Health inspection·November 26, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365707 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm 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. Residents Affected - Many 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365707 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365707 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365707 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm 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. Residents Affected - Many 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365707 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Many 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365707 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365707 If continuation sheet Page 8 of 8