Aristos Nursing and Rehab: Wound Documentation Failures - OH
The resident, identified in inspection documents only as Resident #1, had been admitted to hospice care on August 11. Seven days later, at 4:09 a.m., LPN #547 documented two new pressure areas on his bilateral inner ankles. That incident report, inspectors found, was never made part of his medical record. No formal wound assessment appeared there until August 20.
The gap matters. Pressure wounds on hospice patients, who are often bedridden, can deteriorate rapidly. Two days without documented assessment means two days without a treatment record, two days without a baseline for tracking whether the wounds were worsening, and two days in which any clinician picking up that chart would have had no idea the wounds existed.
The hospice nurse who responded to the 4:00 a.m. call, identified as Hospice Nurse #572, told inspectors she came to the facility later that day, assessed the resident, wrote new treatment orders, and placed her skin assessments in his hospice binder. When inspectors interviewed her on September 24, she confirmed she had no written wound assessments for the right or left ankles. Whatever she documented that afternoon, it was not a formal wound assessment, and it was not in the medical record.
She also confirmed something broader. Hospice staff visited Aristos twice weekly. But when RN #569 reviewed Resident #1's full medical record on September 24, she found no documentation of any hospice nurse or aide visits since his admission to hospice on August 11. Not a single visit. More than a month of hospice care, and the chart was blank.
The Vice President of Operations, identified in the report as Present of Operations #568, sat down with inspectors on September 25. She confirmed the August 18 incident report was not part of the medical record. She confirmed there were no initial wound assessments in the chart until August 20. She did not dispute the findings.
The facility's own wound care policy, dated October 2010, instructs staff to document any change in a resident's condition and all assessment data obtained when inspecting a wound. The policy existed. The documentation did not.
Federal inspectors classified the deficiency under F0686, which covers the prevention and treatment of pressure ulcers and skin integrity. The level of harm was cited as minimal harm or potential for actual harm, affecting a few residents. The violation was investigated under Complaint Number 2591659.
What the inspection report does not say is how Resident #1 fared. It does not say whether the pressure areas on his ankles healed or worsened. It does not say whether the two-day documentation gap delayed any treatment he needed, or whether the missing hospice visit records reflected visits that actually happened but were never written down, or visits that never happened at all. Those are different problems with different consequences, and the record does not resolve which one it was.
What the record does say is that a man on hospice, in the last stretch of his life, developed new wounds overnight, and the facility responsible for his care left those wounds out of his chart for two days. The nurse who assessed him that morning left no written record. The hospice nurse who came that afternoon left no written record. When a complaint triggered a federal inspection five weeks later, the chart still had nothing in it documenting who had visited him or what they had found since the day he entered hospice care.
The Vice President of Operations verified all of it. She did not indicate it had been corrected.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aristos Nursing and Rehabilitation from 2025-09-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 12, 2026 · Our methodology
Aristos Nursing and Rehabilitation in CLEVELAND, OH was cited for violations during a health inspection on September 29, 2025.
The resident, identified in inspection documents only as Resident #1, had been admitted to hospice care on August 11.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.