Aristocrat Berea Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Aristocrat Berea Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 14, 2022

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID- 19 line list, review of facility infection control policies, interviews with staff, observations, interview with the local health department (LHD) and medical record review, the facility failed to timely and appropriately exclude COVID-19 positive staff from working in the facility with COVID-19 negative residents. […]

• Immediate jeopardy, isolatedF689Aug 20, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observations, interviews, open and closed medical record review, review of a local police report, review of the facility's investigations, and facility policy review, the facility failed to provide adequate supervision to prevent the elopements of two residents (Resident #44 and Resident #140) without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when on 05/18/26 at approximately 3:00 P.M., Resident #140, who was moderately cognitively impaired, with diagnoses including borderline intellectual functioning and psychosis, exited the facility's outdoor area during a supervised… […]

• Actual harm, isolatedF600Jul 3, 2024

  Based 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. […]

• Actual harm, isolatedF692May 24, 2021

  Based on interview, record review, and policy review, the facility failed to monitor the nutritional status for one resident (Resident #59). This resulted in actual harm when Resident #59, who was congnitively impaired and required extensive assistance with eating, sustained an unplanned 15.9 percent (%) significant weight loss within a 180 day (six month) time period. This affected one (Resident #59) of seven residents reviewed for nutrition. The facility census was 141 residents. Findings include: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF921Aug 20, 2026

  Based on observation and staff interview, the facility failed to maintain resident rooms and common areas in a clean, sanitary, and well-maintained condition. This deficient practice had the potential to affect all 135 residents who resided in the facility.Findings include: Observations conducted on 08/04/26 between 9:30 A.M. and 10:00 A.M. revealed the following:The wood paneling in the bathroom shared by Residents #54, #72, #104, and #105 had a large crack extending down the middle.The bedsheet used by Resident #35 was visibly soiled and contained numerous black stains.The flooring surrounding the toilet in the room occupied by Residents #37 and #132 was stained brown, and a strong odor of urine was present in the area.Privacy curtains were not present in the rooms occupied by Residents… […]