Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aristocrat Berea Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Multiple areas of the facility were found to be unclean or unsanitary, including a dining room with food debris, a laundry room with soot from a previous dryer fire, and a resident's room with a strong odor due to refusal to bathe. Staff confirmed delays in cleaning and repairs, and residents reported unaddressed maintenance issues.
The facility did not report an allegation of misappropriation involving possible forged signatures on narcotic logs for two cognitively intact residents receiving oxycodone. An LPN raised concerns to management, and the DON conducted an internal investigation, including drug testing of staff, but did not notify the State Agency as required by policy and regulation.
The facility did not fully investigate allegations of misappropriation involving two cognitively intact residents with orders for oxycodone. The DON confirmed that only face-to-face interviews with nurses were conducted, with no written statements or resident interviews documented, contrary to facility policy requiring comprehensive interviews and documentation.
A resident with a history of psychiatric and behavioral issues made an allegation that staff twisted her arm, but later retracted the claim and apologized. Despite internal investigation and staff belief that the allegation was false, the facility did not report the abuse allegation to the State agency as required by policy, resulting in noncompliance.
The facility failed to accommodate residents' dietary preferences, consistently serving Kool-Aid as the only drink option with meals, despite residents' complaints and preferences for alternatives like orange juice, tea, and coffee. Staff interviews and observations confirmed the lack of drink options, and the Dietary Manager acknowledged the issue, noting that other options were available but not provided.
The facility failed to maintain comfortable temperature levels, affecting multiple residents across two units. Observations revealed cold air circulating in the 1 East Unit, with residents expressing discomfort due to the cold temperatures. Interviews with residents and staff confirmed the issue, with reports of cold air blowing from vents. The Maintenance Director was unaware of the temperature concerns and confirmed the findings during a tour, with temperature readings below the facility's policy range.
A facility failed to maintain a Hoyer lift, affecting a resident who required it for transfers. The resident was confined to bed due to the broken lift, and staff were unable to manually transfer her. Interviews with staff confirmed the lift's broken state, and the Maintenance Director was aware but unsure of repair timelines. The facility's policy on maintaining mechanical lifts was not implemented effectively.
The facility failed to maintain cleanliness and proper water temperatures, affecting residents across multiple units. Observations showed dirty rooms with stained linens and inadequate housekeeping. Water temperatures in shower rooms were below the required range, and the Maintenance Director was unaware of these issues, lacking a log of temperature checks. The facility did not implement its policies on cleanliness and water temperature testing.
A resident with cognitive impairment and dietary restrictions did not receive her lunch meal on time, causing distress and a lack of dignity. The CNA discovered the kitchen had forgotten to prepare the meal, resulting in a 19-minute delay before the Regional Culinary Director delivered the tray. This incident violated the facility's policy on resident rights.
A facility failed to maintain a resident's privacy and confidentiality by disclosing hospital admission details to family members, despite the resident's power of attorney requesting that information be shared only with her. The resident had severe cognitive impairment and various behavioral symptoms.
The facility failed to maintain its ice machines in a sanitary condition, affecting all residents. The main ice machine was out of service, and the second-floor machine had mold and a musty smell. The Dietary Manager confirmed the unsanitary condition, indicating a lapse in following the facility's cleaning policy.
The facility failed to maintain a sanitary environment, affecting residents using showers and dining areas. Observations revealed unsanitary conditions, including feces in shower rooms, broken tiles, and soap scum. In the dining room, gnats and spilled milk were noted, and gnats were also found in a resident's room. Staff verified these conditions during the survey.
The facility failed to assess the risks and benefits of bed rail removal, affecting several residents who relied on them for mobility. Staff interviews revealed that residents became dependent on staff for assistance, and reassessment was delayed. Additionally, a resident developed incontinence dermatitis due to inadequate care, with staff acknowledging the rash had been present for some time. The Director of Nursing was unaware of the issue, and the Nurse Practitioner confirmed the dermatitis was due to poor care.
A resident with schizophrenia and mobility issues experienced a fall after the facility removed her bedside rails, which were not included in her care plan. The removal followed an external survey, and the care plan was not updated to reflect this change, leading to the resident's increased dependency on staff for mobility.
