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 Phoenix Of Fairlawn during CMS and state inspections, most recent first.
Staff did not follow the facility's smoking policy, as cigarette butts were found in multiple mulch beds and a trash can with ash marks and flammable materials was observed outside the designated smoking area. The Maintenance Director confirmed these findings, and review of the policy showed smoking was only allowed in a specific patio area.
Multiple environmental hazards were identified, including a deteriorating outdoor smoking area with termite-damaged wooden structures and excessively hot water temperatures in several resident rooms. Facility staff confirmed the issues, and it was noted that a bid to repair the smoking area was not acted upon, with funds instead used for other purchases. Additional concerns included wall damage and disrepair in resident bathrooms and rooms.
Two residents were issued NOMNC letters that did not include the required name and telephone number of the Quality Improvement Organization (QIO), preventing them from having the necessary information to appeal the end of their skilled services. This omission was confirmed by facility staff during interviews.
A resident with severe cognitive impairment was found wearing gardening gloves secured with Velcro, restricting hand movement and preventing self-removal, to stop finger chewing. The intervention was implemented without a physician's order or a documented restraint assessment, contrary to facility policy and regulatory requirements. The DON confirmed the lack of required documentation and assessment.
A resident with severe cognitive impairment and multiple diagnoses, including schizophrenia, was admitted to the facility. The PASARR assessment failed to document the resident's schizophrenia diagnosis, despite it being present in the medical record and confirmed by the DON.
The facility did not fully implement fall prevention interventions as outlined in care plans for two residents, including missing physician orders for certain interventions and failure to consistently ensure environmental safety measures, such as securing a telephone cord. Staff interviews and repeated observations confirmed these deficiencies.
A resident with chronic pain and multiple medical conditions did not receive scheduled hydrocodone-acetaminophen as ordered due to staff failing to reorder the medication on time and not utilizing available stock or contacting the physician for a one-time dose, resulting in a prolonged period without pain relief.
The facility did not update medical records to include appropriate diagnoses for two residents receiving quetiapine, despite pharmacist recommendations and physician agreement. Both residents continued to receive the antipsychotic medication without the required supporting documentation in their records, as confirmed by the DON.
A resident with multiple neurological and cognitive diagnoses was not provided with nectar thick liquids as ordered, receiving thin consistency juice instead. Staff recognized the error after the resident had already consumed most of the unthickened beverage.
Staff failed to follow infection control protocols during wound care and bed linen changes for two residents. An LPN did not change gloves or perform hand hygiene as required while providing wound care, and clean dressings came into contact with bed linens. In a separate case, a CNA left a pile of soiled linens on the floor after changing a resident's bed, instead of placing them in a linen hamper or bag as per facility policy.
A resident with severe cognitive impairment was transported by a CNA in a shower chair while wearing only an untied hospital gown, leaving the resident's buttocks exposed and personal items placed in their lap. This occurred in a public hallway and was confirmed by an RN, violating the facility's policy on resident rights and dignity.
A resident with diabetes and multiple comorbidities did not receive prescribed Novolog insulin on several occasions, as staff held the medication without physician notification or documented parameters. The DON confirmed that the required protocol for holding insulin was not followed.
The facility did not update its posted survey results binder with the most recent survey findings, leaving only outdated information available despite multiple complaint, annual, and infection control surveys having been completed. The Administrator confirmed that no new survey results had been added since the last entry, potentially affecting all 55 residents.
The facility failed to follow enhanced barrier precaution (EBP) guidelines for five residents requiring EBP. Residents with tracheostomies, feeding tubes, and urinary catheters did not have proper signage or consistent use of PPE by staff, as confirmed by interviews and observations. The Director of Nursing verified that these residents should have been on EBP upon admission.
Failure to Enforce Smoking Safety and Policy Compliance
Penalty
Summary
The facility failed to ensure that smoking safety protocols were followed according to its own policy, which only allowed smoking in designated areas. During an observation of the facility parking lot with the Maintenance Director, cigarette butts were found disposed of in multiple mulch beds around the facility, including those near the dumpsters, the main entrance's covered porch, and the 300 Hall entrance. Additionally, a trash can under the covered porch showed ash marks from extinguished cigarettes and contained flammable materials inside. The Maintenance Director confirmed these findings during the interview. Review of the facility's smoking policy and designated smoking area information confirmed that smoking was only permitted on the 100/200 Hall dining room patio, indicating that the observed smoking activity and disposal of cigarette butts in other areas were not in compliance with facility policy.
Unsafe Environmental Conditions and Failure to Address Structural Hazards
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple environmental hazards and lack of timely corrective action. In the outdoor smoking area, a resident expressed concerns about safety due to the deteriorating condition of the wooden structure, which was observed to have extensive rot, a large hole caused by termite damage, and separating support beams. The Maintenance Director confirmed the termite damage and acknowledged that although a bid for replacement of the structure was received, the facility opted to purchase replacement air conditioners instead, and no further action was taken to address the structural issues. The affected smoking area was used by several residents identified as active smokers. Additionally, observations in multiple resident rooms revealed that hot water temperatures exceeded 120 degrees Fahrenheit, with some readings as high as 124 F. Other environmental concerns included gouges in the walls, paint separating from ceilings, and general disrepair in resident bathrooms and rooms. The Maintenance Director verified these findings during the survey. These deficiencies were identified during an investigation under a specific complaint number and affected a significant portion of the facility's resident population.
