Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Village At St Edward Nrsg Care during CMS and state inspections, most recent first.
Surveyors found that two residents who depended on staff for ADLs and had cognitive impairment did not have their call lights within reach. One resident, who routinely lay on her left side facing the wall, had her call light cord wrapped around the right bed rail and hanging between the rail and mattress on multiple observations, and both an LPN and an RN had difficulty locating and repositioning it so the resident could reach it. Another resident in bed had a call light placed on a set of drawers several feet away and out of reach, which an RN confirmed.
Surveyors found that staff failed to provide needed ADL assistance to two residents who required help with self-care tasks. One resident with hemiplegia and documented use of hearing aids was left struggling to insert her devices and unable to open sealed breakfast containers, despite care plans and staff interviews confirming she needed help with hearing aids, morning care, and meal setup. Another resident with post-CVA hemiplegia and documented dependence for toileting and hygiene reported that a CNA responded to his call light by giving him briefs without assisting with incontinence care, and he was later found on the floor after attempting to clean himself following a bowel movement. The CNA acknowledged knowing the resident required assistance but did not provide it, and facility leadership confirmed that the resident needed and did not receive incontinence care, contrary to the facility’s ADL care policy.
A resident with major depressive disorder, lower leg pain, and deep vein thrombosis had an oxycodone order that was active for only a few days, with no active orders or documented administrations in a later month, yet a card of oxycodone tablets remained on the med cart and the narcotic count sheet showed several non-wasted removals. Multiple oxycodone doses were taken from the card without any documentation of their final disposition, indicating the facility failed to properly track and account for these controlled substances.
Inaccurate MDS coding of hearing status. A resident with multiple chronic conditions had MDS and hearing assessments that documented hearing as adequate and no hearing devices, despite audiology records showing bilateral hearing aids/amplifiers. Observation and staff interviews confirmed the resident needed assistance placing and managing the hearing aids, and staff verified the devices were not coded on the MDS.
A resident with ADL assistance needs and documented hearing aid use had no care plan interventions for hearing devices, monitoring, maintenance, or staff help with insertion and removal. Audiology records showed bilateral hearing aids/amplifiers and failed whisper tests, but MDS and hearing assessments incorrectly documented adequate hearing and no devices. During observation, the resident was upset and unable to place the hearing aids, and staff confirmed the resident needed assistance with the devices and charging.
A resident at high risk for falls, with dementia, diabetes, amnesia, edema, and degenerative disease of the nervous system, was found on the floor in front of her wheelchair after apparently slipping out of the chair. Her care plan required Dycem above and below the wheelchair cushion, but only one sheet was present beneath the seat pad, and an RN confirmed the missing placement.
A resident with multiple medical conditions and moderately impaired cognition was observed receiving wound care for a right heel wound by an LPN and an RN without the door being closed or the privacy curtain being pulled, making the procedure visible from the hallway. The LPN confirmed that privacy measures were not taken, contrary to facility policy requiring such actions to protect resident privacy and dignity.
An LPN failed to sanitize an over-the-bed table before placing wound care supplies and saline-soaked gauze on it, resulting in contamination of the dressing materials used for a resident's pressure ulcer. The LPN acknowledged the lapse in infection control after being stopped by a surveyor during the dressing change.
The facility failed to notify the State Ombudsman of resident discharges, affecting a resident with multiple medical conditions who was discharged to the hospital several times. Discharge notifications were not sent for several months in 2024, as confirmed by staff interviews and record reviews.
A resident with multiple health issues experienced a fall and later showed signs of a fractured finger, which was confirmed by an x-ray. The LTC facility failed to notify the resident's representative of the fracture within the required 24-hour period, resulting in a seven-day delay. This was confirmed by interviews with the resident's representative and the DON.
A resident with severe cognitive impairment and multiple health conditions experienced several unwitnessed falls due to the facility's failure to implement timely safety checks and neurological assessments. Despite physician orders and interdisciplinary team recommendations, the facility did not adhere to its fall prevention protocols, leading to noncompliance.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were within reach for residents who required assistance with activities of daily living. One resident with severe cognitive impairment, dementia, impaired balance, and dependence on staff for ADLs was care planned to have the call light within reach and required staff assistance for bed mobility and transfers via mechanical lift. On two separate observations, this resident was lying in bed on her left side facing the wall, with the bed positioned against the left wall, and the call light was not visible or accessible. The call light cord was wrapped around the right bed handrail and hanging between the handrail and mattress, and the resident stated she did not know where the call light was and could not reach it. An LPN and an RN both had difficulty locating the call light, needing to reach under the bed and follow the cord, and both confirmed that the resident typically lay on her left side facing the wall. Even after the RN attempted to reposition the call light on the right handrail, the resident was still unable to reach it. Another resident with moderate cognitive impairment, dementia, diabetes, amnesia, edema, and degenerative disease of the nervous system required at least setup assistance for ADLs. During observation, this resident was in bed with the call light placed on a set of drawers approximately three feet from the bed and out of reach. The resident was not interviewable, and an RN confirmed the observation that the call light was not within the resident’s reach. These findings show that for both residents reviewed, staff did not ensure call lights were positioned so that residents could access them as required by their needs and care plans.