Two residents experienced falls due to inadequate safety measures and supervision. One resident fell after bed rails were removed without proper assessment, while another fell while running in a wet hallway without staff intervention. Both incidents highlight deficiencies in the facility's fall prevention practices.
A resident with cognitive impairment was pushed by another resident, resulting in fractures to the left humerus and right wrist. Both residents had histories of aggressive behaviors and cognitive issues, but no prior incidents of abuse were documented. The facility's investigation confirmed the injuries were due to the altercation, highlighting a failure to protect residents from abuse.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary living environment, as evidenced by multiple observations and interviews. On one occasion, food, dirt, and dust were found in the first floor dining room during breakfast service, and two residents were told by a staff member that the dining room was closed, requiring them to eat in their rooms. In the main laundry room, black soot was observed on several ceiling tiles, a result of a dryer fire that had occurred approximately three months prior. The Housekeeping and Laundry Director confirmed the presence of soot and stated that replacement of affected items was pending insurance approval. Additionally, water damage was observed on two ceiling tiles above a resident's bed, and the resident reported that she had requested replacement but it had not yet occurred. Another deficiency was noted in a resident's room, which had a strong odor attributed to poor personal hygiene. Staff interviews confirmed that the resident was capable of bathing independently but consistently refused to do so, having only accepted one shower in the past three months. The strong odor in the room was acknowledged by both the LPN and CNA, who attributed it to the resident's refusal to bathe. These findings were substantiated through direct observation and staff and resident interviews.
Failure to Report Alleged Misappropriation of Resident Narcotics
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the State Agency as required by regulation and facility policy. Specifically, concerns were raised regarding the administration of oxycodone to two cognitively intact residents with complex medical histories, including conditions such as cerebral infarction, congestive heart failure, multiple sclerosis, and various psychiatric and pain disorders. An LPN reported to nursing management that another nurse may have been forging signatures on narcotic logs related to the administration of oxycodone for these residents. This concern was based on observations and reports from other nurses, including suspicions of signature forgery. Despite these allegations, the Director of Nursing (DON) confirmed that an internal investigation was conducted, which included requiring all nurses in the affected area to undergo drug testing. However, the DON did not consider the situation to be an allegation of misappropriation and therefore did not report it to the State Agency, as required by both facility policy and state regulations. The facility's policy clearly states that all incidents and allegations of misappropriation must be reported immediately to the administrator or designee and to the state department of health within two hours if abuse or serious bodily injury is alleged. The failure to report the incident constituted non-compliance with regulatory requirements.
Failure to Properly Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to fully investigate allegations of misappropriation involving two residents who were both cognitively intact and had physician orders for oxycodone for pain management. For one resident, the medical record showed an admission with multiple complex diagnoses, including dementia, heart failure, and chronic pain, while the other had a history of conditions such as antiphospholipid syndrome, depression, and fibromyalgia. Both residents had ongoing orders for oxycodone, and their Minimum Data Set assessments confirmed cognitive intactness at the time of the events. The Director of Nursing (DON) confirmed that an investigation was conducted regarding a nurse and the administration of narcotics, but no written statements were obtained from staff or residents. The DON stated that only face-to-face interviews were conducted with the nurses involved, and no documentation of interviews or statements from any potential resident victims was completed. This approach was not in accordance with the facility's policy, which requires interviews with the resident, the accused, and all witnesses, as well as documentation of the investigation. The lack of proper documentation and failure to interview residents directly led to the deficiency.
Failure to Report Resident Abuse Allegation as Required
Penalty
Summary
The facility failed to report an allegation of abuse as required by its policy and regulatory standards. A resident with a history of schizoaffective disorder, bipolar disorder, anxiety, depression, and chronic obstructive pulmonary disease made an allegation that staff twisted her arm behind her back. The resident's statements about the incident changed multiple times, and she later retracted her allegation and apologized to staff. Despite this, the facility's policy required all allegations of abuse to be reported to the State agency immediately, but the facility did not do so. The investigation was documented in a soft file, and the interdisciplinary team determined the allegation was false based on witness statements, a timeline, behavioral history, and a head-to-toe assessment. Interviews with facility staff, including the DON, administrator, and CNAs, confirmed that the allegation was not reported to the State agency because the resident retracted her statement and was known for making false allegations. The administrator stated that the incident was investigated internally, but not reported externally as required. The facility's policy clearly stated that all allegations, regardless of perceived credibility or retraction, must be reported to the State agency within two hours, and the results of the investigation must be reported within five days. This failure to report the allegation constituted noncompliance with both facility policy and regulatory requirements.
