Health inspection·September 28, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to notify Resident #100's emergency contact of a significant change in condition. This affected one of three residents reviewed. The facility census was 43. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE], with diagnoses including atrial fibrillation, left-side hemiplegia and hemiparesis following cerebral infarction, bilateral hypertensive retinopathy, hypertension, hyperlipidemia, gastrointestinal reflux disease, borderline personality disorder, anxiety, depression, and nicotine dependence. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was alert and oriented with a Brief Interview for Mental Status score of 15/15. Resident #100 was her own responsible party. A family member was listed as the first emergency contact in the medical record. Review of the nurse progress note dated 09/14/23 timed 5:09 P.M. indicated Resident #100 was observed sitting in her motorized wheelchair outside in the resident courtyard. Resident #100's eyes were semi-open and she was non-responsive to verbal commands and a sternal rub. Emergency Medical Services were contacted via the 911 system. Narcan (opioid overdose treatment) was administered twice. Resident #100 became more aroused than previously but not at 100 percent. Resident #100 was transported to the hospital Emergency Department for evaluation and treatment. Review of the Discharge-Anticipated Return MDS assessment dated [DATE] indicated Resident #100 was discharged to the hospital due to a change in condition. During interview on 09/26/23 at 11:37 A.M., the Director of Nursing (DON) indicated she had a conversation with Resident #100 ten minutes prior to the resident going to the courtyard area to smoke. The DON indicated there was no evidence of an impending medical crisis. The DON indicated she was notified by staff that Resident #100 was in the courtyard slumped in her wheelchair and non-responsive. During interview on 09/26/23 at 3:11 P.M., Licensed Practical Nurse (LPN) #500 indicated she had spoken to Resident #100 approximately five minutes prior to the resident exiting into the courtyard to smoke when another resident entered the building to inform staff of the resident's unresponsiveness. LPN #500 indicated she called Resident #100's emergency contact and left a voicemail message that (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366058 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aristos Nursing and Rehabilitation 4650 Rocky River Dr Cleveland, OH 44135 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)