Aristocrat Berea Healthcare and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and resident interviews, the facility failed to maintain a clean and sanitary living environment. This had the potential to affect all 137 residents in the facility. Findings Include:Observation on 08/29/25 at 8:20 A.M. revealed multiple items of food, dirt, and dust on the first floor dining room. Breakfast was being served at that time, but no residents were in the dining room. Observation during that time revealed an unidentified nursing staff person tell two residents in the hallway that the dining room was closed and they had to eat in their room. Observation on 08/29/25 from 9:05 A.M. to 9:15 A.M. revealed black soot on multiple ceiling tiles in the main laundry room. The black soot was caused by a dryer fire that happened in that room on approximately 05/29/25. Interview with the Housekeeping and Laundry Director #120 on 08/29/25 at 9:22 A. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to report an allegation of misappropriation to the State Agency as required. This affected two residents (#13 and #22) of three residents reviewed for misappropriation. The facility census was 137. Findings Include:1. Review of Resident #13's medical record revealed an admission date of 10/20/23. Her diagnoses included cerebral infarction, congestive heart failure, type II diabetes, COPD, multiple sclerosis, dementia, hypertension, factitious disorder, hypertensive heart disorder, anxiety disorder, chronic pain syndrome, psychosis disorder, osteoarthritis, personality disorder, hyperlipidemia, and glaucoma. Review of Resident #13 physician orders, dated 12/12/24 to 06/23/25, revealed an order for oxycodone five (5) milligrams (mg) every six hours as needed for pain. [...]

Inspectors wroteBased on medical record review, staff interview, facility investigative document review, and facility policy review, the facility failed to fully investigate an allegation of misappropriation as required. This affected two residents (#13 and #22) of three residents reviewed for misappropriation. The facility census was 137. Findings Include:1. Review of Resident #13's medical record revealed an admission date of 10/20/23. Her diagnoses included cerebral infarction, congestive heart failure, type II diabetes, COPD, multiple sclerosis, dementia, hypertension, factitious disorder, hypertensive heart disorder, anxiety disorder, chronic pain syndrome, psychosis disorder, osteoarthritis, personality disorder, hyperlipidemia, and glaucoma. [...]

Inspectors wroteBased on interviews, medical record review, and policy review, the facility failed to report an allegation of abuse as required. This affected one (Resident #63) of of six residents reviewed for abuse. The facility census was 143. Findings Include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, anxiety, depression, and chronic obstructive pulmonary disease. Review of the admission comprehensive Minimum Data Set (MDS) assessment, dated 01/24/25, revealed Resident #63 was cognitively intact, had delusions, verbal outbursts directed towards others, and wandered. Review of a nurse note dated 03/10/25 timed 6:45 A.M. revealed Resident #63 was verbally abusive, intrusive and arguing with staff and residents. [...]

Inspectors wroteBased on observation, resident interviews, staff interviews, and facility policy review, the facility failed to ensure dietary preferences were followed. This had the potential to affect all residents, except Resident #68, who the facility identified as receiving no food or drink by mouth (NPO) from the facility kitchen. The facility census was 142.

Inspectors wroteBased on observation, resident interviews, staff interviews, and facility policy review, the facility failed to ensure temperatures in the facility were at a comfortable level. This affected nineteen residents (#11, #17, #38, #44, #45, #47, #49, #58, #61, #77, #82, #97, #119, #123, #124, #125, #129, #136, #140) of twenty-nine residing on the 1 East Unit located on the first floor and two residents (#30, #109) of seventeen residing on the 2 East Unit located on the second floor. The facility census was 142.

Inspectors wroteBased on record review, observation, resident interview, staff interviews, and facility policy review, the facility failed to ensure facility equipment was maintained to ensure residents received the care pertaining to their needs and preferences. This affected one resident (#17) of one resident, but had the potential to affect five additional residents (#11, #74, #86, #98, #133) residing on the 1 East Unit, who required a mechanical lift. The facility census was 142.

Inspectors wroteBased on observation, resident interviews, staff interviews, and facility policy review, the facility failed to ensure a clean environment and water temperatures were at a comfortable level. This affected seventeen residents (#10, #20, #26, #30, #34, #41, #56, #70, #76, #78, #92, #101, #109, #118, #127, #130, #134) of seventeen residing on the 2 East Unit located on the second floor and forty-one residents (#1, #2, #5, #6, #7, #8, #15, #16, #19, #23, #27, #28, #31, #32, #35, #36, #46, #50, #51, #52, #53, #59, #71, #73, #75, #80, #88, #89, #96, #99, #100, #102, #112, #113, #114, #116, #121, #122, #131, #135, #137) of forty-one residing on the 3 East and 3 [NAME] Units located on the third floor. The facility census was 142.

