-acetaminophen for Resident #19 from the stock medication because they were depleted and did not have any to give her.
On 04/28/25 at 1:00 P.M. a second interview with the DON revealed she was incorrect about the hydrocodone-acetaminophen stock being depleted. She stated they actually did have the medication in the stock kit, but because her pain medication had already been sent with the full prescription amount of 30 pills from the pharmacy, they were unable to pull one from stock and give Resident #19. The DON verified they could have called the physician and ordered a one-time dose of hydrocodone-acetaminophen to be pulled from the contingent supply but it had not been done. She stated her medication was not reordered until the morning of 04/20/25 and did not know why it was not ordered sooner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, pharmacy recommendation review, and staff interview, the facility failed to act upon pharmacist ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, pharmacy recommendation review, and staff interview, the facility failed to act upon pharmacist recommendations that were agreed to by the residents physicians as required. This affected two (#51 and #54) of five residents reviewed for unnecessary medications. The facility census was 55.
Findings Include:
1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired, required extensive assistance of one staff person for completing her activities of daily living, and had no verbal, physical, or other behaviors.
Review of Resident #51's admission physician's orders from October 2024 revealed an order dated 10/16/24 noting that Resident #51 was prescribed quetiapine fumarate (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 25 milligrams (mg) once daily for anxiety/depression.
Review of the pharmacist recommendation from 11/30/24 revealed documentation of, The resident (#51) is currently receiving the antipsychotic medication quetiapine and does not have an appropriate diagnosis to support therapy. Please evaluate and update their records accordingly. Further review revealed the recommendation also provided a list of acceptable diagnoses for prescribing quetiapine per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The list of diagnoses included, schizophrenia, schizo-affective disorder, delusional disorder, mood disorder (mania, bipolar disorder, depression with psychotic features), schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms and medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. Resident #51's physician reviewed the recommendation and agreed that Resident #51 did not have an appropriate diagnosis for quetiapine fumarate but did indicate a diagnosis to add to the record.
Review of the current physician's orders for April 2025 revealed Resident #51 was prescribed quetiapine fumarate 25 mg one-half tablet once daily with the indication of use as, antipsychotic.
Interview with the Director of Nursing (DON) on 04/22/25 at 2:45 P.M. verified the facility did not act on the pharmacist's recommendation on 11/30/24 to update Resident #51's medical record with appropriate indications for the continued use of quetiapine fumarate.
2. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses that included a fractured nose, post-traumatic stress disorder, and psychotic disorder.
Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #54 was cognitively intact and was independent for completing her activities of daily living (ADLs).
Review of Resident #54's admission physician's orders from December 2024 revealed Resident #54 was prescribed quetiapine fumarate 100 mg once daily at bedtime for agitation.
Review of the pharmacist recommendation from 12/31/24 revealed documentation of, The resident (#54) is currently receiving the antipsychotic medication quetiapine and does not have an appropriate diagnosis to support therapy. Please evaluate and update their records accordingly. The recommendation also provided a list of acceptable diagnoses for prescribing quetiapine per the DSM-IV. The list of diagnoses included, schizophrenia, schizo-affective disorder, delusional disorder, mood disorder (mania, bipolar disorder, depression with psychotic features), schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms and medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. Resident #54's physician reviewed the recommendation and agreed to add schizo-affective disorder as the appropriate diagnoses for use of quetiapine .
Review of the current physicians orders for April 2025 revealed Resident #54 was prescribed quetiapine fumarate 100 mg twice daily for agitation.
Further review of Resident #54's medical record did not contain a diagnoses of schizo-affective disorder.
Interview with the DON on 04/22/25 at 11:45 A.M. verified the facility did not act on the pharmacist's recommendation on 12/31/24 to update Resident #54's medical record with appropriate indications for the continued use of quetiapine fumarate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy recommendations, staff interview, and policy review, the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy recommendations, staff interview, and policy review, the facility failed to ensure appropriate indications and/or diagnoses were in place for residents receiving antipsychotic medication. This affected one (#51) of five residents reviewed for unnecessary medications. The facility census was 55.
Findings Include:
Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired, required extensive assistance of one staff person for completing her activities of daily living, and had no verbal, physical, or other behaviors.
Review of Resident #51's admission physician's orders from October 2024 revealed an order dated 10/16/24 noting Resident #51 was prescribed quetiapine fumarate (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 25 milligrams (mg) once daily for anxiety/depression.
Review of the pharmacist recommendation from 11/30/24 revealed documentation of, The resident (#51) is currently receiving the antipsychotic medication quetiapine and does not have an appropriate diagnosis to support therapy. Please evaluate and update their records accordingly. Further review revealed the recommendation also provided a list of acceptable diagnoses for prescribing quetiapine per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The list of diagnoses included, schizophrenia, schizo-affective disorder, delusional disorder, mood disorder (mania, bipolar disorder, depression with psychotic features), schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms and medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. Resident #51's physician reviewed the recommendation and agreed that Resident #51 did not have an appropriate diagnosis for quetiapine fumarate but did indicate a diagnosis to add to the record.
Review of Resident #19's current physician's orders for April 2025 revealed an order dated 12/09/24 for staff to monitor behaviors every shift. Further review of the current physician's orders for April 2025 revealed Resident #51 was prescribed quetiapine fumarate 25 mg one-half tablet once daily with the indication of use as, antipsychotic.
Review of Resident #19's treatment administration records (TARs) since admission revealed no documented behaviors were noted by the facility on the TARs.
Interview with the Director of Nursing (DON) on 04/22/25 at 2:45 P.M. verified there was no appropriate diagnoses or documentation of presenting features of an appropriate diagnosis for the continued use of quetiapine fumarate in Resident #51's medical record.
Review of the policy titled, Chemical Restraint Use, dated 03/06/25, revealed residents will only receive psychotropic medications when necessary to treat specific diagnosis/conditions for which they are indicated and effective.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with staff, the facility failed to ensure a resident was given insulin as or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with staff, the facility failed to ensure a resident was given insulin as ordered. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55.
Findings included:
Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, angiodysplasia of the stomach and duodenum with bleeding, urinary tract infections, skin cancer, necrotizing fascitis, polyneuropathy, mild protein calorie malnutrition, diabetes, chronic kidney, mood disorder, suicidal ideations, chronic obstructive pulmonary disease, chronic pain syndrome, cirrhosis of the liver, hypertension, congestive heart failure, depression, sleep apnea, and anxiety disorder.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had intact cognition and received insulin.
Review of the April 2025 physician's orders revealed Resident #19 had an order for Novolog Flexpen three units subcutaneously before meals for diabetes.
Review of the electronic medication administration record (eMAR) progress notes revealed Novolog insulin for Resident #19 was held on 04/02/25 at 8:32 A.M., 04/02/25 at 5:07 P.M., 04/03/25 at 1:15 P.M., 04/12/25 at 10:17 A.M., 04/12/25 at 12:27 P.M., 04/12/25 at 5:10 P.M., and 04/17/25 at 10:22 A.M. without perimeters or physician's notification.
On 04/23/25 at 10:45 A.M. an interview with the Director of Nursing (DON) revealed the nurses were to call the physician prior to holding any insulin without perimeters or if the resident refused. The DON verified the eMAR progress notes from 04/02/25, 04/03/25, 04/12/25, and 04/17/25 indicating the insulin for Resident #19 was held without perimeters or the physician being notified.
This deficiency represents non-compliance investigated under Master Complaint Number OH00164429.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and interview with the staff, the facility failed to ensure residents were p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and interview with the staff, the facility failed to ensure residents were provided thickened liquids as ordered. This affected one (#29) of three residents reviewed for nutrition. The census was 55.
Findings included:
Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, hypothyroidism, hypertension, restless legs syndrome, essential tremor, collapsed vertebrae, polyneuropathy, low back pain, spondylosis, repeated falls, slurred speech, disorder of the peripheral nervous system, diabetes, dementia without behaviors, cerebral infarction, major depressive disorder, Alzheimer's disease, and anxiety disorder.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #29 had moderately impaired cognition, required supervision with eating, received a therapeutic diet, and did not have an weight loss.
Review of the April 2025 physician's orders revealed Resident #29 had an order for a regular, mechanical soft texture diet with nectar consistency liquids dated 04/16/25.
Review of the undated breakfast meal ticket revealed Resident #29 was to have a regular diet with mechanical soft texture and nectar thick liquids.
Observation and interview on 04/23/25 at 8:35 A.M. revealed Agency Certified Nurse Aide (CNA) #611 gave Resident #29 two glasses of thin consistency apple juice even though the meal ticket was highlighted with thicken liquid, nectar thick. At 8:36 A.M., CNA #527 verified Resident #29 was to get thickened liquids and went into the room immediately and retrieved the two glasses of thin consistency apple juice; however, Resident #29 had already drank three-fourths a four-ounce glass of apple juice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to maintain proper infectio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to maintain proper infection control measures during wound care and bed linen changes. This affected two (#29 and #33) of two residents observed for proper infection control measures maintained during care and services. The census was 55.
