Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbors At Fairlawn The during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced several significant events, including hospital transfers, refusals of treatment, and not returning from a leave of absence, without required notifications being made to the physician or the resident's daughter. Documentation did not show that the physician or family were informed, and staff interviews confirmed inconsistencies in the notification process.
A resident with multiple chronic conditions, who was permitted unsupervised community outings, did not return from an LOA as expected. Staff failed to follow facility policy by not promptly contacting the resident, his emergency contacts, or local hospitals when he was overdue. The lack of timely action and communication resulted in a delay in discovering that the resident had passed away at a hospital.
A facility failed to provide sufficient staffing, resulting in inadequate care for residents, including missed showers, delayed incontinence care, and neglect of personal hygiene. Residents reported not receiving scheduled showers and being left in soiled conditions due to staff shortages. Observations confirmed that residents were not checked or changed as required, highlighting significant staffing issues.
The facility failed to provide scheduled showers for residents dependent on staff for ADLs, affecting four residents. Due to staffing shortages, residents were often given bed baths instead of showers, leading to inadequate personal hygiene. Interviews with residents and CNAs confirmed the issue, and observations noted poor hygiene in some residents.
A facility failed to implement fall interventions for a resident with a history of falls and cognitive impairment. The resident's care plan included wearing hipsters, having a call light within reach, and removing the wheelchair from the room while in bed. However, observations revealed these interventions were not followed, as the wheelchair was left next to the bed, the call light was not accessible, and the resident was not wearing hipsters. The resident had a history of multiple falls, some with injuries, and the Director of Nursing confirmed the interventions were not being implemented as required.
The facility failed to provide timely incontinence care for three residents, leading to a deficiency. A resident with an indwelling catheter was found with a bowel movement and not changed since the start of the CNA's shift. Another resident was found with a saturated brief and red skin due to lying on wrinkled bedding. A third resident was found in a urine-saturated gown and bedding, having waited all day to be changed. The DON stated residents should be checked and changed by 8:30 A.M., but this was not followed.
A resident with psychiatric conditions was emergently discharged to a hospital without proper notification to their legal guardian or mother. The facility placed the discharge notice in the resident's belongings, which were not accessible to the resident or their representatives. Interviews revealed that the discharge notice was not sent by certified mail, leading to confusion and a lack of proper discharge planning.
A facility failed to collaborate with a hospital to assess a resident's condition before refusing their return after hospitalization. The resident, with a history of mental health issues, was deemed stable by the hospital, but the facility did not perform an onsite visit or communicate effectively. An immediate discharge notice was improperly handled, and the facility did not evaluate the resident's condition as required by policy.
A resident with severe cognitive impairment and mobility issues sustained a significant leg injury during a manual transfer by two STNAs, contrary to her care plan which required a mechanical lift. The incident highlighted a lack of communication and training regarding transfer procedures, as confirmed by the DON. The facility's policy on accident prevention was not followed, leading to the resident's hospitalization for treatment.
A facility failed to administer treatments as ordered for a resident with multiple diagnoses, including skin cancer and dementia. The resident's treatment for biopsy sites was not completed on several occasions, as confirmed by nursing staff and other residents. This deficiency was part of a complaint investigation affecting one of four residents reviewed.
The facility did not secure resident medical records, affecting multiple residents. Sensitive information, including medication details, therapy information, and bowel movement records, was found in an easily accessible file holder near the main entrance. The administrator confirmed the records were unsecure and accessible to the public.
A resident with an indwelling urinary catheter did not have appropriate physician's orders or monitoring in place, leading to inadequate catheter care. The resident reported that staff did not clean the catheter entry site, and the collection bag and tubing had not been changed since admission. Staff confirmed the lack of specific orders for catheter care, contrary to facility policies requiring such interventions.
The facility failed to date and monitor the replacement of oxygen tubing for three residents, despite having policies requiring weekly changes. A resident with chronic respiratory conditions and another with COPD were found with undated tubing, confirmed by an LPN and an RN. Additionally, a third resident's records showed no documented tubing changes for over a month, contrary to facility policy.
