Carecore at Mentor

Inspectors wroteBased on interview and record review, the facility failed to ensure that facility heating units were maintained in good repair. This affected 20 residents (#8, #23, #30, #37, #39, #41, #42, #43, #49, #55, #58, #60, #65, #70, #72, #75, #81, #85, #86, and #93) of 93 residents residing in the facility. The facility census was 93.

Inspectors wroteBased on closed record review and interview, the facility failed to adequately monitor Resident #85's condition including bowel and bladder elimination to timely identify and treat infection and constipation. This affected one resident (#85) of three residents reviewed for change in condition. The facility census was 80. Actual harm occurred on 06/25/25 after Resident #85 who had cystitis (inflammation of the bladder), reflux, diabetes, impaired cognition and mobility, a high risk for constipation and infection, and a history of sepsis (a life-threatening response to an infection) failed to receive sufficient monitoring to timely treat constipation and infection. [...]

Inspectors wroteBased on closed medical review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to promote healing and to prevent a decline and infection in pressure ulcers. This affected one resident (#87) of three residents reviewed for pressure ulcers. The facility census was 80. Actual harm occurred beginning on 04/30/25 when Resident #87, who was admitted to the facility with two Stage IV (a severe open sore that has penetrated through all layers of the skin and underlying tissue exposing muscle, tendon or bone) pressure wounds was noted to have a deterioration in wound status (green drainage indicative of infection and increase in size). Wound cultures were not obtained until 05/15/25. [...]

Inspectors wroteBased on record review and interviews, the facility failed to timely notify Resident #84's family of the resident's hospitalization. This affected one resident (#84) of three residents reviewed for change in condition. The facility census was 80.

Inspectors wroteBased on record review and interview, the facility failed to timely collect a urine sample and start an antibiotic for a urinary tract infection (UTI). This affected one (Resident #84) of three residents reviewed for timely lab work. The facility census was 80.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure the ice machine filter was clean and sanitary and that staff properly secured and covered their hair while working in the kitchen. This had the potential to affect all residents (except Residents #45 and #85 who were identified by the facility as having orders for nothing by mouth) who received food from the kitchen. The facility census was 84.

Inspectors wroteBased on observation, interview, review of email communication between the facility and the repair company, and review of the quote for repairs, the facility failed to maintain the walk-in freezer in a proper working condition and address a malfunction of the freezer door in a timely manner. This had the potential to affect all residents (except Residents #45 and #85 who were identified by the facility as having orders for nothing by mouth) who received food from the kitchen. The facility census was 84.

Inspectors wroteBased on observation, interview and record review, the facility failed to change nasal cannula oxygen tubing in a timely manner. This affected four residents (#22, #32, #64 and #69) of 18 residents identified as utilizing oxygen. The facility census was 84.

Inspectors wroteBased on record review, staff interview, admitting facility documents and hospital paperwork, the facility failed to adequately capture Resident #47 health status at the time of the Minimum Data Set Assessments (MDS). This affected one (#47) of one reviewed for dialysis. The facility census was 84.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to develop and implement a plan of care for use of psychotropic medications for Resident #72. This affected one (#72) of five residents reviewed for unnecessary medications. The facility census was 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to securely administer medications according to Resident #3's needs. This affected one resident (Resident #3) of five residents reviewed for medications. The total census was 84.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5 percent (%). A total of 27 medications were observed with two errors identified for a medication error rate of 14.8 %. This affected one (Resident #3) of five residents reviewed for medication administration. The total census was 84.

Inspectors wroteBased on record review, review of hospital records, facility policy review and interview the facility failed to ensure Resident #91 was free from a significant medication error when the facility administered Resident #91's diuretic (medication to increase the production of urine) when it should have been on hold. Actual Harm occurred on 03/29/24 when the facility failed to hold Resident #91's diuretic medication resulting in a significant change in the resident's condition resulting in an unplanned hospitalization. [...]

Inspectors wroteBased on medical record review, facility policy review and interview the facility failed to ensure Resident #91's medical record was complete and accurate. This affected one resident (#91) of nine residents reviewed for accuracy of medical records. The facility census was 87.

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to provide comprehensive, individualized and sufficient wound care for Resident #28 and Resident #95. This affected two residents (#28 and #95) of three residents reviewed for non-pressure related wound care. The facility census was 90. Actual harm occurred on 03/21/24 when Resident #28, who was incontinent and admitted for wound care, was directly admitted to the hospital with a foul smelling, pus draining, painful wound and diagnosed with cellulitis/infection due to a lack of monitoring and adequate wound care following the resident's admission on [DATE].