Failure to Include QIO Contact Information on NOMNC Letters
Penalty
Summary
The facility failed to provide required information on the Notice of Medicare Non-Coverage (NOMNC) letters for two residents who were reviewed for beneficiary notices. Specifically, the NOMNC letters for these residents did not include the name or telephone number of the Quality Improvement Organization (QIO), which is necessary for residents or their representatives to appeal the termination of skilled services. This omission was confirmed during interviews with the Chief Clinical Officer, who acknowledged the missing information, and the Business Office Manager, who indicated she received the corrected form from the Administrator after the deficiency was identified. The review of the medical records showed that both residents had been admitted to the facility and had skilled services ending on specific dates, but their NOMNC letters lacked the required QIO contact details.
Failure to Assess and Obtain Order for Use of Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Alzheimer's disease, dementia, and severely impaired cognition, was found to be using gardening gloves with Velcro fasteners on both hands to prevent her from chewing on her fingers. The gloves were applied in such a way that the resident's hands were balled up inside the gloves, restricting movement, and the Velcro around the wrists prevented her from removing them independently. The medical record did not contain a physician's order for the gloves to be used as a restraint, nor was there documentation of a restraint assessment being completed for this intervention. Staff interviews confirmed that the gloves were used because the resident would chew on her fingers and that other interventions, such as skin preparation and bandages, had been attempted without success. The DON acknowledged that the physician was aware of the situation but verified that no order or restraint assessment was in place for the use of the gloves as a restraint. Facility policy required a restraint assessment and physician order prior to the use of any restraint, which was not followed in this case.
Failure to Accurately Update PASARR Assessment for Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) assessment for a resident was updated and accurate. Record review showed that the resident was admitted with diagnoses including dementia, schizophrenia, high cholesterol, and urinary retention. The most recent Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living. However, the PASARR assessment did not indicate the resident's diagnosis of schizophrenia in response to the question regarding significant mental health diagnoses. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the PASARR did not address the resident's documented diagnosis of schizophrenia.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans and did not ensure that all required physician orders were in place for two residents reviewed for falls. For one resident with multiple diagnoses including dementia, schizophrenia, and heart failure, the care plan specified interventions such as a non-slip pad on the wheelchair, proper footwear when out of bed, a perimeter mattress, and participation in restorative therapy. While physician orders were present for the perimeter mattress and non-slip pad, there were no orders for proper footwear or restorative therapy, despite these being listed as care plan interventions. Staff interviews confirmed the absence of these orders. For another resident with diagnoses including major depressive disorder, anxiety, and COPD, the care plan required several fall prevention measures, including keeping the telephone cord tucked behind the nightstand. Multiple observations over several days revealed that the telephone cord was not consistently tucked away as required, and this was confirmed by various staff members at the time of each observation. The facility's policy required the interdisciplinary team to identify and implement pertinent interventions based on the resident's fall history, but these interventions were not fully executed as documented.
Failure to Provide Timely Pain Medication for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure that pain medication was available and administered as ordered for a resident with chronic pain and multiple complex medical conditions, including chronic pain syndrome, bipolar disorder, diabetes, and congestive heart failure. The resident had a physician's order for hydrocodone-acetaminophen 5-325 mg to be given three times daily. However, review of medication administration records and narcotic count sheets showed a gap of 16 hours between doses, despite the medication being scheduled every eight hours. The resident reported experiencing significant pain during this period and stated that running out of pain medication was a recurring issue. Staff interviews revealed that the nurse did not reorder the pain medication in a timely manner, despite being informed by the resident that the supply would not last through the weekend. The DON initially stated that the stock supply was depleted, but later clarified that the medication was available in the stock kit, though it was not accessed due to procedural issues. The facility did not contact the physician to obtain a one-time order from the contingent supply, resulting in the resident missing scheduled doses and experiencing unmanaged pain.