Findings include:
1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, hypothyroidism, hypertension, restless legs syndrome, essential tremor, collapsed vertebrae, polyneuropathy, low back pain, spondylosis, repeated falls, slurred speech, disorder of the peripheral nervous system, diabetes, dementia without behaviors, cerebral infarction, major depressive disorder, Alzheimer's disease, and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had moderately impaired cognition.
Review of the April 2025 physician's orders revealed Resident #29 had an order to paint the right scapula wound with betadine and leave open to air every day for cellulitis.
Observation and interview during wound care on 04/23/25 at 10:55 A.M. revealed wound care was provided to Resident #29 by Licensed Practical Nurse (LPN) #515 and Physician #613. LPN # 515 brought the wound care supplies in the room in her hand and was observed to already have gloves on when she entered the room. LPN #515 and Physician #613 positioned Resident #29 on his left side away from them. LPN #515 pulled on the bed pad to position him farther over on his left side and did this all with her gloves on and with the four inches long by four inches wide (four by four) pad dressings in her right hand so the clean dressings touched all of Resident #29's bed linens. Physician #613 removed the old dressing from the resident, dated 04/22/25, and measured the wound. There was a moderate amount of serosanguinous drainage (a fluid that contains both serum (clear, watery fluid) and blood) on the old dressing. LPN #515 stated the staff must have placed a dressing on the wound due to all the drainage because he did not have an order for the dressing. LPN #515 cleaned the wound with the four by four pad she had in her right hand and wound cleanser then with a betadine swab without changing her gloves or washing her hands. Physician #613 told her to go ahead an place another foam dressing on the wound so she went out of the room to get a dressing. LPN #515 came back into the room and placed the foam dressing onto the wound.
On 04/23/25 at 1:38 P.M. an interview with LPN #6515 verified she wore her gloves into the room, she had the four by four pad dressings in her hand when she repositioned the resident in bed and then cleaned his wound with them, and did not change gloves or wash her hands during the procedure.
Review of the facility policy titled, Dressing Change (Clean), dated 11/03/22, revealed the purpose was to protect the wound, prevent infection, to prevent irritation and promote healing. The procedure indicated to wash hands, create a clean field with paper towels, put on a pair of disposable gloves, remove the old dressing an discard in a plastic bag, dispose of the gloves, wash hands, put on a second pair of disposable gloves, clean the wound as ordered, dispose of the gloves, wash hands apple prescribed medication and dressing, remove the gloves and wash hands.
2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included adult failure to thrive, bifascicular block, aphasia, schizoaffective disorder, malignant carcinoid tumor of the transverse colon, hypertensive heart disease, cataract, dementia, depression, anemia, atrial fibrillation, peripheral vascular disease, hypertension, dysphagia, benign prostatic hyperplasia, osteoarthritis, glaucoma, alcohol abuse, and cerebral infarction.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had severely impaired cognition.
Observation on 04/21/25 at 9:55 A.M. revealed a large pile of soiled linen on the floor in the room of Resident #33. An interview at this time with Certified Nurse Aide # 547 revealed she just changed the resident's bed because he was wet and did not did not know where else to put the soiled linens.
Review of the facility policy titled, Bedmaking (Occupied), dated 11/13/23, revealed the purpose was to provide a clean, comfortable environment for the resident. Further review revealed for staff to remove the soiled linen by rolling edges toward the center with the soiled side inward and place in a linen hamper or a bag.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and review of a bid quote for work from a local construction company, the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and review of a bid quote for work from a local construction company, the facility failed to provide a safe and homelike environment. This affected 18 (#4, #6, #8, #10, #15, #17, #18, #19, #22, #23, #25, #36, #37, #38, #39, #42, #46, and #50) of 55 residents reviewed for environment. The facility census was 55.
Findings Include:
1. Interview with Resident #19 in the facility's outdoor smoking area on 04/22/25 at 9:50 A.M. revealed the resident did not feel safe in the smoking area and felt it was only a matter of time before the wooden [NAME] structure surrounding the smoking area was going collapse around the residents.
Observation of the smoking area on 04/22/25 at 10:00 A.M. revealed the area was covered by a wooden [NAME]. The wood on the structure beams were noted to be visibly rotting to various degrees all throughout the area. The center beam of the [NAME] had an over five and one-half feet long hole in the wood that had been made by a large termite infestation and subsequent damage. A plastic roof was visualized to cover half the [NAME] with an active substance growth on it. A number of vertical support beams throughout the [NAME] had pieces of wood that were actively separating from the support beam.
Interview with Maintenance Director (MD) #511 on 04/22/25 at 10:15 A.M. verified the condition of the wooden [NAME] in the smoking area and the damage to the main center beam had been caused by a termite infestation. MD #511 also noted the facility received a bid on replacing the [NAME] structure a while ago and the facility chose to purchase replacement air conditioners instead.
Review of the bid quote from a local construction company revealed the facility received a bid for replacement of [NAME] structure on 04/20/23 with multiple options of replacement of the structure. No further action was noted to have been taken on the quote received on 04/20/23 and no other quotes from other companies regarding replacement of the structure were received.
The facility identified Resident #4, Resident #8, Resident #15, Resident #17, Resident #19, Resident #23, Resident #25, Resident #36, Resident #37, Resident #39, Resident #46, and Resident #50 as active smokers residing in the facility.
2. Observation on 04/28/25 beginning at at 9:29 A.M. of hot water temperatures from the bathroom faucets in resident rooms and room conditions with MD #511 revealed the water temperature exceeded 120 degrees Fahrenheit (°F) in resident rooms and there were also other environmental issues noted. Observation of Resident #22 and Resident #8's hot water revealed it was 123 °F and there were gouges on the bathroom wall and near the window. Resident #10's hot water was 124 °F and had gouges on the wall and paint separating from the ceiling in the bathroom. Resident #38's room had large gouges on the walls of the room. Resident #42 and Resident #6's hot water was 124 °F and had gouges in the wall by the door. Resident #18's hot water was 124 °F.
Interview with MD #511 on 04/28/25 between 9:29 A.M. and 9:55 A.M. verified each temperature reading and environmental concern at the time of discovery.
This deficiency represents non-compliance investigated under Complaint Number OH00163638.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure smoking safety was followed on facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure smoking safety was followed on facility grounds per facility policy. This had the potential to affect all 55 residents of the facility. The census was 55.
Findings Include:
Observation on 04/28/25 at 9:57 A.M. of the facility parking lot with Maintenance Director (MD) #511 revealed cigarette butts disposed of in mulch beds. The mulch bed nearest the facility dumpsters contained 17 cigarette butts. The mulch bed nearest the wooden [NAME]-cochere (a covered porch where vehicles can pick up and drop off people) at the main entrance contained 10 cigarette butts. The trash can under the [NAME]-cochere was observed to have ash marks on the sides of it from cigarettes being extinguished and the inside of the trash can was observed to contain flammable materials. The mulch bed nearest the 300 Hall entrance contained three cigarette butts.
Interview on 04/28/25 at 10:08 A.M. with MD #511 confirmed the presence of cigarette butts disposed of in the facility mulch beds and ash marks on the sides of the trash can.
Review of the facility smoking policy dated 02/26/25 revealed smoking was only allowed in designated smoking areas.
Review of the smoking area information provided by the facility confirmed the designated smoking location was the 100/200 Hall dining room patio.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation of the posted survey results, review of previous survey history, and staff interview, the facility failed to ensure posted survey results were updated with the most recent survey ...
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Based on observation of the posted survey results, review of previous survey history, and staff interview, the facility failed to ensure posted survey results were updated with the most recent survey results. This had the potential to affected all 55 residents. The facility census was 55.
Findings include:
Observation of the facility survey results binder on 04/28/25 at a random time found the last survey included was dated 06/10/22.
Review of facility's survey history revealed, between 06/10/22 and 04/28/25, there were eleven complaint surveys, an annual survey on 10/24/22, and 15 Focused Infection Control surveys completed.
Interview on 04/28/25 at 10:56 A.M. with the Administrator confirmed there were no survey results in the facility binder since 06/10/22.
Apr 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of QSO-24-08-NH and review of facility policy, the facility failed to ensure enhanced ba...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of QSO-24-08-NH and review of facility policy, the facility failed to ensure enhanced barrier precaution (EBP) guidelines were followed for all residents that required EBP. This affected five of ten residents (Resident #1, #23, #50, #51, #57) reviewed for EBP. The facility census was 59.
Findings Include:
1. Review of the medical record for Resident #23 revealed and admission date of 12/07/23. Diagnoses included respiratory disorders, tracheostomy, morbid obesity and acute respiratory failure with hypoxia.
Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 was on oxygen, required suctioning, had a tracheostomy and required a mechanical ventilator for respiratory support.
Review of the physician orders for April 2024 revealed Resident #23 was on Levofloxacin (antibiotic) 500 milligram (mg) tablet for ten days for pneumonia. There were also orders for tracheostomy care, use of ventilator and suctioning when needed.
