Health inspection·January 10, 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 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. Findings include: Review of the medical record for Resident #8 revealed she admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, schizoaffective disorder, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ten that indicated Resident #8 had cognitive impairment. Resident #8 required setup or clean-up assistance for eating. Review of Resident #8's physician orders dated 05/29/19 revealed an order for a no added salt diet, pureed texture with thin consistency. Review of the care plan dated 10/13/24 revealed Resident #8 had a nutritional risk related to schizoaffective disorder with interventions that included provide and serve diet as ordered. Observation on 01/09/25 at 12:10 P.M. revealed the third-floor lunch meal tray carts arrived to the unit and were placed in the dining room. Observation revealed Resident's #8, #27, and #137 were seated at the same table. Observation on 01/09/25 at 12:13 P.M. revealed Certified Nurse Assistant (CNA) #817 provided Resident's #27 and #137 their lunch trays. Observation revealed Resident's #27 and #137 begin to eat their lunch meal. Observation revealed Resident #8 was without a lunch meal tray. Observation on 01/09/25 at 12:14 P.M. revealed CNA #817 returned to check the lunch meal tray carts. CNA #817 was unable to located Resident #8's lunch meal tray. Interview on 01/09/25 at 12:14 P.M. with CNA #817 revealed Resident #8 did not have a lunch meal tray and the kitchen forgot to plate her lunch meal. CNA #817 revealed the kitchen was contacted to provide Resident #8 a lunch meal tray. Observation on 01/09/25 at 12:14 P.M. revealed Resident #8 yelling and screaming asking for a lunch Page 1 of 11 365608 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0550 Level of Harm - Minimal harm or potential for actual harm tray. Resident #8 was observed pacing the dining room back and forth, visibly upset, crying, and asking for her food. Resident #8 was unable to be redirected. Observation on 01/09/25 at 12:33 P.M., approximately 19 minutes later, revealed Regional Culinary Director (RCD) #956 arrived to the unit with Resident #8's lunch meal tray in hand. Residents Affected - Few Interview on 01/09/25 at 12:33 P.M. with CNA #817 confirmed and verified the above findings at the time of the observation. Review of the facility document titled Resident's Rights, dated December 2020, revealed the facility had a policy in place that each resident had a right to be treated at all times with courtesy, respect, and full dignity and individuality. Review of the document revealed the facility did not implement the policy. This deficiency is based on incidental findings discovered during the course of the complaint investigation. 365608 Page 2 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

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. Based 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. Findings include: Observation on 01/08/25 from 8:00 A.M. to 8:55 A.M., during tour of the 1 East Unit, revealed a cold and chilled breeze circulating throughout the unit. Interview and observation on 01/08/25 at 8:47 A.M. with Resident #82, who resided on the 1 East Unit, revealed it was cold in her room. Resident #82 was observed lying in bed with a sheet and blanket wrapped around her. Interview and observation on 01/08/25 at 8:49 A.M. with Resident #38, who resided on the 1 East Unit, revealed she was always cold. Resident #38 revealed her bed was located up against the wall with a window. Resident #38 revealed it was cold in her room and the facility staff was aware. Resident #38 was observed wearing a robe, heavy coat, and two blankets. Observation on 01/08/25 at 8:52 A.M. located on the 1 East Unit, revealed a vent affixed to the wall outside of Resident's #124 and #129 room. Observation revealed the vent was blowing cold air. Interview on 01/08/25 at 10:05 A.M. with Resident #58, who resided on the 1 East Unit, revealed it was cold in his room. Interview on 01/08/25 at 10:09 A.M. with Licensed Practical Nurse (LPN) #820 revealed residents normally complained about the temperature in the building. LPN #820 revealed the temperature in the building was spotty with certain areas being warmer than other areas. Observation on 01/08/25 at 10:21 A.M., located on the 1 East Unit, revealed a ceiling vent outside of Resident's #49 and #58 room blasting cold air. Interview on 01/08/25 at 10:21 A.M. with LPN #820 confirmed and verified the cold air blowing from the vent affixed to the wall outside of Resident's #124 and #129 room and the ceiling vent outside of Resident's #49 and #58 room. Interviews on 01/08/25 at 10:44 A.M. with Resident's #30 and #109, who shared rooms and resided on the 2 East Unit, revealed they had no heat in their room. Resident's #30 and #109 revealed their room was as cold as it was outside. Interview on 01/08/25 at 10:44 A.M. with Certified Nurse Assistant (CNA) #833 revealed the building was freezing cold. Observation on 01/08/25 at 10:50 A.M. of Resident's #30 and #109 room revealed a cold and chilled 365608 Page 3 