Failure to Accommodate Dietary Preferences
Penalty
Summary
The facility failed to ensure dietary preferences were followed, affecting all residents except one who was NPO. Multiple interviews with residents and staff revealed that residents consistently received Kool-Aid as their drink with meals, including breakfast, lunch, and dinner. Residents expressed dissatisfaction with this practice, preferring options like orange juice, tea, and coffee. Staff interviews confirmed that Kool-Aid was often the only drink available, leading to resident complaints. Observations in the dining room corroborated these findings, showing a lack of alternative drink options. The Dietary Manager acknowledged the issue, stating that residents had complained about receiving Kool-Aid with breakfast meals and that he had informed his staff that this was unacceptable. Despite having other drink options available, such as orange juice, apple juice, and cranberry juice, these were not being offered to residents. The facility's policy on Resident's Rights, which mandates reasonable accommodations for individual needs and preferences, was not implemented in this case, leading to the deficiency.
Facility Fails to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable temperature levels, affecting multiple residents across two units. Observations revealed cold air circulating in the 1 East Unit, with residents expressing discomfort due to the cold temperatures. Residents were observed wearing multiple layers and using extra blankets to keep warm. Interviews with residents and staff confirmed the issue, with reports of cold air blowing from vents and a general consensus that the building was cold. The Maintenance Director, responsible for maintaining a target temperature of 74 degrees Fahrenheit, was unaware of the temperature concerns and confirmed the findings during a tour. Temperature readings during the tour showed levels below the facility's policy range of 71 to 81 degrees Fahrenheit, with readings as low as 66 degrees Fahrenheit in some rooms. The facility's policy, dated March 2019, was not implemented effectively, leading to non-compliance with the requirement to provide a safe and comfortable environment. This deficiency was investigated under Master Complaint Number OH00161301.
Failure to Maintain Hoyer Lift Affects Resident Care
Penalty
Summary
The facility failed to maintain equipment necessary for resident care, specifically a Hoyer lift required for transferring residents. This deficiency affected one resident directly and had the potential to impact five additional residents who also required the use of a mechanical lift. The issue was identified through a combination of record reviews, observations, and interviews with residents and staff. The facility's policy required that mechanical lifting devices be accessible, maintained regularly, and kept in proper working order, but this policy was not implemented effectively. Resident #17, who was dependent on staff for activities of daily living and required a Hoyer lift for all transfers, was directly affected by the broken lift. The resident expressed dissatisfaction with being confined to bed due to the malfunctioning equipment, which had been broken for at least a week. Attempts to manually transfer the resident were unsuccessful due to her weight, and the facility had not taken steps to repair or replace the lift, leaving the resident unable to leave her bed. Interviews with staff, including an LPN, CNAs, and the Maintenance Director, confirmed the broken state of the Hoyer lift designated for the 1 East Unit. The Maintenance Director acknowledged the issue and mentioned a work order was in place, but was unsure of the timeline for repairs. The facility's work order report showed two related entries, but no resolution was evident. The deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its own mechanical lift policy.
Deficiencies in Cleanliness and Water Temperature
Penalty
Summary
The facility failed to maintain a clean environment and ensure water temperatures were at a comfortable level, affecting multiple residents across different units. Observations revealed that several rooms were consistently dirty, with stained bed linens, dust, and debris present. Interviews with residents and staff confirmed that housekeeping was inadequate, with rooms not being cleaned daily or thoroughly. Additionally, the water temperature in the shower rooms on the 2 East Unit and the third floor was found to be cold, with readings of 95 degrees Fahrenheit, which is below the facility's policy requirement of 105 to 120 degrees Fahrenheit. The Maintenance Director was unaware of the water temperature issues and could not produce a log of temperature checks, despite the facility's policy requiring weekly testing. The facility's housekeeping policy, dated April 2018, was also not implemented, as rooms and common areas were not maintained as required. These deficiencies were identified during a survey, and the facility was found to be non-compliant with its policies, as documented under Master Complaint Number OH00161301.