Observation of Resident #23's room door on 04/26/24 at 5:20 A.M. revealed a yellow bag hanging from the door with personal protective equipment (PPE) in it with no signage on what type of precautions the resident was on.
Interview on 04/26/24 at 5:28 A.M. with Registered Nurse (RN) #300 revealed she did not know if Resident #23 was on enhanced barrier precautions. RN #300 stated she did not wear a gown when connecting or reconnecting Resident #23 from the ventilator or when providing ventilator/tracheostomy care. RN #300 verified there was no enhance barrier precaution sign on Resident #23's door or wall outside of residents' room.
Interview on 04/26/24 at 6:43 A.M. with Resident #23 revealed not all staff wore PPE when caring for him.
2. Review of the medical record for Resident #50 revealed an admission date of 07/17/23. Diagnoses included unspecified tracheostomy complication and respiratory failure.
Review of the MDS assessment dated [DATE] revealed Resident #50 was cognitively impaired, on oxygen, had a tracheostomy, and received tracheostomy care, suctioning and tube feeding.
Review of the physician orders for April 2024 revealed to change split sponge to tracheostomy daily with trach care and enteral feed order.
Observation of Resident #50 and interview with RN #300 on 04/26/24 at 5:40 A.M. revealed Resident #50 had a tracheostomy and a feeding tube. Further observation revealed Resident #50 was not on EBP. RN #300 verified Resident #50 should be on EBP.
3. Review of the medical record for Resident #57 revealed an admission date of 04/12/24. Diagnoses included gastrostomy, respiratory tract disease, acute respiratory failure with hypoxia and tracheostomy.
Review of the physician orders for April 2024 revealed orders for tracheostomy care and enteral feed order.
Observation of Resident #57 and interview with RN #300 on 04/26/24 at 5:40 A.M. revealed a yellow bag of PPE on Resident #57's door. RN #300 confirmed Resident #57 had a tracheostomy and was receiving tube feedings, but RN #300 did not know if Resident #57 was on EBP because there was no sign on Resident #57's door or outside the room indicating the resident was on EBP.
4. Review of the medical record for Resident #1 revealed an admission date of 04/17/24. Diagnoses included acute respiratory failure with hypoxia and urinary retention.
Review of the physician orders for April 2024 revealed orders for urinary catheter care and for a wound to right buttock.
Observation on 04/26/24 at 9:30 A.M. of Resident #1 and his room revealed he was not on any type of isolation precautions. There was no signage and no PPE on the door or outside the room.
Observation on 04/26/24 at 11:00 A.M. of Resident #1 and his room revealed Resident #1 had been placed on EBP and there was PPE and a sign on his door for EBP.
Interview on 04/26/24 at 11:10 A.M. with the Director of Nursing (DON) verified Resident #1 was supposed to be on EBP on admission and had not been put on until 04/26/24.
5. Review of the medical record for Resident #51 revealed an admission date of 03/03/24. Diagnosis included human immunodeficiency virus.
Review of Resident #51's MDS assessment dated [DATE] revealed Resident #51 had intact cognition.
Review of the physician orders for April 2024 revealed Resident #51 had an order for an indwelling urinary catheter.
Observation on 04/26/24 at 9:30 A.M. of Resident #51 and his room revealed he was not on any type of isolation precautions. There was no signage and no PPE on the door or outside the room.
Observation on 04/26/24 at 11:00 A.M. of Resident #51 revealed he had been placed on EBP and there was PPE and a sign on his door for EBP.
Interview on 04/26/24 at 11:10 A.M. with the DON verified Resident #51 was supposed to be on EBP on admission related to his urinary catheter.
Review of the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group reference QSO-24-08-NH revealed EBP recommendations include use of EBP for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their multidrug-resistant organism status.
Review of the facility policy Enhanced Barrier Precautions, dated 04/23/24 revealed the facility would identify residents with central lines, urinary catheters, feeding tubes, hemodialysis catheters and tracheotomy/ventilator status regardless of Multi drug-resistant Organisms (MDRO) colonization status. High contact resident care activities requiring gown and glove use included but were not limited to tracheotomy/ventilator care. Residents identified with MDRO, wound, and or indwelling medical devices would have an EBP sign noting the PPE needed and the high contact care activities placed on the door or wall outside of the resident room.
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to timely address a resident change in conditi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to timely address a resident change in condition. This affected one resident (Resident #65) of three residents reviewed for notification of changes. The facility census was 62.
Findings include:
Review of Resident #65's closed medical record revealed an admission date of 01/13/23 and diagnoses including anemia, failure to thrive, type two diabetes, hypertension, chronic kidney disease, congestive heart failure, mild cognitive impairment, cardiomegaly, COVID-19, heart disease and hypokalemia. Resident #65 was his own responsible party. Resident #65 discharged to the hospital on [DATE] and did not return to the facility.
Review of Resident #65's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was moderately cognitively impaired and required minimal assistance to supervision with activities of daily living. Resident #65 was coded as receiving a diuretic six out of seven days in the seven-day look back period. Resident #65 admitted to the facility from the hospital.
Review of Resident #65's physician's orders revealed orders to monitor vital signs every shift. Resident #65 was a full code.
Review of treatment administration records (TARs) from February 2023 revealed the last set of vitals recorded was on 02/03/23 in the evening (7:00 P.M. to 7:00 A.M.).
Review of a nurses' note dated 02/04/23 at 8:15 A.M. authored by Licensed Practical Nurse (LPN) #104 revealed the following information: This nurse went into Resident #65's room to give morning mediations, resident was noted to have facial, bilateral upper extremity and bilateral lower extremity edema. Vitals as follows: blood pressure 197/129 millimeters mercury (mmHg), heart rate 67 beats per minute (bpm), temperature 98.1 degrees Fahrenheit (F), pulse oximetry (SpO2) 95% on room air and respirations 20 (breaths per minute). Message left for provider [not specified], awaiting call back.
Review of the next available nurses' note dated 02/04/23 at 10:30 A.M. authored by LPN #104 revealed the following information: Resident #65's daughter in facility, wants this nurse to send resident to [hospital name], 9-1-1 (emergency medical services) called and in building. Resident #65 states he goes not want to go to [hospital name] he wants to go to [different hospital name]. Resident transferred to [different hospital name] at 10:10 A.M.
Review of Resident #65's assessments revealed no transfer assessment or other documentation from 02/04/23 regarding Resident #65's change in condition.
Interview on 11/17/23 at 8:58 A.M. with Resident #65's daughter revealed on 02/04/23 the nurse (name not known) never called 9-1-1 after Resident #65 had a change in condition. Resident #65's daughter stated Resident #65 called her to come to the facility and once she was at the facility she made the nurse call 9-1-1. Resident #65's daughter said the nurse told her the doctor ordered labs relative to Resident #65's change in condition. Resident #65 was hospitalized from [DATE] onwards and did not return to this facility.
Interview on 11/17/23 at 10:53 A.M. with LPN #100 revealed for high blood pressures over 190 mmHg (systolic)/100 mmHg (diastolic) she would send residents out to the hospital as she did not mess around with changes in condition.
Interviews were attempted with LPN #104 on 11/17/23 at 11:32 A.M. and 1:14 P.M. but were not successful.
Interview on 11/17/23 at 11:35 A.M. with Certified Nurse Practitioner (CNP) #103 revealed she was a contracted provider thus was not on-call for the facility. CNP #103 indicated she had seen Resident #65 during his stay at the facility and shared he had significant blood pressure readings. CNP #103 stated that this facility did not have a threshold for blood pressure readings to determine if residents should be kept at the facility or sent to the hospital for further evaluation. CNP #103 stated if blood pressures were out of range for the resident, nursing staff should have called the primary care provider (PCP) for further instructions.
Interview on 11/17/23 at 11:54 A.M. with the Director of Nursing (DON) revealed LPN #104 had called her after Resident #65 was sent to the hospital on [DATE] and shared while Resident #65 had facial edema he was still breathing, talking and acting normally and she had contacted Physician #109 but did not get a response. The DON was asked if there was a protocol for staff to follow if physicians did not respond to calls timely and she confirmed there was no protocol and stated staff were to continue to try to contact the doctor. The DON did not recall Physician #109 having a nurse practitioner or other staff that covered for him in his absence. The DON could not state if Resident #65 should have been sent to the hospital prior to his family requesting him to be sent as she was not present in the facility on 02/04/23 to make that clinical judgement. The DON indicated she kept in contact with Resident #65's family after he was discharged from the facility and it was thought Resident #65 may have had an allergic reaction which caused him to be hospitalized .
Interview on 11/17/23 at 12:34 P.M. with Registered Nurse (RN) #108 revealed she cared for Resident #65 during his admission to the facility and recalled his blood pressure was consistently high. At times she would have to call the doctor for new orders and elaborated this would occur if Resident #65's systolic blood pressure was in the 200 mmHg range and his diastolic blood pressure was in the 100 mmHg range. When asked who staff were to call if the physician was not available, RN #108 stated staff would call the on-call physician and if that person was not available they would send the resident to the hospital.