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0584 breeze circulating throughout the room. Level of Harm - Minimal harm or potential for actual harm Interview on 01/08/25 at 11:11 A.M. with Resident #17, who resided on the 1 East Unit, revealed it was freezing in her room. Residents Affected - Some Interview and observation on 01/08/25 from 11:39 A.M. to 12:00 P.M. with Maintenance Director (MD) #953, during tour of the facility, revealed he routinely checked the temperatures on the different units. MD #953 revealed he attempted to maintain the building temperature with a target temperature of 74 degrees Fahrenheit (F) for the entire facility. Observation during tour of the facility, with MD #953, revealed a temperature reading of 67 degrees F located near the 1 East Nursing station (utilized by residents during medication pass), 68 degrees F located in the 1 East common area, 68 degrees F in Resident's #17 and #61 room, 66 degrees F in Resident's #38 and #82 room, 68 degrees F in Resident's #49 and #58 room, and 68 degrees F in Resident's #45 and #77 room. Observation during tour of the facility with MD #953, of Resident's #30 and #109 room, revealed a temperature reading of 68 degrees F. Interview on 01/08/25 at 12:00 P.M. with MD #953 revealed he was not aware of the concerns in the facility related to temperatures. MD #953 confirmed and verified the above findings at the time of the tour. Follow-up interview on 01/08/25 at 12:15 P.M. with MD #953 revealed the heat on the 1 East Unit was not on. Review of the facility document titled Temperature Extremes, dated March 2019, revealed the facility had a policy in place to provide comfortable and safe temperature levels. Review of the policy revealed the temperature throughout the facility should be maintained between 71 degrees and 81 degrees Fahrenheit. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Master Complaint Number OH00161301. 365608 Page 4 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #17 revealed she was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, type two diabetes mellitus, and hypertensive heart disease. Review of the 5-Day, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was alert and oriented with cognitive impairment. Resident #17 was dependent on staff for activities of daily living (ADL). Review of Resident #17's physician orders dated 04/09/24 revealed an order for Hoyer lift (mechanical lift) for all transfers. Review of the weight summary dated 11/06/24 for Resident #17 revealed a weight of 298.4 pounds (Lbs.). Review of the weight summary revealed she was weighed by a Hoyer scale. 2. Review of the medical record for Resident #11 revealed he was admitted to the facility on [DATE] with diagnoses that included morbid obesity, heart failure, and abnormal posture. Review of the physician orders for Resident #11 revealed orders dated 02/04/23 for Hoyer lift for all transfers. 3. Review of the medical record for Resident #74 revealed he was admitted to the facility on [DATE] with diagnoses that included Lennox-Gastaut syndrome intractable without status epilepticus, encephalopathy, and schizoaffective disorder. Review of Resident #74's physician orders dated 04/09/24 revealed an order for Hoyer lift for all transfers. 4. Review of the medical record for Resident #86 revealed he was admitted to the facility on [DATE] with diagnoses that included lymphedema, hypertension, and obesity. Review of Resident #86's physician orders dated 02/08/23 revealed an order for the resident to be transferred via Hoyer lift with two-person assist. 5. Review of the medical record for Resident #98 revealed he was admitted to the facility on [DATE] with diagnoses that included type two diabetes, major depressive disorder, and acquired absence of left leg below knee. Review of Resident #98's physician orders dated 10/14/24 revealed an order for Hoyer lift for all 365608 Page 5 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0684 transfers. Level of Harm - Minimal harm or potential for actual harm 6. Review of the medical record for Resident #133 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia and insomnia. Residents Affected - Some Review of Resident #133's physician orders dated 04/09/24 revealed an order stating the resident may use Hoyer lift. Review of the medical records for Resident's #11, #17, #74, #86, #98, #133 revealed they all resided on the 1 East Unit that required the use of the broken Hoyer lift. Interview on 01/08/25 at 10:09 A.M. with Licensed Practical Nurse (LPN) #820 revealed Resident #17 required a Hoyer lift for all transfers. LPN #820 revealed each unit in the facility had a designated Hoyer lift. LPN #820 revealed the 1 East Unit, where Resident #17 resided, had a bariatric Hoyer lift that was broken due to the legs not working properly. LPN #820 revealed Resident #17 was not happy about it due to not being able to get up and being stuck in bed. LPN #820 revealed the Hoyer lift designated for the 1 East Unit had been broken for at least, approximately, one week. LPN #820 revealed Resident #17 preferred to get out of bed, even if it was only for 15 minutes at a time. Observation and interview on 01/08/25 at 11:11 A.M. revealed Resident #17 lying in