Failure to Provide Required ADL Assistance With Hearing Devices, Meals, and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), including hearing aid management and meal setup, for a dependent resident. One resident with pulmonary fibrosis, hemiplegia and hemiparesis, and type 2 diabetes had an MDS indicating no cognitive impairment but a need for supervision or touching assistance with eating and some assistance with ADLs. Audiology consultations documented that this resident used hearing aids or amplifiers in both ears and could not hear a whisper test, while the facility’s hearing, speech, and vision assessment inaccurately recorded that her hearing was adequate and that she used no hearing devices. Her care plan addressed an ADL self-care performance deficit and assistance with care but did not include any interventions related to hearing devices, and there were no current physician orders addressing hearing devices despite an earlier order for audiology services. On the morning of observation, the resident was found seated in a recliner with an untouched breakfast tray containing sealed containers, an unmade bed, and was visibly upset while struggling to insert both hearing aids. She reported that staff did not get her up at her requested time, that her shower and dressing were rushed, her bed was not made, and no one assisted her with opening her breakfast containers or inserting her hearing aids, which she stated were difficult for her to manage. An RN confirmed that the resident preferred to get up before breakfast and required help with meal setup and hearing aids, and that CNAs or nurses were responsible for assisting with the hearing devices, which were monitored via the resident’s phone. During a subsequent observation, the RN had to assist the resident with both her hearing aids and breakfast tray after the resident stated she had been trying unsuccessfully for ten minutes to insert the hearing aids and needed help opening her food. The CNA who had provided the resident’s morning care acknowledged that she had assisted with morning care but did not help with hearing aids, did not make the bed, and did not assist with the breakfast tray, explaining that she did not usually work with this resident, even though she stated that information on residents’ care needs was available when assignments changed. Another RN later confirmed that the resident’s hearing aids were linked to her phone, that staff were responsible for assisting with the devices and keeping them charged, and that the resident required more assistance with ADLs due to a decline in health. These observations and interviews show that the resident, who was dependent on staff for certain ADLs and hearing aid management, did not receive the necessary assistance with hearing devices, meal setup, and basic morning care. The deficiency also involves the facility’s failure to provide needed assistance with toileting and incontinence care for another dependent resident with cerebral infarction, lumbar disc displacement, and left-sided hemiplegia and hemiparesis. This resident’s MDS and care plan documented no cognitive impairment but a need for staff assistance with ADLs including toileting, lower body dressing, sit-to-stand, and toilet transfers, as well as mixed bladder incontinence and frequent bowel incontinence. Physician orders and therapy notes indicated the resident required staff assistance for transfers, was dependent for toileting and hygiene, and needed moderate assistance with toilet transfers. Progress notes documented that the resident had previously been found on the floor after his left leg gave out, and that he was educated and encouraged to ask for staff assistance due to ongoing weakness after a cerebrovascular accident. An SRI documented the resident’s allegation that a CNA was neglectful after he requested assistance with incontinence care via the call light; he reported that the CNA questioned why he could not wait until the next shift, provided briefs, but did not assist with care. A later progress note recorded that the resident was found on the floor after attempting to clean himself following a bowel movement, stating he fell due to his bad leg, and that he required assistance from two staff with a gait belt to be transferred from the floor and then needed help donning a clean brief and sweatpants. The resident’s friend reported that a CNA treated the resident rudely, threw a pack of briefs at him, did not offer help, and asked why he could not wait until the next shift. The CNA involved confirmed that the resident required assistance with incontinence care, that she provided a pack of briefs when he said he needed to go to the bathroom, left the room without assisting him, and returned an hour later to find him visibly upset after a bowel incontinence episode, acknowledging she knew he required assistance but did not provide it because he did not explicitly ask for help. In interviews, facility leadership acknowledged that the resident’s concerns about not receiving incontinence care were brought forward and that the resident had requested assistance, a CNA had given him briefs and left, and that the CNA believed the resident could provide his own care despite the medical record indicating he needed assistance. They confirmed that the resident required assistance and was not provided with incontinence care. The facility’s ADL Care Policy stated that individualized, person-centered assistance with ADLs, including essential self-care tasks, assessments, and care planning, was to be provided to all residents. The documented events, interviews, and record reviews show that for both residents, staff did not follow the documented ADL needs and did not provide the necessary assistance with ADLs, including hearing aid management, meal setup, toileting, and incontinence care.