Failure to Update Medical Records Following Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon pharmacist recommendations regarding the use of antipsychotic medications for two residents. In both cases, the consulting pharmacist identified that the residents were receiving quetiapine fumarate without an appropriate diagnosis to support its use, as outlined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The pharmacists provided recommendations to update the residents' medical records with appropriate indications or diagnoses. The physicians for both residents reviewed and agreed with the recommendations, indicating that the records should be updated with the necessary diagnoses. Despite physician agreement, the facility did not update the medical records to reflect the appropriate indications for the continued use of quetiapine fumarate. One resident, who was severely cognitively impaired and had no behavioral symptoms, continued to receive quetiapine without a supporting diagnosis in the record. The other resident, who was cognitively intact and independent in activities of daily living, also continued to receive quetiapine for agitation, but the agreed-upon diagnosis was not added to the medical record. Interviews with the Director of Nursing confirmed that the facility did not act on the pharmacist's recommendations in either case.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide thickened liquids as ordered for a resident with multiple diagnoses, including dementia, cerebral infarction, and Alzheimer's disease. The resident was admitted with a physician's order for a regular, mechanical soft texture diet with nectar consistency liquids. During a breakfast observation, an agency CNA provided the resident with two glasses of thin consistency apple juice, despite the meal ticket being highlighted for nectar thick liquids. Another CNA confirmed the resident required thickened liquids and removed the drinks, but the resident had already consumed most of one glass. The deficiency was identified through observation, medical record review, and staff interviews.
Failure to Maintain Infection Control During Wound Care and Linen Changes
Penalty
Summary
The facility failed to maintain proper infection control measures during wound care and bed linen changes, as observed in two residents. For one resident with multiple diagnoses including diabetes, dementia, and a right scapula wound, an LPN entered the room already wearing gloves and carrying clean wound care supplies in her hand. During the procedure, the LPN repositioned the resident and handled bed linens while holding the clean dressings, causing the dressings to come into contact with the linens. The LPN then cleaned the wound and applied betadine without changing gloves or performing hand hygiene between steps, contrary to the facility's policy, which requires handwashing and glove changes at specific points during wound care. The LPN confirmed in an interview that she did not change gloves or wash her hands during the procedure. In a separate incident, another resident with severely impaired cognition and multiple chronic conditions was found to have a large pile of soiled linen on the floor in their room after a bed change. The CNA responsible stated she did not know where else to put the soiled linens. Facility policy requires soiled linens to be rolled inward and placed in a linen hamper or bag, which was not followed in this instance.
Resident Transported Without Proper Dignity or Coverage
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including cocaine abuse, sepsis, and atrial fibrillation, was observed being transported from the shower to his room by a CNA. The resident was seated on a shower chair, wearing only a thin hospital gown that was not tied at the waist, leaving his buttocks exposed. Additionally, a package of deodorant and an adult incontinence brief were placed in his lap during transport. This lack of proper covering and exposure occurred in a public hallway, as confirmed by a registered nurse, and was not in accordance with the facility's policy on resident rights and dignity.
Insulin Administration Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that a resident received insulin as ordered by the physician. Medical record review showed that a resident with multiple diagnoses, including diabetes, was admitted and had a physician's order for Novolog Flexpen three units subcutaneously before meals. The electronic medication administration record (eMAR) and progress notes indicated that the resident's insulin doses were held on several occasions without any documented parameters or physician notification. The Director of Nursing confirmed that nurses are required to notify the physician prior to holding insulin without parameters or if the resident refuses, and verified that this protocol was not followed for the identified dates.
Failure to Update Posted Survey Results
Penalty
Summary
The facility failed to ensure that posted survey results were updated with the most recent survey findings. Observation of the facility's survey results binder revealed that the last included survey was dated 06/10/22, despite multiple surveys having been conducted since then, including eleven complaint surveys, an annual survey, and fifteen Focused Infection Control surveys. Review of the facility's survey history confirmed these additional surveys occurred between 06/10/22 and 04/28/25. During an interview, the Administrator confirmed that no survey results had been added to the binder since 06/10/22. This deficiency had the potential to affect all 55 residents in the facility, whose census at the time was 55.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precaution (EBP) guidelines were followed for all residents that required EBP. This affected five of ten residents reviewed for EBP. For instance, Resident #23, who had respiratory disorders, a tracheostomy, and required a mechanical ventilator, did not have proper signage indicating EBP, and staff were not consistently wearing personal protective equipment (PPE) when providing care. Similarly, Resident #50, who had a tracheostomy and feeding tube, was not on EBP despite requiring it, as confirmed by a registered nurse. Resident #57, who also had a tracheostomy and was receiving tube feedings, had PPE available but lacked proper signage, leading to uncertainty among staff about the EBP status. Additionally, Resident #1, who had acute respiratory failure and a urinary catheter, was not placed on EBP until later in the day, despite being required to be on EBP upon admission. Resident #51, who had an indwelling urinary catheter, was also not on EBP initially, and it was only later that the necessary PPE and signage were provided. The Director of Nursing confirmed that these residents should have been on EBP from the time of their admission. The facility's policy and the QSO-24-08-NH guidelines were not adhered to, resulting in these deficiencies.
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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 Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Fairlawn The | 0.8 mi | ★★★★★ | 0 | 0 |
| Village At St Edward Nrsg Care | 0.9 mi | ★★★★★ | 9 | 0 |
| Copley Health Center | 1 mi | ★★★★★ | 6 | 0 |
| Timberland Ridge Nursing & Rehabilitation | 1.6 mi | ★★★★★ | 23 | 0 |
| Concordia At Sumner | 1.7 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.