A facility failed to monitor a resident's use of anticoagulant and psychotropic medications, resulting in a deficiency. The resident, with a complex medical history, was prescribed Eliquis and Sertraline but lacked monitoring for side effects. Staff interviews revealed that point-of-care charting did not include side effect monitoring, and necessary orders were missing. The DON confirmed the expected monitoring was not completed, contrary to facility policies.
A facility failed to post adequate signage for a resident on enhanced-barrier precautions (EBP) due to an indwelling catheter. Observations revealed a PPE hanger on the resident's door without any sign indicating the required precautions. Staff relied on verbal communication and the Kardex for information on transmission-based precautions. The facility's policy lacked guidance on signage, contributing to the deficiency, as confirmed by the DON.
Failure to Notify Physician and Family of Resident Status Changes
Penalty
Summary
The facility failed to notify a resident's physician and daughter of significant changes in the resident's status, as required. The resident, who had diagnoses including chronic obstructive pulmonary disorder, diabetes, and congestive heart failure, was cognitively intact and listed as his own responsible party, with his daughter as the secondary contact. On multiple occasions, including when the resident was sent to the emergency room, refused treatments or medications, and did not return from a leave of absence, there was no evidence in the medical record that the physician or the resident's daughter were notified of these events. Progress notes documented the resident's refusals and hospital transfers, but lacked documentation of required notifications to the physician and family member. Additionally, the resident's daughter ultimately contacted the facility to report the resident's death, further indicating a lack of timely communication from the facility regarding the resident's status. Interviews with staff, including the Director of Nursing, confirmed inconsistencies in the notification process for significant changes, hospitalizations, refusals of treatment, and absences from the facility.
Failure to Ensure Resident Safety After Missed Return from LOA
Penalty
Summary
The facility failed to ensure the safety of a resident who did not return in a timely manner after a leave of absence (LOA). The resident, who had diagnoses including chronic obstructive pulmonary disorder, diabetes, and congestive heart failure, was cognitively intact and independent in transfers. His care plan allowed for unsupervised outings in his powerchair, and he routinely took public transportation to visit a nearby city, always returning before midnight. On the day in question, the resident signed out at 11:55 A.M. but did not return by midnight as expected. Staff actions were inconsistent with facility policy and expectations. The LPN on duty noted the resident's absence late at night, attempted to call his cell phone without success, and texted the DON, who instructed her to call local hospitals. However, the LPN did not follow through with these instructions, citing being too busy and assuming the day shift would handle it. There was no evidence that the resident's emergency contacts or local hospitals were called during the night. The DON was not updated until the following morning, at which point it was discovered that the resident had passed away at a hospital after being brought in from a grocery store. Interviews with staff revealed uncertainty about the care plan and the appropriate steps to take when a resident did not return from an LOA. The facility's policy required documentation of the resident's departure, destination, and expected return time, as well as staff knowledge of the resident's whereabouts. Despite these requirements, the lack of timely follow-up and communication contributed to the failure to ensure the resident's safety after he did not return as anticipated.