bed. Resident #17 expressed delight when the state surveyor entered her room. Resident #17 revealed the Hoyer lift was broken, and she had been stuck in bed. Resident #17 revealed the facility would not get the Hoyer lift fixed, and she had been stuck in bed for three weeks. Resident #17 revealed the Hoyer lift being broken was a big issue for her because she did not like being stuck in bed. Resident #17 revealed two staff members had attempted to manually transfer her out of bed, but the attempt was unsuccessful due to her weight. Resident #17 revealed the facility refused to purchase a new Hoyer lift. Interview on 01/08/25 at 2:41 P.M. with Certified Nurse Assistant (CNA) #921 revealed the Hoyer designated for the first-floor unit was broken, and she was unable to get residents up who required a Hoyer lift for transfers. Interview on 01/08/25 at 2:47 P.M. with CNA #808 revealed the first-floor Hoyer lift was broken. Interview on 01/08/25 at 3:24 P.M. with Maintenance Director (MD) #953 revealed he was aware of the broken Hoyer lift designated for the first-floor unit. MD #953 revealed he had a current work order in place due to the legs of the Hoyer not spreading under load. MD #953 revealed each unit had their own designated Hoyer lift. MD #953 revealed the Hoyer lift cost to repair, was unaware how long it had been broken, and was unsure of when it would be repaired. Review of the work order report dated 12/08/24 to 01/09/25, provided by the facility, revealed two work orders regarding a Hoyer lift not working and a Hoyer battery charger broken. Review of the work order report revealed no other work orders related to Hoyer lifts. Review of the undated facility document titled Mechanical Lift Policy revealed the facility had a policy in place to ensure residents received appropriate, high-quality care, and mechanical lifting devices were accessible to staff, maintained regularly, and was kept in proper working order. Review of the documents revealed the facility did not implement the policy. This deficiency is based on incidental findings discovered during the course of this complaint 365608 Page 6 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0684 investigation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365608 Page 7 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based 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. Findings include: Interview on 01/08/25 at 8:47 A.M. with Resident #17 revealed she always received Kool-Aid as her drink for breakfast. Resident #17 revealed Kool-Aid was not considered a breakfast drink, and she was sick of getting it all the time. Interview on 01/08/25 at 8:53 A.M. with Certified Nurse Assistant (CNA) #808 revealed residents received Kool-Aid as a drink with the breakfast meal. CNA #808 revealed residents preferred orange juice, tea, and coffee. Interview on 01/08/25 at 10:09 A.M. with Licensed Practical Nurse (LPN) #820 revealed residents often complained about receiving Kool-Aid with their breakfast meals. Interview on 01/08/25 at 10:27 A.M. with LPN #855 revealed residents often received Kool-Aid with their breakfast meals. Interview on 01/08/25 at 10:44 A.M. with CNA #833 revealed residents were served Kool-Aid for breakfast, lunch, and dinner. CNA #833 revealed sometimes Kool-Aid was the only drink available, and residents would get upset with their lack of options. Interview on 01/08/25 at 10:56 A.M. with LPN #866 revealed residents complained about receiving Kool-Aid with their breakfast. LPN #866 revealed she had never worked at a facility that served Kool-Aid with all of the meals. Interviews on 01/08/25 at 11:05 A.M. with CNA's #826 and #919 revealed residents often complained about receiving Kool-Aid with their breakfast meals. Observation on 01/08/25 at 11:06 A.M. of the third-floor dining room revealed a drink cart with an orange-colored liquid in a clear pitcher. Observation revealed no other drink options. Observation and interview on 01/08/25 at 11:09 A.M. with Dietary Aide (DA) #931 revealed she was pushing a black cart with a clear pitcher of orange-colored liquid and multiple clear-colored cups. Observation revealed no other options. DA #931 identified the orange-colored liquid as orange Kool-Aid. DA #931 revealed she was providing the resident Kool-Aide as their only option of drinks for the lunch meal. Interview on 01/08/25 at 3:41 P.M. with Dietary Manager (DM) #911 revealed he attended food committee meetings every month. DM #911 revealed residents complained about receiving Kool-Aid with their breakfast meals. DM #911 revealed he informed his staff that serving Kool-Aid with the breakfast meal was unacceptable, and residents did not want it. DM #911 revealed there were other options of drinks to be served with the breakfast meal such as orange juice, apple juice, and cranberry juice. DM 365608 Page 8 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0806 #911 confirmed and verified the above findings at the time of the interview. Level of Harm - Minimal harm or potential for actual harm Review of the list of current residents and their diets provided by the facility, revealed only one resident (#68) was listed as NPO. Residents Affected - Many Review of the facility document titled Resident's Rights, dated December 2020, revealed the facility had a policy in place that each resident had a right to receive services with reasonable accommodations of their individual needs and references. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Master Complaint Number OH00161301. 365608 Page 9 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