Resident Dignity Compromised Due to Meal Service Delay
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity, as evidenced by an incident involving Resident #8. The resident, who had cognitive impairment and required assistance for eating, was admitted with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, and hypothyroidism. On the day of the incident, Resident #8 did not receive her lunch meal tray while seated with other residents who were served their meals. The CNA responsible for distributing the trays discovered that the kitchen had forgotten to prepare Resident #8's meal, leading to a delay in service. During the delay, Resident #8 became visibly upset, yelling, screaming, and crying while pacing the dining room, unable to be redirected. Approximately 19 minutes later, the Regional Culinary Director arrived with the resident's meal. The facility's policy on resident rights, which mandates treating residents with courtesy, respect, and dignity, was not implemented in this instance, as confirmed by the CNA and the facility's documentation. This deficiency was identified during a complaint investigation.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records. Resident #3, who had diagnoses including psychosis, impulse disorder, and alcohol dependence with alcohol-induced dementia, was involved in this incident. The resident had severely impaired cognition and exhibited various behavioral symptoms. The facility's administrator posted on the Electronic Medical Record (EMR) screen that the resident's daughter, who was also the power of attorney, requested that no information be shared with family members except for her. Despite this request, when a large group of family members visited the facility while the resident was hospitalized, they were informed by the facility about the resident's hospital admission and the reason for it. This breach of confidentiality was verified through interviews with the Director of Nursing and the resident's daughter.
Unsanitary Ice Machine Conditions
Penalty
Summary
The facility failed to maintain its ice machines in a clean and sanitary condition, which had the potential to affect all residents. During an observation, it was noted that the main ice machine had been out of service since June, and the facility was using an alternative machine on the second floor. Upon inspection, the second-floor ice machine was found to have a large area of slimy brown and green mold on its top portion and emitted a musty smell when opened. The Dietary Manager confirmed the unsanitary condition of the ice machine at the time of observation. The facility's policy on cleaning schedules, dated October 2021, indicated that the culinary manager or a designee is responsible for monitoring the sanitation of the department and assigning corrections as needed. However, the presence of mold and the musty smell in the ice machine suggest that these procedures were not adequately followed, leading to the deficiency.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for its residents, affecting 68 residents who used the showers and 21 residents who ate in the third-floor dining room. Observations revealed unsanitary conditions in the shower rooms, including feces left by a resident with a colostomy bag, towels and blankets on the floor, a toothbrush in the shower stall, and broken tiles. Additionally, the third-floor shower room had a malfunctioning shower head and unsecured drain cover, with soap scum present on the walls and floor. These conditions were verified by staff members during the survey. In the dining room, approximately 12 gnats were observed flying around, and a large amount of spilled milk was found between a tray and a cart. In a resident's room, gnats were seen crawling on a washcloth and lying in a box on the floor. Despite the presence of gnats, the resident expressed no concern. Staff members, including a State Tested Nurse Assistant (STNA) and a Licensed Practical Nurse (LPN), confirmed these observations. The deficiency was investigated under Complaint Numbers OH00156449 and OH00155557.