Inadequate Staffing Leads to Neglect in Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in inadequate assistance with showers, bathing, incontinence care, dressing, personal hygiene, and changing of soiled sheets. This deficiency affected six residents and had the potential to impact all 73 residents in the facility. Observations and interviews revealed that residents did not receive scheduled showers or were forced to accept bed baths due to staffing shortages. For instance, Resident #46 did not receive scheduled showers on multiple occasions, and Resident #38 reported feeling forced to accept bed baths instead of showers. Resident #9 experienced significant neglect in personal hygiene and incontinence care. On one occasion, Resident #9 was found with oily hair, strong body odor, and dirty fingernails, indicating a lack of proper bathing. Additionally, Resident #9 was left in soiled bedding for an extended period after spilling coffee and having a bowel movement, as the assigned CNA was too busy to provide timely care. Similar issues were observed with Resident #49, who was found with saturated briefs and red, creased skin due to prolonged exposure to urine and bowel movements. The facility's staffing issues were further highlighted by the experiences of Residents #49 and #56, who were left in soiled conditions for extended periods. Resident #49's brief was saturated with urine and bowel movement, and the resident's skin showed signs of neglect. CNA #241 admitted to being unable to provide timely care due to being busy with other residents. Resident #56 also reported being saturated with urine and waiting all day for assistance. The Director of Nursing confirmed that residents should be checked and changed every two hours, but this standard was not met due to insufficient staffing.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and showers, for residents who were dependent on staff. This deficiency affected four residents who were reviewed for ADLs. The facility's census was 73, and the issue was identified through observations, resident and staff interviews, and record reviews. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain good grooming and hygiene. Resident #46, who was cognitively intact and required supervision or touch assistance with bathing, did not receive scheduled showers on two occasions due to staff shortages. Interviews with the resident and a CNA confirmed the lack of showers as per the resident's preference. Similarly, Resident #38, who was dependent on staff for bathing, did not receive scheduled showers and was instead given bed baths, which the resident felt were inadequate. The CNA attributed this to insufficient staffing, which led to a preference for bed baths over showers due to time constraints. Resident #9, who required substantial assistance with bathing, was observed with poor hygiene, including oily hair and a strong body odor, indicating missed showers. The resident confirmed not receiving baths as scheduled. Resident #13, who required assistance with personal care, also missed several scheduled showers due to staff shortages, as confirmed by the Director of Nursing. The facility's failure to provide scheduled showers and maintain personal hygiene for these residents was documented as a deficiency under a complaint investigation.
Failure to Implement Fall Interventions for At-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident with a history of falls and who was at risk for falls. The resident, who was moderately cognitively impaired and used a wheelchair for mobility, had a care plan that included interventions such as wearing hipsters, having a call light within reach, a 'call before fall' sign in the room, and removing the wheelchair from the room while in bed. However, during observations, it was noted that the resident's wheelchair was next to the bed, the call light was not within reach, and there was no 'call before fall' sign in the room. Additionally, the resident was not wearing hipsters, and the CNA confirmed that the resident had not worn hipsters since moving to a different hall. The resident had a documented history of multiple falls, some resulting in injuries, over a period of several months. Despite this history, the interventions outlined in the care plan were not consistently implemented. The Medication Technician and CNA both failed to ensure the resident's environment was free from fall hazards, as they left the wheelchair and walker within reach and did not assist the resident in wearing hipsters. The Director of Nursing confirmed that the resident was at high risk for falls and that the interventions were still in place, yet they were not being followed, leading to noncompliance with the facility's policy on accidents and supervision.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for three residents, leading to a deficiency in care. Resident #9, who was cognitively intact and had an indwelling catheter, was found lying in bed with an odor of stool. Despite confirming a bowel movement, the resident had not been changed since the start of the CNA's shift at 6:00 A.M. It was only after the surveyor's request that the CNA attended to the resident, revealing a large bowel movement. Resident #49, who was moderately cognitively impaired and always incontinent of bowel and bladder, was found with a saturated brief and red, creased skin due to lying on wrinkled bedding. The CNA admitted this was the first time she had checked on the resident for incontinence needs during her shift, as she was occupied with other residents. Resident #56, who was cognitively intact and frequently incontinent, was found sitting in a urine-saturated gown and bedding. The resident reported waiting all day to be changed, and the CNA confirmed this was the first time she had attended to the resident for incontinence care that day. The Director of Nursing stated that residents should be checked and changed by 8:30 A.M., but this was not adhered to, as evidenced by the observations.
Failure to Properly Notify Resident and Representatives of Emergency Discharge
Penalty
Summary
The facility failed to properly notify Resident #74 and their representatives of an emergency discharge. Resident #74, who had a legal guardian, was transferred to a hospital for an acute psychiatric stay and did not return to the facility. The facility did not provide written notification of the discharge to the resident's guardian or mother, nor did they ensure the resident received the discharge notice. The discharge notice was placed in the resident's belongings, which were not accessible to the resident or their representatives. Resident #74 had a history of schizoaffective disorder, mood disorder, and other psychiatric conditions. The resident exhibited behaviors such as verbal aggression, refusal of care, and wandering. On 12/09/24, the resident's condition worsened, leading to an emergency psychiatric admission. The facility determined that the resident's behaviors posed a risk to others and initiated an emergency discharge without proper notification to the resident's guardian or mother. Interviews with facility staff and the resident's representatives revealed that the discharge notice was not sent by certified mail, and there was no evidence that the guardian or mother received it. The facility's failure to communicate the discharge and appeal rights to the resident's representatives resulted in confusion and a lack of proper discharge planning. The resident's mother was unaware of the discharge and expected the resident to return to the facility.