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, 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. Findings include: Interview and observation on 01/08/25 at 10:05 A.M. with Resident #58 revealed his room was always dirty. Observation of Resident #58 room, shared with Resident's #49 and #123, revealed Resident #123 bed had multiple areas of food crumbs with brown and yellow substance-stained bed linen. Resident #49's bed linen was stained with brown stains with trash, food crumbs, and various pieces of paper underneath his bed. Resident #49's nightstand had an unmeasurable amount of dust with a white landline phone with red and brown stains (appeared to be blood) covering the receiver end of the phone. Observation also revealed the entire floor was covered in dirt, sticky substances with various red and brown colored stains. Interview and observation on 01/08/25 from 10:09 A.M to 10:18 A.M. with Licensed Practical Nurse (LPN) #820 revealed the housekeepers didn't clean resident's rooms on a daily basis and when the rooms were cleaned, it wasn't a good job. LPN #820 confirmed and verified the appearance of the room belonging to Resident's #49, #58, and #123. Interview on 01/08/25 at 10:40 A.M. with Certified Nurse Assistant (CNA) #888 revealed the temperature of the shower water located on the 2 East Unit was ice cold. Interview on 01/08/25 at 10:43 A.M with CNA #947 revealed the water in the shower room located on the 2 East Unit did not get hot. Observation on 01/08/25 at 10:54 A.M. with CNA #947 of the shower room located on the 2 East Unit revealed the shower water was turned on and was cold to the touch. The shower water ran for approximately three minutes with no changes or fluctuations. Interview and observation on 01/08/25 at 11:02 A.M. with Resident #29 revealed his room floors were dirty and needed cleaned. Resident #29 revealed he needed clean bed linen. Observation of Resident #29 room, shared with Resident #81, revealed both beds linen was stained, and the entire floor was covered in various stains and trash and/or unknown debris. Observation of Resident #81 bed revealed multiple sheets balled up underneath his bed. Interview and observation on 01/08/25 at 11:04 A.M. with LPN #855 revealed housekeepers were seen daily but she did not know the schedule of cleaning. LPN #855 revealed the housekeeping staff would leave garbage bags at the nursing stations for nurses and aides to assist with clean-up, but nursing required a lot of their time. LPN #855 confirmed and verified the observations in the room belonging to Resident's #29 and #81. 365608 Page 10 of 11 365608 01/10/2025 Aristocrat Berea Healthcare and Rehabilitation 255 Front Street Berea, OH 44017

F 0921 Level of Harm - Minimal harm or potential for actual harm Interview on 01/08/25 at 11:06 A.M. with CNA's #826 and #919 revealed the shower room located on the third floor, belonging to the 3 East and 3 [NAME] Units of the facility, shower water did not get hot. Interview on 01/08/25 at 11:11 A.M. with Resident #17, who resided on the 1 East Unit, revealed her room did not get cleaned. Residents Affected - Some Interview and observation on 01/08/25 from 11:39 A.M. to 12:00 P.M. with Maintenance Director (MD) #953, during tour of the facility, revealed the water temperatures in the building were checked routinely, and as recently as 01/07/25. MD #953 revealed he was unaware of any concerns related to water temperatures in the facility shower rooms and he kept a log of his water checks. Observation during tour of the facility, with MD #953, revealed the shower room located on the 2 East Unit produced a water temperature reading of 95 degrees Fahrenheit and the shower room located on the third floor, belonging to the 3 East and 3 [NAME] Units of the facility, produced a water temperature reading of 95 degrees Fahrenheit. Follow-up interview on 01/08/25 at 12:15 P.M. with MD #953 revealed he was unable to produce a log of checked water temperatures. MD #953 revealed water temperatures were to reach between a minimum of 105 degrees Fahrenheit and a maximum of 120 degrees Fahrenheit. MD #953 confirmed and verified the above findings during the tour of the facility. Review of the facility document titled Water Temperature Testing, revised March 2023, revealed the facility had a policy in place to test the temperature of the water at least weekly to ensure temperatures were held between 105- and 120-degrees Fahrenheit. Review of the document revealed the facility did not implement the policy. Review of the facility document titled Housekeeping, dated April 2018, revealed the facility had a policy in place that the rooms and common areas were cleaned and maintained. Review of the document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00161301. 365608 Page 11 of 11