Follow-up interview on 11/17/23 at 1:49 P.M. with the DON revealed if Physician #109 was out of the country his nurse practitioner would take calls but that person would not be on-call. The DON stated Physician #109 was not out of the country on 02/04/23 so staff would have called him and only him, there was no one else they would have called. The DON reiterated nursing staff were to use their clinical judgement and indicated Resident #65's blood pressure of 197/129 mmHg was not abnormal for him. The DON stated LPN #104 had called the physician multiple times on 02/04/23 but was made aware during the interview this was not documented in the medical record. The DON verified there was no protocol in place in the event a resident's physician could not be reached. During the interview the DON was made aware after LPN #104's progress note on 02/04/23 at 8:15 A.M. there were no additional blood pressure readings to check Resident #65's status, there were no other notes indicating that the physician was contacted additional times and the record lacked a change in condition/transfer assessment and DON did not disagree.
Review of a policy, Change in a Resident's Condition, dated 12/16/20 revealed the facility would notify the resident, their physician and their sponsor of changes in the residents' medical/mental condition. Except in medical emergencies, notifications will be made timely of a change occurring in the residents' medical/mental condition or status. The nurse supervisor/charge nurse would record in the residents' medical record information relative to changes in the residents' medical/mental condition or status. The policy lacked guidance for staff to follow in the event the physician was not available.
This deficiency represents non-compliance investigated under Complaint Number OH00147933.
Oct 2022
8 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure care planned interventions were in place to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure care planned interventions were in place to prevent falls for Resident #11, Resident #53, Resident #37 and Resident #20. Actual harm occurred when Resident #11 and Resident #53 suffered a fall with a fracture nose and right femur respectively and were admitted to the hospital. This affected four residents (Resident #11, Resident #20, Resident #37, and Resident #53) out of six residents reviewed for falls. The facility census was 57.
Findings include:
1. Resident #53 was admitted on [DATE] with diagnoses including malnutrition, chronic obstructive pulmonary disease, dementia with behaviors, delusional disturbances, iron deficiency anemia, constipation, aortic valve stenosis, congestive heart failure, fracture of the right femur, asthma, unsteadiness, difficulty walking and muscle weakness.
Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed he needed extensive assistance of two staff members for bed mobility and transfers.
Review of Resident #53's fall assessment dated [DATE] indicated he had a moderate risk for falls.
Review of Resident #53's plan of care revealed he was at risk for falls related to unstable mood/medical condition, congestive heart failure, debilitation, weakness, dementia, impaired balance and required assistance for activities of daily living and toileting. An intervention on the plan of care was initiated on 01/22/22 to maintain a clear pathway in his room.
Resident #53's nursing progress note dated 08/28/22 at 3:21 A.M. indicated the staff at the desk heard a loud noise and heard Resident #53 yell, help, I fell!. Resident #53 was found lying on the floor on his back next to his bed near the door of his room. When asked what happened Resident #53 stated, I fell getting back into the bed when returning from the bathroom, I hit my head on the door, I hit my knee. Resident #53's knee was noticeably swollen and unable to move or bend his right leg. The note indicated the staff called 9-1-1 and Resident #53 was transported to the hospital. The nursing progress note on 08/28/22 at 8:29 A.M. indicated Resident #53 was admitted to the hospital with a fracture of the right femur and was seen by an orthopedic specialist.
Resident #53's fall investigation dated 08/28/22 indicated Resident #53 had sustained a fall in his room and was sent to the hospital for an evaluation. The investigation indicated Resident #53 was attempting to remove his shoes and transfer back to bed and his walker was out of reach. The investigation indicated the nurse found the room cluttered and blocking the path to the bathroom.
An observation of Resident #53's room on 10/17/22 at 11:26 A.M. and 1:30 P.M. and on 10/18/22 at 4:10 P.M. revealed oxygen equipment, a wheelchair and other personal items blocking the path to the bathroom. Resident #53's room was cluttered with personal items and medical equipment and only a very small path was available to walk to the bathroom for both Resident #53 and his roommate (Resident #11).
An interview with Resident #53 on 01/17/22 at 1:47 P.M. revealed he had fallen and fractured his right leg which caused him pain when attempting to participate during therapy sessions. Resident #53 indicated he was attempting to walk from the bathroom to his bed and tripped over personal items on his way from the bathroom when he fell and fractured his leg while attempting to put on his shoes.
An interview with Director of Nursing (DON) on 10/19/22 at 11:00 A.M. verified the above findings.
2. Resident #11 was admitted on [DATE] and re-admitted to the facility on [DATE] with diagnoses including epilepsy, convulsions, cerebral vascular accident (stroke) with hemiparesis (weakness of one entire side of the body) and hemiplegia (complete paralysis of half of the body), homonymous field defect (a field loss deficit in the same halves of the visual field of each eye, often resulting from cerebrovascular injury or tumor.), apraxia (brain is unable to make and deliver correct movement instructions to the body), aphasia (a disorder that affects how you communicate) and unsteadiness on feet.
Resident #11's plan of care initiated on 08/06/21 revealed he had a risk for falls and potential injury related to stroke, weakness, impaired balance and impaired cognition. The goal of the plan of care was to minimize potential risk factors related to falls. Interventions on the plan of care included to provide an anti-rollback wheelchair for mobility with a nonskid pad on the seat of the wheelchair, remove the wheelchair from the bedside, provide a commode/urinal at the bedside and commonly used articles in reach and provide a visual reminder to use the call light and wait for assistance. Additional interventions included to use a mechanical lift for transfers and to maintain a clear pathway.
Resident #11's smoking evaluation dated 08/25/21 indicated he was a smoker, had cognition loss, dexterity problems and needed supervision while smoking.
Resident #11's MDS assessment dated [DATE] revealed Resident #11 was minimally verbal due to aphasia diagnosis and needed extensive assistance of one person for transfers and supervision while using a wheelchair for mobility.
Review of Resident #11's fall assessment dated [DATE] revealed he had a high risk for falls due to Resident #11 exhibited loss of balance while standing, was confined to a chair, sometimes had memory problems and was receiving antiseizure medication.
Resident #11's clinical record indicated he had sustained multiple falls from 07/01/22 to 10/18/22. Three falls occurred in Resident #11's room on 08/29/22, 08/20/22, 07/28/22 while trying to self-transfer out of bed to his wheelchair with no injury sustained from the falls.
Review of Resident #11's nursing progress note dated 07/15/22 at 11:07 A.M. revealed when Resident #11 was outside smoking another resident reported he appeared to have a seizure and fell out of his wheelchair. Resident #11 hit his face and was bleeding profusely. The staff called 9-1-1 and Resident #11 was sent to the hospital for evaluation of his injuries. The nursing note dated 07/15/22 at 11:59 P.M. indicated the nurse called the hospital for a report on Resident #11's condition and was informed the hospital admitted Resident #11 with breakthrough seizure.
Resident #11's fall investigation dated 07/15/22 revealed he was outside smoking with other residents and appeared to have a seizure and fell out of his wheelchair and hit his head on the ground. There were no staff supervising Resident #11 and the eyewitness account of the fall was provided by another resident (Former Resident #58) who no longer resided in the facility.
Review of Resident #11's nurse practitioner progress note dated 07/21/22 upon re-admission assessment revealed he had sustained nasal fractures following a fall after having a seizure. The nurse practitioner note indicated Resident #11 had no further seizure activity and to follow-up with neurology.
An observation of Resident #11's room on 10/17/22 at 1:30 P.M. revealed he shared a room with another resident and both residents had multiple personal items and designated medical equipment within reach in their room. There was a very small path from the door to Resident #11's bed with his roommate's wheelchair partially blocking the path to the door. Resident #11's bed was close to the privacy curtain and was difficult to navigate the path to enter and exit his bed and travel to the bathroom or exit the room win a wheelchair.
An interview with DON on 11/19/22 at 11:00 A.M. verified the above findings and indicated she was aware of the problem with the clutter in Resident #11's room. DON indicated this was an ongoing problem due to both residents in the room were at risk for falls.
3. Resident #20 was admitted on [DATE] and re-admitted to the facility with diagnoses including psychosis, sacroiliitis (an inflammation of one or both of the immovable joints formed by the bones of the pelvis), epilepsy, Todd's paralysis (a seizure is followed by a brief period of temporary paralysis), bipolar disorder and anemia and unsteady gait.
Review of Resident #20's MDS assessment dated [DATE] revealed she needed assistance with transfers, ambulation, use of the toilet and bathing.
Review of Resident #20's Fall assessment dated [DATE] revealed she had a moderate risk of falls due to a history of multiple falls, use of a mobility assistance device, and use of antiseizure medications.