Inspectors wroteBased on record review, observations, staff interviews, and facility policy review, the facility failed to ensure Resident #8 was treated with dignity. This affected one resident (#8) of one reviewed for dignity. The facility census was 142.

Inspectors wroteBased on record review and interview, the facility failed to ensure that Resident #3's privacy was maintained. This affected one resident (#3) of two residents reviewed for personal privacy and confidentiality. The facility census was 145.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to ensure ice machines were maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 140.

Inspectors wroteBased on interview and observations the facility failed to maintain a safe and sanitary resident environment. This affected 68 residents who used the showers (#1, #4, #5, #13, #17, #22, #23, #29, #31, #32, #35, #41, #46, #48, #52, #55, #56, #70, #71, #73, #75, #87, #88, #89, #93, #96, #97, #100, #102, #104,#112, #113, #114, #129, #132, #134, #135, #10, #14, #19, #26, #34, #37, #43, #44, #45, #47, #60, #61, #63, #67, #72, #77, #79, #80, #82, #85, #98. #107, #116, #119, #122, #123, #124, #128, #130, #131, #133, and #137) and 21 residents who ate in the dining room on the third-floor secured unit (#7, #9, #20, #24, #27, #28, #30, #33, #38, #51, #57, #59, #64, #65, #78, #92, #99, #101, #110, #118, and #126). Facility census was 140.

Inspectors wroteBased on record review and interview the facility failed to ensure timely assessment of residents and review of the risks and benefits of bed rails with the residents after removing all bed rails that were currently in place and being used by the residents. This affected six (Resident #7, #12, #16, #85, #131, and Resident #133) of 19 residents whose side rails and grab bars were removed. Based on observation, record review and interview the facility also failed to provide timely incontinence care to prevent incontinence dermatitis. This affected one (Resident #66) of three reviewed for incontinence care.

Inspectors wroteBased on record review and interview the facility failed to develop a comprehensive care plan for Resident #133 related to the use of bed side rails which assisted Resident #133 with bed mobility and getting in and out of bed. This affected one (Resident #133) of six residents whose care plans were reviewed.

Inspectors wroteBased on record review and interview the facility failed to ensure residents were redirected from safety hazards affecting Resident #135 and failed to ensure bed rails were not removed prior to assessing the resident's ability to exit the bed safely without the rails affecting Resident #133. This affected two of six residents reviewed for falls.

Inspectors wroteBased on observation, record review, review of a facility Self-Reported Incident (SRI) and related facility investigation, review of hospital records, facility policy review and interviews, the facility failed to ensure Resident #143 was free from an incident of resident-to-resident physical abuse. This affected one resident (#143) of three residents reviewed for abuse. The facility census was 145. Actual harm occurred on 06/18/24 when Resident #143, who was cognitively impaired and had been independent with activities of daily living (ADLs) prior to 06/18/24, sustained a fall after being pushed by Resident #109, was sent to the local hospital emergency room for an examination on 06/18/24 and was found to have a left humerus (major upper arm bone) fracture. [...]

Inspectors wroteBased on interview, and observation the facility did not ensure there was sufficient linens including washcloths, towels and fitted sheets available. This affected 117 residents (all residents on unit one, all residents on unit two South and West, and all residents on unit three including Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #15, #16, #17, #19, #20, #21, #22, #23, 24, #25, #27, #28, #29, #30, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #48, #50, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #64, #65, #67, #68, #69, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #86, #87, #88, #89, #90, #93, #94, #95,#96, #97, #98, #99, #100, #101, #102, #103, #104, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #122, #123, #125, #126, #127, #129, #130, #131, #132, #133, #134, #135, #136, #137, #242, [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and even flooring for dietary staff who provide meal service for residents. This had the potential to affect 137 out of 138 residents in the facility as Resident #72 received nothing by mouth. Findings Include: Observation on 01/09/24 at 12:38 P.M. during lunch meal service revealed the floor in the kitchen had a depressed area for equipment. Part of the area no longer contained any food preparation equipment. The food plating area butted up against the area. The person serving had to step in and out of the uneven area. Interview on 01/09/24 at 12:38 P.M. with Dietary Manager #377 verified there was uneven flooring and the person serving meals stepped in and out of the area. Interview on 01/09/24 at 12:42 P.M. Administrator #444 verified the uneven flooring. [...]

Inspectors wroteBased on interview, observation, record review and review of facility incontinence policy ,the facility did not ensure timely incontinence care was completed for Resident #50. This affected one resident (Resident #50) out of two residents (Residents #50 and #96) reviewed for incontinence care. The facility census was 138.

Inspectors wroteBased on interview, record review and policy review, the facility failed to offer Resident #111 an influenza and pneumococcal vaccine. This affected one resident (Resident #111) out of five residents (Resident #34, #38, #69, #111, #242) reviewed for influenza and pneumococcal vaccines. The facility census is 138.

