Health inspection·April 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **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. Page 1 of 18 365707 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm 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. Residents Affected - Many 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. 365707 Page 2 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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. 365707 Page 3 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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. 365707 Page 4 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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. 365707 Page 5 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0604 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 365707 Page 6 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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. 365707 Page 7 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 365707 Page 8 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0697 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 365707 Page 9 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **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). 365707 Page 10 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 365707 Page 11 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

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. **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. 365707 Page 12 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0758 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 365707 Page 13 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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. 365707 Page 14 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **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. 365707 Page 15 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

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, 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. Residents Affected - Few 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. 365707 Page 16 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0880 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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. 365707 Page 17 of 18 365707 04/28/2025 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Many 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. 365707 Page 18 of 18