Review of Resident #20's plan of care revised on 06/12/22, revealed Resident #20 was at risk for falls/injury due to seizure disorder, depression, osteoarthritis, activity of daily living functional status, psychotropic/antidepressant medication use, muscle weakness, anxiety, reoccurring cystitis, sacroiliitis, overactive bladder, currently experiencing uncontrolled seizure activity and need for glasses due to impaired vision. Interventions on the plan of care included to provide two staff members for assistance, use of a gait belt for transfers, and Resident #20 to wear tennis shoes when transferring.
Review of Resident #20's clinical record revealed she sustained five falls from 09/01/22 to 10/18/22.
A review of Resident #20's fall investigation dated 09/27/22 revealed Activities Assistant (AA) #400 went to the nurse and informed her they needed her in Resident #20's room. The nurse observed Resident #20 on her buttocks in front of her recliner. Resident #20 only had socks on and the call light was in reach. AA #20 entered Resident #20's room and asked if she wanted to attend an activity to play a game. AA #20 placed Resident #20's wheelchair close to Resident #20 and informed Resident #20 she was not able to assist her with transferring from the recliner to her wheelchair. Resident #20 attempted to self-transfer to the wheelchair. Resident #20's leg became weak, and she fell to the floor.
An interview on 10/20/22 at 10:15 A.M. with AA #400 indicated she rounded on the residents to ensure they had an activity calendar and invited them to attend activities. AA #400 stated she assisted the residents by pushing them in a wheelchair to the activity room to participate in the activity programs. AA #400 stated she would notify the state tested nursing assistant assigned to care for residents needing assistance with transferring to a wheelchair. Once the resident was assisted to their wheelchair AA #400 would proceed to push them in their wheelchair to the activity room. AA #400 stated on 09/27/22 when she entered Resident #20's room to invite her to participate in the activity she was seated in her recliner. AA #400 thought Resident #20 was independent with transfers and informed her she could not assist her to her wheelchair. AA #400 indicated Resident #20 attempted to self-transfer to her wheelchair and her leg became weak and she fell to the floor.
An interview with DON on 10/20/22 at 11:20 A.M. verified the above findings.
A review of the facility policy and procedure titled, Falls Clinical Protocol, revised 07/25/21 indicated the initial assessment would attempt to identify residents at risk for falls. Staff would evaluate and document falls that occur in the facility and indicate where the fall occurred, how the fall happened and if the fall was witnessed or unwitnessed. After a fall occurred, the facility would attempt to find the root cause of the fall and initiate interventions to prevent future falls. Based on the assessments of the resident a plan of care would be initiated, revised as needed and implement pertinent interventions to attempt to prevent subsequent falls.
4. Review of the medical record for Resident #37 revealed admission date of 11/18/16 and diagnoses included Alzheimer's disease, anxiety disorder, insomnia, dementia with behavioral disturbance, and polyosteoarthritis.
Review of Care Plan dated 06/27/22 revealed Resident #37 was at risk for falls with intervention of the bed in lowest position.
Review of Nursing Post Fall Review assessment dated [DATE] revealed Resident #37 was found to have fallen out of bed and was found by staff on knees with arm and face laying on bed still. Resident #37 had noted facial bruising after fall. Interventions implemented were to move bed into lowest position when occupied.
Review of Physician's Order dated 10/09/22 revealed bed in lowest position when occupied.
Review of MDS quarterly assessment dated [DATE] revealed Resident #37 had impaired cognition, disorganized thinking, and behavioral concerns. Resident #37 required total two staff assistance for transfers.
Observation on 10/18/22 at 3:34 P.M. revealed Resident #37 was resting comfortably in bed. Resident #37's bed was not observed to be in lowest position.
Interview on 10/18/22 at 3:37 P.M. with State Tested Nursing Assistant (STNA) #212 revealed she was aware Resident #37 had recent fall and was unsure what interventions were added.
Follow up observation on 10/18/22 at 3:43 P.M. with STNA #212 verified Resident #37's bed was not in lowest position. STNA #212 adjusted Resident #37's bed to lowest position.
Interview on 10/18/22 at 3:47 P.M. with Director of Nursing (DON) and Chief Clinical Officer (CCO) #247 confirmed Resident #37's bed should have been in lowest position as implemented from the fall on 10/08/22.
Review of facility policy titled, Falls Clinical Protocol, dated 07/25/21 revealed based on falls assessment staff and physician would identify interventions to prevent falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Resident #11 and Resident #53's room was unclu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Resident #11 and Resident #53's room was uncluttered to maintain a safe environment. This affected two residents (Resident #11 and Resident #53) out of 57 residents reviewed for accommodation of needs. The facility census was 57.
Findings include:
1. Resident #53 was admitted on [DATE] with diagnoses including malnutrition, chronic obstructive pulmonary disease, dementia with behaviors, delusional disturbances, iron deficiency anemia, constipation, aortic valve stenosis, congestive heart failure, fracture of the right femur, asthma, unsteadiness, difficulty walking and muscle weakness.
Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed he needed extensive assistance of two staff members for bed mobility and transfers.
Review of Resident #53's fall assessment dated [DATE] revealed he had a moderate risk for falls.
Review of Resident #53's plan of care revealed he was at risk for falls related to unstable mood/medical condition, congestive heart failure, debilitation, weakness, dementia, impaired balance and required assistance for activities of daily living and toileting. An intervention on the plan of care was initiated on 01/22/22 to maintain a clear pathway in his room.
Review of Resident #53's nursing progress note dated 08/28/22 at 3:21 A.M. revealed the staff at the desk heard a loud noise and heard Resident #53 yell, help, I fell!. Resident #53 was found laying on the floor on his back next to his bed near the door of his room. When asked what happened Resident #53 stated, I fell getting back into the bed when returning from the bathroom, I hit my head on the door, I hit my knee. Resident #53's knee was noticeably swollen and unable to move or bend his right leg. The note indicated the staff called 9-1-1 and Resident #53 was transported to the hospital. The nursing progress note on 08/28/22 at 8:29 A.M. indicated Resident #53 was admitted to the hospital with a fracture of the right femur and was seen by an orthopedic specialist.
Review of Resident #53's fall investigation dated 08/28/22 revealed Resident #53 had sustained a fall in his room and was sent to the hospital for an evaluation. The investigation indicated Resident #53 was attempting to remove his shoes and transfer back to bed and his walker was out of reach. The investigation indicated the nurse found the room cluttered and blocking the path to the bathroom.
An observation of Resident #53's room on 10/17/22 at 11:26 A.M. and 1:30 P.M. and on 10/18/22 at 4:10 P.M. revealed oxygen equipment, a wheelchair and other personal items blocking the path to the bathroom. Resident #53's room was cluttered with personal items and medical equipment and only a very small path was available to walk to the bathroom for both Resident #53 and his roommate (Resident #11).
An interview with Resident #53 on 01/17/22 at 1:47 P.M. indicated he had fallen and fractured his right leg which caused him pain when attempting to participate during therapy sessions. Resident #53 indicated he was attempting to walk from the bathroom to his bed and tripped over personal items on his way from the bathroom when he fell and fractured his leg while attempting to put on his shoes.
An interview with Director of Nursing (DON) on 10/19/22 at 11:00 A.M. verified the above findings.
2. Resident #11 was admitted on [DATE] and re-admitted to the facility on [DATE] with diagnoses including epilepsy, convulsions, cerebral vascular accident (stroke) with hemiparesis (weakness of one entire side of the body) and hemiplegia (complete paralysis of half of the body), homonymous field defect (a field loss deficit in the same halves of the visual field of each eye, often resulting from cerebrovascular injury or tumor), apraxia (brain is unable to make and deliver correct movement instructions to the body.), aphasia (disorder that affects how you communicate) and unsteadiness on feet.
Review of Resident #11's plan of care initiated on 08/06/21 revealed he had a risk for falls and potential injury related to stoke, weakness, impaired balance and impaired cognition. The goal of the plan of care was to minimize potential risk factors related to falls. Interventions on the plan of care included to provide an anti-rollback wheelchair for mobility with a nonskid pad on the seat of the wheelchair, remove the wheelchair from the bedside, provide a commode/urinal at the bedside and commonly used articles in reach and provide a visual reminder to use the call light and wait for assistance Additional interventions included to use a mechanical lift for transfers and to maintain a clear pathway.
Resident #11's clinical record indicated he had sustained multiple falls from 07/01/22 to 10/18/22. Three falls occurred in Resident #11's room on 08/29/22, 08/20/22, 07/28/22 while trying to self transfer out of bed to his wheelchair with no injury sustained from the falls.
Review of Resident #11's MDS assessment dated [DATE] revealed Resident #11 was minimally verbal due to aphasia diagnosis and needed extensive assistance of one person for transfers and supervision while us a ing a wheelchair for mobility.
Review of Resident #11's fall assessment dated [DATE] revealed he had a high risk for falls due to Resident #11 exhibited loss of balance while standing, was confined to a chair, sometimes had memory problems and was receiving antiseizure medication.