Inspectors wroteBased on a test tray and interview the facility failed to provide palatable meals. This had the potential to affect all residents, except Resident #84 who was identified as not receiving meals from the kitchen related to a nothing by mouth (NPO) status. The facility census was 133.

Inspectors wroteBased on observations, interviews, record review, and and policy review, the facility failed to ensure Resident #6 was treated in a [NAME] that enhanced his quality of life and promoted his rights. The facility also failed to ensure residents had private unrestricted communications including the telephone, mail, and newspaper delivery. This affected all 19 (Residents #2, #6, #17, #26, #32, #50, #52, #54, #55, #59, #66, #68, #71, #76, #81, #88, #117, #124, and #133) residents residing on the second floor secured unit. The facility census was 141 residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure residents had private unrestricted communications including telephone use. This affected all 19 (Residents #2, #6, #17, #26, #32, #50, #52, #54, #55, #59, #66, #68, #71, #76, #81, #88, #117, #124, and #133) residents residing on the second floor secured unit. The facility census was 141 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility did not ensure nursing staff administered medications within the acceptable parameters of time. This affected three (Residents #6, #24, and #76) of seven residents reviewed for unnecessary medications. The facility census was 141 residents.

Inspectors wroteBased on observation, interview, and review of manufacturer's guidelines on insulin storage, the facility failed to ensure multi-dose insulin vials were dated with the date they were opened. This affected two (Residents #42 and #90) of three residents reviewed for insulin administration. The facility census was 141 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wore face mask per guideline from the Centers for Disease Control and Prevention (CDC). This had the potential to affect all 37 residents (Residents #4, #8, #11, #13, #16, #18, #24, #25, #29, #34, #35, #37, #40, #44, #45, #46, #65, #70, #74, #77, #78, #86, #97, #100, #104, #107, #110, #114, #116, #118, #119, #123, #124, #125, #129, #137, and #139) who resided on the third floor secured unit. The facility census was 141 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to promote and facilitate resident self-determination through support of resident choice in psychiatrist, interact with members of the community outside the facility, and choose schedules of medication and appointments with providers of his their choosing. This affected one (Resident #6) of seven residents reviewed for choices. The facility census was 141 residents.

Inspectors wroteBased on interview and review of facility investigation reports, the facility failed to ensure policies and procedures were implemented relative to reporting allegations of abuse to adminstration, initiating abuse allegations timely, and protecting residents from further abuse while an investigation is in process. This affected two (Residents #70 and #80) of five residents reviewed for abuse allegations. The facility census was 141 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure a residents plan of care included interventions for physical immobility. This affected one (Resident #112) of 10 residents reviewed for restorative services. The facility census was 141 residents.

Inspectors wrote3. Resident #112 was admitted to the facility on [DATE]. Her admitting diagnoses included schizophrenia, pressure ulcer of sacral region (Stage 4), gastrostomy, dementia, and blindness of one eye. Review of this resident's Minimum Data Set Assessment (MDS) dated [DATE] revealed this resident had severe cognitive impairment. She needed extensive assistance of two people for all activities of daily living including toileting and personal hygiene. Review of this resident's plan of care for nutrition dated 04/03/19 revealed the resident had a nutritional problem related to past medical history of acute respiratory failure, type II diabetes, constipation, hypotentions and schizophrenia. She was receiving a tube feeding at the present time that runs continuously. Review of the interventions for this plan of care included: Administer medications as ordered; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a restorative program was implemented to further meet the needs of its residents. This affected one (Resident #112) of 10 residents reviewed for restorative services. The facility census was 141 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper pericare was provided to Resident #112. This affected one (Resident #112) of two residents reviewed who had urinary catheters. The facility census was 141 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to monitor the nutritional status for one resident (Resident #59). This affected one (Resident #59) of seven residents reviewed for nutrition. The facility census was 141 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure tube feedings were stopped while laying a resident flat to provide care. This affected one (Resident #112) of three residents who were receiving a tube feeding. The facility census was 141 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was sufficient trained staff available to supervise and effectively implement interventions for residents who have mental disorders and demonstrated behaviors affecting other residents at the facility. This affected two (Residents #112 and #142) of five residents reviewed for behavioral needs. The facility census was 141 residents.

Inspectors wroteBased on interview and record review, the facility failed to identify the source of Resident #6's post-traumatic stress disorder (PTSD) to provide appropriate treatment and services to identify triggers and possible interventions. This affected one (Resident #6) of three residents reviewed for mood and behavior. The facility census was 141 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain the second floor dining room chairs in good condition. This had the potential to affect all 19 (Residents #2, #6, #17, #26, #32, #50, #52, #54, #55, #59, #66, #68, #71, #76, #81, #88, #177, #124, and #133) residents residing on the second floor secured behavioral unit. The facility census was 141 residents.