Failure to Collaborate with Hospital for Resident's Return
Penalty
Summary
The facility failed to collaborate with the hospital to ascertain the accurate status of a resident's condition before refusing to allow the resident to return to the facility after hospitalization. The resident, who had a history of schizoaffective disorder, anxiety, and other mental health issues, was transferred to the hospital for an acute psychiatric stay due to worsening psychotic behaviors. Despite the hospital's assessment that the resident was stable and ready for discharge back to the facility, the facility did not perform an onsite visit or communicate effectively with the hospital to evaluate the resident's condition. The facility issued an immediate discharge notice to the resident, citing safety concerns, but failed to properly notify the resident's legal guardian and mother. The discharge notice was placed in the resident's belongings and not directly communicated to the resident or their family. Interviews with facility staff revealed that there was no attempt to collaborate with the hospital to assess the resident's mental health status or determine if the resident was stable for discharge back to the facility. The facility's actions were based on their assessment of the resident's behavior prior to hospitalization, without considering the hospital's findings. The facility's policy required them to evaluate the resident's condition to ensure their needs were within the facility's scope of care, which they failed to do. The lack of communication and collaboration with the hospital and the improper handling of the discharge notice contributed to the deficiency. The resident's legal guardian and mother expressed a desire for the resident to return to the facility, but the facility did not take the necessary steps to facilitate this process.
Failure to Ensure Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a significant injury. The resident, who was severely cognitively impaired and dependent on two staff members for transfers, sustained a 10-centimeter laceration to her right calf during a staff-assisted transfer. This injury required emergency medical attention and resulted in the resident being transferred to a local hospital for treatment, which included 21 sutures. The resident's care plan, initiated prior to the incident, indicated a need for one-person assistance for certain activities and two-person assistance with a mechanical lift for transfers. However, there were no specific physician orders detailing the transfer method. On the night of the incident, two State Tested Nursing Assistants (STNAs) manually transferred the resident without using the mechanical lift, which was contrary to the care plan. During the transfer, the resident sustained the laceration, and the staff were unable to explain how the injury occurred. Interviews with staff revealed a lack of communication and training regarding the resident's transfer status. The Director of Nursing (DON) confirmed that the resident required a mechanical lift for transfers, but this was not communicated effectively to the staff. Additionally, staff members reported not receiving recent training on transfer techniques or the use of assistive devices. The facility's policy on accidents and supervision emphasized the need for individualized care plans and adequate supervision to prevent accidents, which was not adhered to in this case.
Failure to Administer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that all treatments were completed according to physician orders for Resident #39. This resident, who was admitted with diagnoses including malignant neoplasm of the skin, hypothyroidism, dementia, Alzheimer's disease, and hypertension, required various levels of assistance for daily activities due to impaired cognition. The physician orders specified that biopsy sites should be cleansed with soap and water, followed by the application of Mupirocin 2% cream, and covered with a bandage daily for 10 to 14 days post-procedure. However, the Treatment Administration Record (TAR) for August and September 2024 showed that these treatments were not completed on several specified dates. Interviews with nursing staff, including RNs and LPNs, confirmed that there were instances when Resident #39 did not receive the prescribed treatment for her biopsy sites. Additionally, interviews with other residents revealed that they also experienced times when their treatments were not completed as ordered. This deficiency was investigated under Complaint Number OH00157498, affecting one resident of the four reviewed for treatment administration, within a facility census of 69.
Breach of Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident medical records, affecting thirteen out of thirty-six sampled residents. During an observation, it was noted that a plastic file holder on the wall near the main entrance contained unsecured files. These files included sensitive information such as specific medications taken by several residents, skilled therapy information for one resident, and details concerning bowel movements for two residents. The administrator confirmed in an interview that these records were unsecure and easily accessible to the general public.