An observation of Resident #11's room on 10/17/22 at 1:30 P.M. revealed he shared a room with another resident and both residents had multiple personal items and designated medical equipment within reach in their room. There was a very small path from the door to Resident #11's bed with his roommate's wheelchair partially blocking the path to the door. Resident #11's bed was close to the privacy curtain and was difficult to navigate the path to enter and exit his bed and travel to the bathroom or exit the room with a wheelchair.
An interview with DON on 11/19/22 at 11:00 A.M. verified the above findings and indicated she was aware of the problem with the clutter in Resident #11's room. DON indicated this was an ongoing problem due to both residents in the room were at risk for falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and medical record review, the the facility failed to properly treat Resident #21's constipation. This affected one resident (Resident #21) out of one resident reviewe...
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Based on observation, interview, and medical record review, the the facility failed to properly treat Resident #21's constipation. This affected one resident (Resident #21) out of one resident reviewed for constipation.
Findings include:
Review of Resident #21's medical record revealed an admission date of 11/16/20 with diagnoses including acute kidney failure, muscle weakness, morbid obesity, and acquired absence of right leg above the knee.
Review of Resident #21's Care Plan dated 07/01/22 revealed the resident was at risk for constipation due to decreased mobility and medications. Interventions included for the facility to follow their bowel protocol for bowel management and record bowel movement patterns each day.
Review of Resident #21's October 2022 physicians orders revealed the resident had orders for MiraLax Packet with instructions to give 17 grams by mouth every 24 hours as needed for constipation and Bisacodyl Suppository with instructions to insert one suppository rectally every 24 hours as needed for constipation. Additionally the resident was noted to be on several medications that can cause constipation including Tramadol, Klonopin, and Zoloft.
Review of Resident #21's bowel record from 09/19/22 through 10/16/22 revealed the resident did not have a recorded bowel movement on 09/23/22, 09/24/22, 09/25/22, 09/26/22, 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/11/22, 10/12/22, 10/13/22, 10/14/22, 10/15/22, and 10/16/22.
Review of Resident #21's Medication Administration Record for September and October 2022 revealed she did not receive any of her as needed medications for constipation which included MiraLax or a Bisacodyl Suppository.
Interview on 10/17/22 at 12:02 P.M. with Resident #21 revealed she has frequent constipation.
Interview on 10/19/22 at 10:00 A.M. with Director of Nursing confirmed the facility did not initiate their bowel protocol for Resident #21 after she went over 72 hours without a bowel movement several times.
Review of the facility's policy, Bowel Program, dated 11/13/19, revealed if the resident did not have a bowel movement in 72 hours the following actions would be taken: assess bowel sounds, assess nutritional status, initiate standing orders for constipation, or notify the the physician for an order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure Resident #24's pressure ulcer treatment was completed as ordered. This affected one resident (Resident #24) out of one...
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Based on observation, interview, and record review, the facility failed to ensure Resident #24's pressure ulcer treatment was completed as ordered. This affected one resident (Resident #24) out of one resident reviewed for pressure ulcers.
Findings include:
Review of resident #24's medical record revealed an admission date of 10/18/22 with diagnoses including major depressive disorder, diabetes mellitus, and an unstageable pressure ulcer to right great toe.
Review of Resident #24's Care Plan, dated 05/23/22, revealed the resident was at risk for impaired skin integrity due to anemia, vitamin D deficiency, diabetes, and osteomyelitis. Intervention included to complete medications and treatments as ordered.
Review of Resident #24's October 2022 physicians orders revealed an order to clean the resident's right great toe stump with wound cleaner, apply skin prep, cover with an abdominal pad, and wrap with gauze every day shift and as needed.
Observation on 10/18/22 at 11:00 A.M. revealed Assistant Director of Nursing (ADON) #242 complete the pressure dressing change for Resident #24 right great toe. During the dressing change ADON #242 removed a boarder dressing from Resident #24's great toe which was dated 10/16/22.
Interview on 10/18/22 at 11:18 A.M. with ADON #242 revealed Resident #24's dressing was dated for two days prior when it was scheduled to be changed daily. She also confirmed the correct dressing was not used. She confirmed the dressing should have been an abdominal pad and the stump was to be wrapped with Kerlix.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview the facility failed to maintain Resident #30's right hand splint to prevent con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview the facility failed to maintain Resident #30's right hand splint to prevent contracture. This affected one out of four residents reviewed for limited range of motion. The facility census was 57.
Findings include:
Resident #30 was admitted on [DATE] with diagnoses including stoke, kidney stone, high blood pressure, aortic aneurysm, congestive heart failure and hyperlipidemia. A review of Resident #30's occupational therapy discharge note indicated he received occupational therapy services from 08/10/22 to 09/22/22. The occupational therapy recommended a restorative program for a restorative splint and brace program. Resident #30 was to wear a right hand splint to decrease further contracture as tolerated. Resident #30's physician order dated 09/14/21 indicated to apply a right hand splint daily as tolerated. There was no documentation in Resident #30's clinical record of Resident #30 refusing to wear the splint or removing the splint after the staff applied the splint. Resident #30's plan of care had no interventions regarding the application of the right hand splint.
An interview with Resident #30 on 10/17/22 at 5:22 P.M. indicated he had therapy in the past and was supposed to wear a splint on his right hand due to he was flaccid on the right side from a stoke. Resident #30 indicated the staff did not routinely assist him with applying his splint and he was not assisted with wearing the splint during his morning care on the day of the interview.
An observation and interview with Resident #30 on 10/18/22 at 2:00 P.M. indicated the staff did not apply his splint in the morning. There was no splint observed on Resident #30's right wrist. Resident #30's right wrist/hand were contracted and he was unable to voluntarily move the right wrist joint or fingers.
An interview with Physical Therapist Assistant (PTA) on 10/18/22 at 1:31 P.M. indicated Resident #30 had received occupational therapy for his right hand contracture and were working on strengthening, passive range of motion and right hand splinting. The restorative program recommended by occupational therapy upon discharge of the therapy sessions on 09/22/22 indicated a right hand splint to be worn daily as tolerated to prevent further contracture.
On 10/18/22 at 1:56 P.M. and interview with Licensed Practical Nurse (LPN) #233 verified Resident #30 was not wearing a splint and indicated she couldn't recall if she assisted him with applying the splint earlier in the day.
An interview with Director of Nursing (DON) on 10/19/22 at 11:00 A.M. verified the above findings and indicated the staff should have assisted him with application of his right hand splint.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #37 revealed admission date of 11/18/16 and diagnoses included Alzheimer's disease,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #37 revealed admission date of 11/18/16 and diagnoses included Alzheimer's disease, vitamin deficiency, and dementia with behavioral disturbance.
Review of Medicare Minimum Data Set (MDS) 3.0 Quarterly assessment dated [DATE] revealed Resident #37 had impaired cognition, disorganized thinking, and behavioral concerns. Resident #37 required extensive one staff assistance for eating. The assessment indicated Resident #37 had no swallowing difficulties, no significant weight changes and was on mechanically altered diet.
Review of Weight Documentation for Resident #37 revealed 04/01/22 weight of 174.4 pounds (#), 04/14/22 weight 173.3#, 08/01/22 weight 174.6#, 09/29/22 weight 169.7#, ,and 10/01/22 weight of 156.4 #. There were no additional weights for review from April 2022 to October 2022. Resident #37 had a 8.50 percent (%) weight loss in less than one month and 11.51% weight loss over six months.
Review of facility assessment Nutrition Evaluation dated 06/09/22 revealed Resident #37 was on regular diet with puree textures. Resident #37 was ordered four ounces of house supplement four times per day. Resident #37 did not have significant weight loss. Resident #37 required extensive assistance for feeding and was consuming 25 to 50% of meals.
Review of care plan dated 07/14/22 revealed Resident #37 was at nutritional risk related to history of significant weight loss. Interventions included monitor need for increased nutritional intervention, monitor weights, and diet/supplements as ordered.
Review of Dietary Progress Note dated 09/08/22 revealed Resident #37 remained on puree diet and staff reported consuming 51 to 100% of meals. Resident #37 received 8 ounces Ensure Plus three times per day and 2 ounces of ProStat daily.
Review of facility assessments from October 2022 revealed no additional evaluations or interventions for the significant weight loss identified on 10/01/22.
Review of Progress Notes from October 2022 revealed no additional evaluations or interventions for significant weight loss identified on 10/01/22.
Interview on 10/20/22 at 9:39 A.M. with Dietitian #272 confirmed Resident #37 had triggered for weight loss on 10/01/22 however had not yet completed assessment of weight loss. Dietitian #272 indicated Resident #37 was on her list for visit for 10/20/22.
Follow up interview on 10/20/22 at 10:12 A.M. with Dietitian #272 indicated they had requested a reweigh for Resident #37 however it had not yet been completed. Dietitian #272 confirmed there had been no additional interventions implemented for weight loss on 10/01/22.