Failure to Properly Track and Account for Oxycodone Doses
Penalty
Summary
The facility failed to appropriately track and account for dispensed narcotics for one resident when multiple oxycodone doses were removed from the resident’s medication card without documentation of their final disposition. The resident was admitted with diagnoses including major depressive disorder, pain in the lower leg, and deep vein thrombosis, and had a single oxycodone tablet order that began on 08/24/25 and was discontinued on 08/27/25. Review of the October medication administration record showed no active oxycodone orders or documented administrations during that month. However, observation of the 200-hall medication cart on 03/02/26 revealed a card containing 54 oxycodone tablets for this resident, with the card count matching the narcotic count sheet, and the most recent non-wasted removals documented on 10/01/25, 10/12/25, and 10/31/25. The Administrator confirmed that multiple doses had been removed from the oxycodone card with no documentation of what ultimately happened to those doses. This deficiency represents noncompliance with the requirement to provide pharmaceutical services that meet each resident’s needs and to properly track and account for controlled substances, as investigated under Complaint Number 2791137.
Inaccurate MDS Coding of Hearing Status
Penalty
Summary
The facility failed to accurately assess and document a resident’s hearing status on the MDS. Resident #1 was admitted with diagnoses including pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The MDS assessments, including quarterly and annual assessments, documented that the resident’s hearing was adequate and that she did not use hearing devices, and the care plan contained no interventions related to hearing devices. The hearing, speech, and vision assessment also reflected no hearing devices. Record review and observations showed the resident used hearing aids in both ears. Audiology consultations dated 05/16/23 and 08/16/23 documented that she utilized hearing aids and/or amplifiers in both ears, and one consultation noted she was working with the audiologist because the hearing aids were echoing. During observation on 02/25/26, the resident was visibly upset and struggling to place both hearing aids into her ears and stated no one had helped her. Staff interviews confirmed she required assistance with hearing aids, that staff were responsible for helping her with them and keeping them charged, and that the hearing aid devices were not coded on the MDS assessments.
Care Plan Did Not Reflect Resident’s Hearing Aid Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that reflected a resident’s hearing impairment and hearing aid use. Resident #1 was admitted with diagnoses including pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The medical record showed no cognitive impairment on MDS assessment, and the resident required supervision or touching assistance with eating and some assistance with ADLs. Although the care plan addressed an ADL self-care performance deficit, it did not include any interventions related to hearing devices, monitoring, maintenance, or staff assistance with application and removal of hearing aids. The record also showed conflicting documentation about the resident’s hearing status. Audiology consultations documented that the resident used hearing aids and/or amplifiers in both ears, and whisper tests were positive because the resident could not hear the whisper test. However, multiple MDS assessments and a hearing, speech, and vision assessment documented that hearing was adequate and that no hearing devices were used. During observation, the resident was visibly upset and struggling to place both hearing aids into her ears and stated that no one had helped her and that it was hard to put them in. Staff interviews confirmed that the resident used hearing aids linked to her phone, required assistance with ADLs, and that staff were responsible for assisting with the hearing aids and keeping them charged, yet these needs were not included in the care plan.
Failure to Follow Wheelchair Fall-Prevention Care Plan
Penalty
Summary
The facility failed to provide care planned interventions to prevent falls for Resident #67, who was admitted with diagnoses including unspecified dementia, diabetes, amnesia, edema, and degenerative disease of the nervous system. Her last fall assessment identified her as high risk for falls, and her care plan noted fall risk related to impaired cognition, poor safety awareness, and impaired mobility. One care planned intervention required a Dycem sheet above and below the pressure cushion in her wheelchair, but observation showed only one Dycem sheet beneath the seat pad. Resident #67 was later observed lying on the floor in front of her wheelchair in the second-floor hallway by the dining room and stated she was not sure how she fell and felt she just slipped out of the chair. The RN confirmed the care planned Dycem placement was supposed to be both above and below the wheelchair pad, but only one sheet was present below it.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to provide privacy during wound care for a resident with multiple medical conditions, including respiratory failure, diabetes, pulmonary hypertension, atrial fibrillation, coronary atherosclerosis, flaccid neuropathic bladder, insomnia, dementia, depression, and congestive heart failure. The resident, who had moderately impaired cognition, was observed receiving wound care for a right heel wound by an LPN with assistance from an RN. During the procedure, staff did not close the door or pull the privacy curtain, allowing the resident to be visible from the hallway. The LPN confirmed in an interview that privacy measures were not taken. Facility policy requires staff to close doors or pull privacy curtains during assessments or procedures to protect resident privacy and dignity.