Inspectors wroteBased on observation, review of the medical record, facility policy and procedure, and interviews with staff, Physician #397 and Psychiatrist #398, the facility failed to ensure one resident (Resident #152) who was diagnosed with mental disorder and post-traumatic stress disorder received appropriate care, treatment and interventions to meet the resident's individual needs. This resulted in Immediate Jeopardy that was actual harm when Resident #152, who was known to inflict personal injury, opened a previously self-inflicted wound with an electrical cord, made multiple self-harming body cuts, threatened to harm others and had suicidal ideation without appropriate action by the facility. On 11/21/19 at 5:30 P.M. the Administrator, Director of Nursing (DON), and Quality Assurance Nurse #396 were notified the Immediate Jeopardy began on 11/03/19 at 6:24 P.M. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to implement a comprehensive abuse policy and procedure to ensure adequate screening systems were in place for all employees prior to hire. The facility failed to implement their abuse policy to ensure all employees were checked against the Nurse-Aide Registry (NAR). This affected six of 18 employees whose personnel files were reviewed (Administrator, Director of Nursing (DON), Licensed Practical Nurse (LPN) #281, LPN #292, Registered Nurse (RN) #370 and RN #371). In addition, the facility identified six additional nurses (LPN #298, LPN #297, LPN #293, LPN #286, RN #306 and RN #361) who had been hired since 09/10/18 who had not been checked against the nurse aide registry. This had the potential to affect all 163 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure food was stored and prepared under sanitary conditions to prevent contamination and/or food borne illness. This had the potential to affect all 163 residents who resided in the facility, as all residents consumed food by mouth.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure all residents were provided a dignified dining experience and failed to ensure staff interacted with residents in a dignified manner. This affected four residents (#303, #56, #37 and #12) of 163 residents residing in the facility who were observed during dining and for dignity.

Inspectors wroteBased on observation, record review, interview and review of the food temperature guidelines, the facility failed to ensure food items were served at appropriate temperatures. This affected five residents (#25, #134, #106, #107 and #303) and had the potential to affect all 43 residents residing on the third floor of the facility. The facility census was 163.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #21 and Resident #120's rooms were maintained at a comfortable temperature. This affected two residents (#21 and #120) of 44 residents who were interviewed related to environmental concerns.

Inspectors wroteBased on record review, interview and policy review, the facility failed to notify Resident #35 or the resident's representative when the resident's personal fund account was within $200.00 of the eligibility limit for Medicaid. This affected one resident (#35) of five residents reviewed for personal funds.

Inspectors wroteBased on observation, record review and interview the facility failed to provide Resident #352 personal privacy while performing tracheostomy care. This affected one resident (#352) of one resident reviewed for tracheostomy care.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure Resident #124 was free from misappropriation. This affected one resident (#124) of one resident reviewed for misappropriation of property.

Inspectors wroteBased on record review and interview the facility failed to ensure a timely Preadmission Screening/ Resident Review (PAS/RR) assessment was completed at the time of the 30 day Hospital Exemption for Resident #146. This affected one resident (#146) of one resident reviewed for PAS/RR screening.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #125, who required staff assistance for personal care received adequate and timely assistance with personal hygiene including shaving. This affected one resident (#125) of three residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #120 and Resident #131 were served the right portion size of pureed cabbage casserole. This affected two residents (#120 and #131) of four residents reviewed for pureed meal service.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #74 received timely assistance in scheduling an ear, nose, and throat specialist appointment. This affected one resident (#74) of two residents reviewed for vision and hearing.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to maintain acceptable infection control practices for Resident #146 related to the storage of respiratory equipment and during wound care, for Resident #352 during tracheostomy care and while handling Resident #149's dirty linens to prevent the spread of infection. This affected two residents (#146 and #352) related to respiratory care, one resident (#146) of two residents reviewed for pressure ulcers and one resident (#149) of 33 residents observed for general infection control procedures.

Inspectors wroteBased on observation and interview the facility failed to ensure Resident #5's mattress was maintained in good repair. This affected one resident (#5) of five residents reviewed for equipment. Findings Include: On 11/18/19 at 3:18 P.M. an interview with Resident #5 revealed concerns that his mattress was torn on the side of the mattress. Resident #5 stated it had been torn for a long time. On 11/18/19 at 3:20 P.M. observation of Resident #5's mattress revealed it was ripped approximately two foot on the side seam of the mattress. Interview on 11/25/19 at 9:58 A.M. with Housekeeper (HK) #347 revealed each residents shower days, their mattress was to be wiped down. HK #347 revealed if a tear was noticed at that time, staff should put a work order in to maintenance for a replacement mattress. Observation on 11/25/19 at 10:00 A.M. [...]