Review of facility policy titled, Weight Protocol, undated, revealed residents who have experiences unplanned, significant weight loss shall be weighed weekly until stable.
Review of facility policy titled, Weight Monitoring, dated 11/13/19, revealed Dietitian would assess weights and initiate appropriate interventions and reweights will be obtained within 48 hours if at least five pound deviation was noted.
Based on observation, interview, record review, and policy review, the facility failed to ensure Resident #37 and #43 had nutritional interventions implemented timely. This affected two residents (Resident #37 and Resident #43) out of four residents reviewed for nutrition.
Findings include:
1. Review of Resident #43's medical record revealed an admission date of 10/16/19 with diagnoses including dementia, hypertension, anemia and GERD.
Review of Resident #43's Minimum Data Set 3.0 assessment, dated 09/17/22, revealed the resident had intact cognition and required supervision and set help for eating.
Review of Resident #43's weight record revealed a 04/01/22 weight of 138.6 pounds and a 08/27/22 weight of 131.4 pounds.
Review of Resident #43's 08/11/22 nutrition note by Dietitian #272 stated a weight loss notification was triggered for the resident. The resident's body mass index revealed underweight status at 17.9. The resident exhibited clinical signs of malnutrition. Added interventions included eight ounces of Boost Breeze twice a day, add the resident to weekly weight list for monitoring, and add double protein portions to diet regimen.
Review of Resident #43's September 2022 physician orders revealed the intervention for Boost Breeze and weekly weights were not ordered until 09/22/22. The resident was never order the recommended double protein.
Interview on 10/19/22 at 10:22 A.M. with Dietitian #272 revealed she notified the facility on 08/11/22 of the recommend interventions for Resident #43 which included double protein, boost breeze twice a day, and weekly weights. She confirmed it is her expectation that the interventions would be implemented timely.
Interview on 10/18/22 at 1:56 P.M. the Director of Nursing (DON) verified Resident #43's dietary interventions for weekly weights and boost breeze were not timely implemented and confirmed the intervention to add double protein to the residents diet was not implemented at all.
Review of the facility's undated, weight protocol, revealed residents who experience unplanned significant weight loss or gradual weight loss shall be weighed weekly until stable. A report indicating significant weight variances shall be copied and distributed to the Administrator, DON, Nutrition Professional, Director of Food and Nutrition Services and other interdisciplinary team members per facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy and procedure review, the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication erro...
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Based on observation, interview, record review, and facility policy and procedure review, the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 6.9% and included two medication errors of 29 medication administration opportunities. This affected two residents (#11 and #26) of six residents observed during medication administration.
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 05/11/21 with diagnoses including anxiety disorder, hypertension, major depressive disorder, and epilepsy.
Review of the October 2022 physician's orders revealed Resident #11 had an order to receive Hydralazine HCL 25 milligrams (mg) by mouth twice daily for hypertension.
Observation on 10/19/22 at 8:25 A.M. revealed Licensed Practical Nurse (LPN) #233 administered Resident #11 Hydralazine HCL 50 mg.
Interview on 10/19/22 at 8:38 A.M. with LPN #233 confirmed she administered Resident #11 Hydralazine HCL 50 mg when he was ordered to receive Hydralazine 25 mg.
Review of the facility policy titled, Guidelines for Medication Administration dated 08/2020, revealed at a minimum the five rights, which include, right resident, right drug, right dose, right route, and right times should be applied to all medications administered and reviewed at three steps in the process of preparation.
2. Review of Resident #26's medical record revealed an admission date of 05/04/22 with diagnoses including diabetes mellitus, hypertension and dementia.
Review of Resident #26 October 2022 physician's order revealed an order for Insulin Lispro 100 units/milliliter insulin pen with instructions to inject 10 units subcutaneously with meals for diabetes mellitus.
Observation on 10/19/22 at 7:52 A.M. revealed LPN #215 administered medications to Resident #26. The LPN obtained the insulin pen and administered 10 units to Resident #26 without first priming the needle with two units of insulin prior to administration to ensure the correct dose of the medication was administered.
Interview on 10/19/22 at 7:59 A.M. with LPN #215 confirmed she did not prime Resident #26's insulin pen before administering it to the resident
Interview on 10/19/22 at 10:00 A.M. Chief Clinical Officer #247 revealed that insulin pens should be primed before use.
Review of the insulin pen manufacturer instructions for use revealed the insulin pen needed to be primed before injection. Priming meant removing the air from the needle and cartridge that might collect during normal use. It was important to prime the pen before each injection so that it would work correctly. If the pen was not primed before each injection, it may cause you to get too much or too little insulin.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary kitchen area and ensure appropriate glove usage. This had the potential to affect all 57 of 57 re...
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Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary kitchen area and ensure appropriate glove usage. This had the potential to affect all 57 of 57 residents receiving meals from kitchen, as the facility identified no residents with nothing by mouth diet orders.
Findings include:
Observations on 10/17/22 from 11:30 A.M. to 12:15 P.M. of facility kitchen revealed significant dried food debris and dark grease build up on floors, under equipment, and in corners of kitchen. The floor left a sticky substance on shoes throughout kitchen. Observation of juice machine revealed dried juice spray on wall next to the machine. Observed cleaning cloths and food wrappers on ground stuck between prep table holding microwave and wall. Observation of large food preparation table in middle of kitchen revealed storage drawer handles were sticky and had crumbs within drawers, there was dried food splatter and debris on lower shelving of tables and legs, and an open undated container of liquid margarine on lower-level shelf. Observation of oven revealed dark grease buildup running down front observation windows. There was food splatter and crumbs on front and sides of oven. Observation of deep fryer revealed dark grease with food floating. The bottom of the fryer was not visible through cooking grease. There was significant dark grease build up on back and sides of fryer. The deep fryer control unit was coated with cooking grease overspray. Observation of kitchen mixer revealed to be covered however had dried food debris on base of mixer. Observation of steam table revealed food splatter was dripping down front and sides. The lower-level shelf revealed dripping water from steam table caused significant rust build up. Observation of stove range revealed rust build up on grates. Observation of dish washing area revealed significant food debris and wrappers under equipment including dish machine and sinks. Observation of storage for cleaning supplies revealed two brooms and mop with bucket on floor in front of hand washing sink and significant food debris on floor. Observation of dry food storage revealed chemical rack with large spill of unknown red substance underneath.
Observation of walk-in cooler revealed food debris and liquid red substance dripped on floor below metal racks. Observation of walk-in freezer revealed French fries and other food debris on floor.
Observation on 10/17/22 at 12:00 P.M. of Dietary #267 was serving lunch meal. Dietary #267 was observed wearing pair of gloves while serving. Dietary #267 pushed the door to kitchen open and gave plate to dietary aide delivering cart. Dietary #267 returned to kitchen wearing same gloves and adjusted pants with gloved hands. Dietary #267 then walked over to rack holding bread and gathered items to prepare burger for resident. Dietary #267 prepared burger using same gloved hands then continued to serve rest of tray line without changing gloves.
Interview on 10/17/22 at 12:15 P.M. with Food Service Supervisor (FSS) #226 confirmed findings with cleanliness and glove use. FSS #226 indicated there has been an issue with cleanliness and there are no current formal cleaning schedules in place. FSS #226 indicated equipment is cleaned as needed.
Interview on 10/20/22 at 9:39 A.M. with Dietitian #272 revealed there was a monthly sanitation audit completed. Dietitian #272 indicated there had been concerns with kitchen cleanliness and concerns were addressed with FSS #226.
Review of facility policy titled, Department Cleaning Schedule, undated, revealed a schedule outlining cleaning assignments would be posted and completed to maintain sanitation of the Food and Nutrition Services Department. The Director of Food and Nutrition Services shall be responsible for assuring the cleaning schedule is maintained at all times.
Review of facility policy Refrigerated Storage undated revealed refrigerated food shall be stored in a manner that optimizes food safety.
Review of facility policy Floors undated revealed all kitchen floors shall be cleaned after each meal and as needed.
Review of facility policy Disposable Gloves undated revealed disposable gloves shall be used for only one task and shall be discarded when damaged, soiled, or when interruptions occur in operation.
Nov 2019
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure personal resident information was communicated i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure personal resident information was communicated in a way to protect the confidentiality of the information and the dignity of the resident. This affected one of 50 facility residents, Resident #31. Facility census was 50.
Findings include:
Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, major depressive disorder, diabetes mellitus, clostridium difficile colitis and speech and language development delay due to hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/19 revealed the resident had the absence of useful hearing and was cognitively intact. The resident required extensive assistance of two staff for bed most activities of daily living.
Observation on 11/24/19 at 11:55 P.M. revealed a sign posted on the hallway wall, outside Resident 31's room indicating: Resident is deaf, please get resident's attention as soon as you enter the room, can read lips, utilizes a white board for communication, is a two person transfer for safety, and flickering lights is okay. This was verified at the time of observation by Registered Nurse #29.