Infection Control Lapse During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to maintain infection control during wound care for a resident with multiple diagnoses, including diabetes, dementia, and congestive heart failure. The resident had a physician's order for daily wound care to the right heel, which included cleansing with normal saline, applying Santyl ointment, and covering with a foam dressing. During an observed dressing change, the LPN did not sanitize the over-the-bed table before placing a paper towel and clean dressing supplies on it. The LPN then soaked four-by-four gauze in normal saline and placed it on the paper towel, which allowed the saline to soak through onto the unsanitized table surface. The LPN proceeded to use the now-contaminated gauze to clean the resident's wound, but was stopped by the surveyor. The LPN confirmed during an interview that she had not sanitized the table and acknowledged that the gauze had become contaminated by contact with the unsanitized surface. The facility's policy required clean technique for dressing changes unless otherwise specified by a physician, but this protocol was not followed during the observed wound care event.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure timely notification to the State Ombudsman regarding resident discharges, affecting one resident and potentially impacting all 76 residents in the facility. The deficiency was identified through a review of records and staff interviews, which revealed that the facility did not send discharge notifications for several months in 2024, including January, February, May, June, August, September, October, and November. Specifically, a resident with multiple medical conditions, including hereditary spastic paraplegia, osteoporosis, and multiple sclerosis, was discharged to the hospital multiple times in 2024 for various health issues, but these discharges were not reported to the Ombudsman. Interviews with the Licensed Social Worker and the Administrator confirmed the omission of the resident from the discharge lists for several months. The Licensed Social Worker admitted to only sending discharge lists for March, April, and July 2024, stating that she had missed the other months. The facility's policy on Transfer/Discharge Notification requires that all resident discharge notices be sent to the Office of the State Long Term Care Ombudsman, but this was not adhered to, leading to the deficiency.
Failure to Timely Notify Resident Representative of Fracture
Penalty
Summary
The facility failed to timely notify the representative of a resident who experienced a significant change in health status. The resident, who was admitted with multiple diagnoses including vascular dementia, diabetes, and rheumatoid arthritis, had a fall on two separate occasions without injury, and the representative was notified. However, on a subsequent occasion, the resident's representative noticed swelling and bruising on the resident's left hand during a visit, which led to an x-ray being ordered. The x-ray revealed an acute displaced fracture of the 5th digit. Despite the discovery of the fracture, the facility did not notify the resident's representative of this significant change in health status until seven days later. The facility's policy required that the resident's responsible party be notified within 24 hours of discovery of a clinical complication, which was not adhered to in this case. Interviews with the resident's representative and the Director of Nursing confirmed the delay in notification.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident with severe cognitive impairment and multiple health conditions, including vascular dementia and rheumatoid arthritis. The resident experienced multiple unwitnessed falls, one of which occurred near the nurses' station, and another in the hallway while attempting to get into bed. Despite physician orders for every 15-minute safety checks following the initial fall, these checks were not initiated until several hours later. Additionally, the facility did not complete the required 24-hour neurological checks after the resident's fall, as per their policy. Further incidents involved the resident falling twice in one day while self-ambulating with a walker in her room. Although the interdisciplinary team recommended therapy evaluation and 15-minute safety checks, these were not documented in the resident's records. Interviews with the Administrator, DON, and the resident's representative confirmed the lapses in safety checks and adherence to the facility's fall prevention protocols. The facility's failure to implement and document these interventions represents noncompliance with their own policies.
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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) |
|---|---|---|---|---|
| Phoenix Of Fairlawn | 0.9 mi | ★★★★★ | 0 | 0 |
| Arbors At Fairlawn The | 1.3 mi | ★★★★★ | 0 | 0 |
| Wyant Woods Healthcare Center | 1.3 mi | ★★★★★ | 8 | 0 |
| Bath Manor Special Care Centre | 1.5 mi | ★★★★★ | 2 | 0 |
| Copley Health Center | 1.9 mi | ★★★★★ | 6 | 0 |
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