Inadequate Urinary Catheter Care for Resident
Penalty
Summary
The facility failed to ensure appropriate orders and monitoring were in place for a resident with a urinary catheter. Resident #112, who was moderately cognitively intact, had an indwelling catheter but lacked physician's orders for changing the catheter bag monthly or as needed, monitoring urine, or changing the catheter prior to a specified date. Interviews with the Director of Nursing and staff revealed that the resident was on enhanced barrier precautions due to the catheter, but there were no specific orders regarding catheter care in the medical record before the deficiency was identified. Observations and interviews indicated that the resident's catheter care was inadequate. The resident reported that staff did not clean the catheter where it entered her body, and the collection bag and tubing had not been changed since her admission. Staff interviews confirmed that the resident had the catheter since admission, and there were no orders for changing the tubing or collection bag. The facility's policies on catheterization and catheter irrigation required interventions to prevent complications and specific orders for catheter care, which were not followed in this case.
Failure to Date and Replace Oxygen Tubing
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically oxygen tubing, was dated and monitored for routine replacement, affecting three residents. Resident #35, who was cognitively intact and had a history of chronic respiratory conditions, was observed with undated oxygen tubing despite a physician's order for continuous oxygen use. An LPN confirmed that the tubing should have been dated and changed weekly, but no such documentation was present. Similarly, Resident #113, who had multiple diagnoses including COPD and acute respiratory failure, was found with undated oxygen tubing. Although the resident had an order for oxygen use as needed, there were no orders for routine tubing replacement. An RN confirmed the absence of a date on the tubing. Resident #19, with a history of COPD and other health issues, also had undated oxygen tubing, and records showed no documented tubing changes for over a month. The facility's policy required weekly changes of oxygen tubing, which was not adhered to in these cases.
Failure to Monitor Anticoagulant and Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor a resident's use of anticoagulant and psychotropic medications, leading to a deficiency in medication management. Resident #113, who was cognitively intact, had a complex medical history including type two diabetes, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, chronic congestive heart failure, depression, insomnia, and hyperlipidemia. Despite being prescribed medications such as Eliquis (an anticoagulant) and Sertraline hydrochloride (an antidepressant), there was no evidence of monitoring for side effects in the resident's medical records, medication administration records, or treatment administration records. Interviews with staff revealed that the facility's point-of-care charting did not include monitoring for medication side effects, and there were no orders on the MAR or TAR for such monitoring. The Director of Nursing confirmed that the expected monitoring for signs and symptoms of bleeding and side effects was not completed, as the necessary ancillary orders had not been entered. The facility's policies on medication monitoring and adverse drug events emphasized the importance of ongoing evaluation and documentation, which were not adhered to in this case.
Inadequate Signage for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure adequate signage was posted to instruct staff and visitors of proper precautions for a resident on enhanced-barrier precautions (EBP). This deficiency was identified during an observation where Resident #112's door had a yellow personal protective equipment (PPE) hanger with various PPE items, but no sign was present to communicate the reason for the PPE or the specific precautions required. The Director of Nursing (DON) confirmed that signage should have been present, as Resident #112 was on EBP due to an indwelling catheter. Interviews with staff, including State tested Nursing Assistants (STNAs) and a Licensed Practical Nurse (LPN), revealed that information about transmission-based precautions was typically communicated verbally or through the Kardex, rather than through signage. The facility's policy on Enhanced Barrier Precautions, revised in March 2024, did not provide guidance on the use of signage, which was a contributing factor to the deficiency. The CDC guidance on EBP emphasizes the importance of signage to inform individuals entering a resident's room about the necessary precautions and recommended PPE. The lack of signage for Resident #112, who had been on EBP since admission, indicates a gap in the facility's infection prevention and control program, as confirmed by the DON during a follow-up interview.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fairlawn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberland Ridge Nursing & Rehabilitation | 0.8 mi | ★★★★★ | 23 | 0 |
| Phoenix Of Fairlawn | 0.8 mi | ★★★★★ | 0 | 0 |
| Concordia At Sumner | 1.1 mi | ★★★★★ | 10 | 0 |
| Village At St Edward Nrsg Care | 1.3 mi | ★★★★★ | 9 | 0 |
| Copley Health Center | 1.3 mi | ★★★★★ | 6 | 0 |
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