Review of the policy titled, Confidentiality of Personal and medical records dated 03/23/19 revealed paper notes or reminders with resident's personal information should not be viewable by unauthorized persons.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure as needed (PRN) medication orders for psychotropic drugs were limited to 14 days and failed to timely follow pharmacy recommen...
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Based on record review and staff interview, the facility failed to ensure as needed (PRN) medication orders for psychotropic drugs were limited to 14 days and failed to timely follow pharmacy recommendations. This affected one Resident (Resident #27) of five residents reviewed for unnecessary medications.
Findings include:
Review of Resident's #27 medical record revealed an admit date of 05/17/17 with diagnoses of major depression disorder, psychosis and dementia. The Minimum Data Set (MDS) 3.0 assessment revealed the resident had moderate depression, trouble falling asleep and concentrating. Resident #27 exhibited physical and verbal behaviors directed toward others.
Review of the signed physician orders for May 2019 revealed Resident #27 had a PRN order dated 05/23/29 for Ativan (antianxiety medication) 0.5 milligram (mg) every six hours as needed.
Review of the Pharmacist's Medication Regimen Review dated 06/21/19 revealed the order for Ativan 0.5 mg every six hours as need was due for a re-evaluation.
Review of the pharmacy note to the attending physician dated 06/21/19 revealed the certified nurse practitioner (CNP) addressed the recommendation on 07/22/19 and wrote a new order for Ativan.
Review of Medication Administration Record for May, June and July 2019 revealed Ativan was administered four times in May, twelve times in June and four times in July.
Interview with Director of Nursing on 11/25/19 at 4:10 P.M. verified the Ativan order should be limited to 14 days and was not addressed timely by the CNP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to maintain a clean and sanitary environment for Residents #5, #6, #10, #11, #12, #13, #14, #17, #18, #20, #28, #35, #38, #40, #148, #248. ...
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Based on observation and staff interview the facility failed to maintain a clean and sanitary environment for Residents #5, #6, #10, #11, #12, #13, #14, #17, #18, #20, #28, #35, #38, #40, #148, #248. This affected 16 of 50 residents.
Findings include:
An environmental tour was conducted with Maintenance Director (MD) #35 on 11/25/19 between 6:58 A.M. and 7:22 A.M. The following was observed and verified by MD #35 during the environmental tour.
1. The rooms belonging to Residents #5, #10, #12, #14, #17, #28 and #148 contained privacy curtains that were stained to various degrees by unknown substances.
2. The room belonging to Resident #35 had a crack in the tile floor.
3. The window seal and ledge was cracked in half in Resident #11's room.
4. The sheets on Resident #13's bed were noticeable stained by an unknown substance.
5. The room belonging to Residents #6 and #40 had numerous broken vertical blinds.
6. The toilet in the room belonging to Residents #18 and #20 was stained dark brown in color.
7. The toilet seat in the room belonging to Resident #38 had dried fecal matter on it.
8. The bathroom floor in Resident #248's room was significantly stained and dirty.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interview the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner and that all food was labeled, dated and stored properly. This had...
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Based on observation and staff interview the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner and that all food was labeled, dated and stored properly. This had the potential to affect all residents. The facility census was 50.
Findings include:
During the initial kitchen tour conducted on 11/24/19 between 8:00 A.M. and 8:19 A.M. the following was observed and verified with [NAME] #22.
1. A half of a ham in the cooler was covered in Saran wrap with no date or label.
2. Four open packages of turkey deli meat were in the cooler with no date or label.
3. An open package of mustard was in the dry storage area with no date.
4. A package of Brussel sprouts in the freezer was open, undated and exposed to air.
5. The air vents located above the food prep area and the steam table used to store cooked food prior to meal service were rusted and had noticeable instances of dust and other dirt that was easily flaked off with the touch of a finger.
Review of the undated policy titled Food storage revealed food will be stored under sanitary conditions.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, the facility failed to ensure infection control practices were followe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, the facility failed to ensure infection control practices were followed for isolation precautions for one resident (Resident #31) with clostridium difficile (C-diff). This had the potential to affect all 50 residents who resided in the facility.
Findings include:
Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, major depressive disorder, diabetes mellitus, clostridium difficile colitis and speech and language development delay due to hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/19 revealed the resident had the absence of useful hearing and was cognitively intact. The resident required extensive assistance of two staff for most activities of daily living. Review of Resident #31's care plan dated 11/19/19 revealed contact isolation.
Observation on 11/24/19 at 9:15 A.M. revealed Housekeeper #63 was wearing the same pair of gloves coming out of the room of Resident #31 that she wore going into the room and she was not wearing personal protective equipment (PPE). There was a sign on the door for isolation and PPE was stocked just outside the door. Interview with Housekeeper #63 at the time of the observation revealed she was never trained on isolation precautions and did not know she was supposed to wear PPE or that she should wash her hands prior to exiting the room.
Observation on 11/24/19 at 11:55 A.M. revealed there was there was no soap to wash hands in the room of Resident #31. This was verified by Registered Nurse #29 immediately after the observation.
Review of the policy titled, Isolation Precautions dated 2019 revealed that PPE should be worn when entering a room with a resident on contact precautions.
Review of the facility policy titled, Handwashing/Hand hygiene dated 03/23/19 revealed that soap should be assessable and hand washing should occur before and after entering isolation precaution settings.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0576
(Tag F0576)
Minor procedural issue · This affected most or all residents
Based on resident and staff interview the facility failed to ensure mail was delivered to residents on Saturdays. This affected five residents (Residents #11, #34, #36, #45 and #249) and had the poten...
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Based on resident and staff interview the facility failed to ensure mail was delivered to residents on Saturdays. This affected five residents (Residents #11, #34, #36, #45 and #249) and had the potential to affect all 50 residents residing in the facility.
Findings include:
During the resident council portion of the annual survey conducted on 11/25/19 between 1:00 P.M. and 1:30 P.M. with Residents #11, #34, #36, #45 and #249 multiple concerns were expressed that residents were not receiving mail on Saturdays.
Interview with Activities Director #49 on 09/12/18 at 1:45 P.M. revealed she was in charge of passing out resident mail on they days she worked. Activities Director #49 verified resident mail was not being delivered on Saturdays and that often their was a stack of mail to be passed out on Monday mornings when she came to work.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on record review and staff interview the facility failed to ensure posted nursing staff information was updated timely. This had the potential to affect all residents. The facility census was 50...
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Based on record review and staff interview the facility failed to ensure posted nursing staff information was updated timely. This had the potential to affect all residents. The facility census was 50.
Findings include:
Observation of the posted nursing staff information on 11/25/19 at 10:15 A.M. revealed the posted nursing staff information was from 11/24/19.
Interview on 11/25/19 at 10:17 A.M. with Assistant Director of Nursing #43 verified the posted nursing staff information was not up to date.
MINOR
(C)
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected most or all residents
Based on observation and staff interview the facility failed to ensure the garbage disposal area was maintained in a clean and sanitary condition. This had the potential to affect all 50 residents res...
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Based on observation and staff interview the facility failed to ensure the garbage disposal area was maintained in a clean and sanitary condition. This had the potential to affect all 50 residents residing in the facility.
Findings include:
Observation of the facility garbage disposal area on 11/24/19 at 10:00 A.M. revealed two dumpsters positioned side by side, both overflowing with garbage bags and with numerous bags of garbage laying on the ground surrounding the dumpsters.
Interview with Dietary [NAME] #22 and the Administrator verified the above observations at the time of discovery.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • $4,922 in fines. Lower than most Ohio facilities. Relatively clean record.
Concerns
- • 31 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Phoenix Of Fairlawn's CMS Rating?
CMS assigns PHOENIX OF FAIRLAWN an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Phoenix Of Fairlawn Staffed?
CMS rates PHOENIX OF FAIRLAWN's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the Ohio average of 46%.
What Have Inspectors Found at Phoenix Of Fairlawn?
State health inspectors documented 31 deficiencies at PHOENIX OF FAIRLAWN during 2019 to 2025. These included: 1 that caused actual resident harm, 26 with potential for harm, and 4 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Phoenix Of Fairlawn?
PHOENIX OF FAIRLAWN is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 80 certified beds and approximately 55 residents (about 69% occupancy), it is a smaller facility located in AKRON, Ohio.
How Does Phoenix Of Fairlawn Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, PHOENIX OF FAIRLAWN's overall rating (4 stars) is above the state average of 3.2, staff turnover (47%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Phoenix Of Fairlawn?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Phoenix Of Fairlawn Safe?
Based on CMS inspection data, PHOENIX OF FAIRLAWN has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Phoenix Of Fairlawn Stick Around?
PHOENIX OF FAIRLAWN has a staff turnover rate of 47%, which is about average for Ohio nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Phoenix Of Fairlawn Ever Fined?
PHOENIX OF FAIRLAWN has been fined $4,922 across 2 penalty actions. This is below the Ohio average of $33,128. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Phoenix Of Fairlawn on Any Federal Watch List?
PHOENIX OF FAIRLAWN is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.