Failure to Assess Bed Rail Removal and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely assessment of residents and review of the risks and benefits of bed rails after removing all bed rails that were in use. This affected six residents who were previously using side rails and grab bars for mobility and transfers. Interviews with staff revealed that the removal of bed rails left residents dependent on staff for mobility, making it more difficult for both residents and staff. The facility had an outside company survey the facility, which led to the directive to remove all bed rails, but residents were not reassessed for bed mobility until over a month later. Several residents expressed their dissatisfaction with the removal of bed rails, stating that they felt safer and more independent with the rails in place. For instance, one resident reported that she was able to get in and out of bed independently with the grab bars, but now required staff assistance. Another resident mentioned spending more time in bed due to the increased difficulty in performing bed mobility tasks without the rails. The lack of timely reassessment and communication with residents about the removal of bed rails contributed to the deficiency. Additionally, the facility failed to provide timely incontinence care for a resident, resulting in incontinence dermatitis. The resident's medical record indicated a potential for pressure ulcer development, but documentation showed inconsistent incontinence care. Observations revealed a red rash covering the resident's peri-area, which staff acknowledged had been present for some time. The Director of Nursing was unaware of the rash, and the Nurse Practitioner confirmed the dermatitis was due to poor incontinence care. This deficiency was investigated under multiple complaint numbers.
Failure to Update Care Plan Following Removal of Bedside Rails
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident regarding the use of bedside rails, which were essential for the resident's bed mobility and independence in getting in and out of bed. The resident, who had diagnoses including schizophrenia and unsteadiness on feet, was admitted with a care plan that did not include the use of side rails or grab bars, despite their importance for her daily living activities. The resident's quarterly Minimum Data Set (MDS) assessment indicated she had intact cognition and required assistance for certain movements, but the care plan lacked specific interventions related to the use of side rails. An incident occurred where the resident was found on the floor after attempting to use the removed side rails, which she relied on for mobility. The facility had removed all bed side rails and grab bars following an external survey, without updating the resident's care plan to reflect this change or providing alternative solutions. Interviews with staff and the resident confirmed that the removal of the side rails directly contributed to the resident's fall, as she was previously able to get in and out of bed independently with their assistance.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents by not adequately assessing and managing the removal of bed rails, which led to a fall incident involving Resident #133. This resident, who had diagnoses including schizophrenia and unsteadiness on feet, was found on the floor after attempting to use bed rails that had been removed without proper assessment of her ability to exit the bed safely. The resident had previously used the bed rails for mobility and had no falls prior to their removal. Interviews with staff revealed that the removal of bed rails left residents dependent on staff for mobility, contributing to the fall incident. Additionally, the facility did not provide adequate supervision to prevent accidents for Resident #135, who was severely cognitively impaired and at moderate risk for falls. The resident was observed sprinting in a hallway that was wet due to floor cleaning activities, with staff present but not intervening to prevent the hazardous situation. The resident fell after running alongside an activities worker, who confirmed the events. The facility's fall policy emphasizes the need for proper review and intervention to prevent falls, which was not adhered to in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect Resident #143 from an incident of resident-to-resident physical abuse, resulting in actual harm. On June 18, 2024, Resident #143, who was cognitively impaired but independent with activities of daily living (ADLs), was pushed by Resident #109, leading to a fall. This incident resulted in Resident #143 sustaining a left humerus fracture and later a right wrist fracture, which significantly impacted his independence in ADLs. The facility's investigation confirmed that both fractures were a result of the incident on June 18, 2024. Resident #143 had a history of aggressive behaviors and cognitive impairment, as noted in his care plan dated March 24, 2024. Similarly, Resident #109, who was also cognitively impaired, had a history of delusions and physically aggressive behaviors. Despite these histories, there were no documented incidents of resident-to-resident abuse between them prior to the incident. The facility's self-reported incident (SRI) and subsequent investigation revealed that Resident #109 initially denied but later admitted to pushing Resident #143 due to delusional thoughts involving a non-existent wife. The facility's policy on abuse, neglect, and exploitation defines physical abuse as any demeaning physical contact, which was violated in this case. The incident was reported to the state agency, and the facility's investigation included witness statements and medical record reviews. Despite the lack of prior incidents, the physical altercation between the residents resulted in significant injuries to Resident #143, highlighting a failure in ensuring resident safety and protection from abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Berea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hopkins Rehabilitation And Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Northwestern Healthcare Center | 0.7 mi | ★★★★★ | 30 | 1 |
| O'neill Healthcare Middleburg Heights | 1 mi | ★★★★★ | 7 | 0 |
| Parkside Villa | 1.1 mi | ★★★★★ | 0 | 0 |
| Berea Center | 1.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.