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure Resident #62 received nutritional supplements as ordered, failed to develop and implement a comprehensive and effective nutrition program, and failed to obtain re-weights and/or weekly weights when a severe weight loss was noted. This affected one resident (#62) of three residents reviewed for nutrition. The facility census was 90. Actual harm occurred when Resident #62, who weighed 11.0 pounds on 01/04/24, experienced a severe 6.2% weight loss from 01/04/24 to 02/01/24, continued to lose an additional 8.4% from 02/01/24 to 03/01/24, and the weight loss was not addressed until 02/28/24. Resident #62 did not receive nutritional supplements as ordered. Resident #62's weight of 95.4 pounds on 03/01/24 reflected a severe weight loss of 14.5% over 56 days.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient tracheostomy care for Residents #19 and #29. This affected two residents (#19 and #29) of three residents reviewed for tracheostomy care. The facility census was 90. Actual harm occurred on [DATE] and on [DATE] when Resident #19, who was cognitively impaired and was dependent on staff for tracheostomy care, was admitted to the hospital with acute on chronic respiratory failure with hypoxia, recurrent infection, and need for mechanical ventilation. On [DATE] there was concern for mucus plugging prior to the hospital stay which contributed to the respiratory failure. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff used appropriate infection control practices by not implementing required enhanced barrier precautions for Residents #19 and #61, appropriately handling soiled linen and paper hand towels for Resident #61, and not performing hand hygiene and using a clean barrier during wound care for Resident #22. This affected three residents (#19, #22 and #61) and had the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean and homelike environment within resident hallways and a shower room. This affected eight residents (#17, #24, #33, #35, #38, #46, #55 and #73) and had the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure thorough and accurate fall investigations were completed for Residents #5, #94, and #97. This affected three residents (#5, #94, and #97) of four residents reviewed for accidents. The facility census was 90.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain orders for and provide sufficient urinary catheter related care for Resident #19. This affected one resident (#19) of one resident reviewed for urinary catheters. The facility census was 90.

Inspectors wroteBased on interview, observation, and record review the facility did not ensure a safe, functional, sanitary, and comfortable shower room. This affected two residents (#42 and #82) out of two residents reviewed for the accommodation of showers and had the potential to affect all 17 residents (#2, #12, #23, #32, #34, #39, #41, #42, #47, #60, #61, #62, #71, #77, #78, #79, #82) residing on the secured unit. The facility census was 93.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure all medications were properly dated when opened to ensure they were not used after expiration and failed to ensure all medications were properly stored and not left unattended. This affected four residents (#28, #18, #331 and #19) and had the potential to affect all 77 residents residing in the facility. Findings Include: 1. On 03/30/22 at 11:11 A.M. observation and interview with Registered Nurse (RN) #258 of the medication storage room for the 300-400 hall revealed a vial of floucolvax (flu vaccine) dated as filled 10/11/21 was opened with no date marked as to when it was opened. Interview with RN #258 at the time of the observation confirmed the vial was not dated when opened. On 03/30/22 at 11:18 A.M. [...]

Inspectors wroteBased on observation, facility policy and procedure review and interview the facility failed to ensure all staff wore hair restraints in the kitchen and failed to ensure food items were properly stored and labeled to prevent contamination and/or food borne illness. This had the potential to affect 76 of 76 residents who received meals from the kitchen. The facility identified one resident (Resident #47) who received nothing by mouth. The facility census was 77. Findings Include: On 03/28/22 from 6:50 A.M. to 7:10 A.M. an initial tour of the kitchen revealed Dietary Manager (DM) #216 was not wearing any type of hair restraint/hair net while in the kitchen. In addition, frozen cupcakes observed in the walk in freezer not dated. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure the State Ombudsman was notified of resident transfers/discharges as required. The facility identified 38 discharged / transferred residents (#18, #20, #78, #79, #80, #81, #82, #83, #84, #85, #87, #89, #90, #91, #92, #93, #94, #280, #281, #282, #283, #284, #285, #286, #287, #288, #289, #290, #291, #292, #293, #294, #295, #296, #297, #298, #283, #299, #300, #301 and #302) between 10/01/21 and 10/31/21 and from 12/01/21 through 02/28/22 for whom notification was not completed. The facility census was 77. Findings Include: Review of a facility discharge report, dated 04/01/22 for residents discharged from 10/01/21 to 10/31/21 and 12/01/21 to 02/28/22 revealed the following residents were discharged /transferred during those time periods: Resident #18 was discharged [DATE]. Resident #20 was discharged [DATE]. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #332, Resident #11, Resident #13 and Resident #19, who required staff assistance for personal care received timely and adequate assistance with showers and/or nail care to maintain proper hygiene. This affected four residents (#11, #13, #19 and #332) of six residents reviewed for activities of daily living (ADL) care. Findings Include: 1. Review of the medical record for Resident #332 revealed an admission date of 03/09/22 with diagnoses including chronic obstructive pulmonary disease (COPD), muscle wasting, difficulty walking, type 2 diabetes mellitus, constipation, malignant neoplasm of anterior mediastinum (cancer of breastbone), generalized edema, hypertensive heart disease, ascites and pleural effusion. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure an advance directive/code status was identified and documented for Resident #330 to reflect the resident's wishes in the event the resident required life sustaining measures. This affected one resident (#330) of four residents reviewed for advanced directives. Findings Include: Review of the medical record for Resident #330 revealed an admission date of [DATE] and a readmission date of [DATE]. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #31 was offered/provided privacy during a medical procedure (laboratory testing). This affected one resident (#31) randomly observed during the annual survey. The facility census was 77. Findings Include: Review of medical record for Resident #31 revealed an admission date of 12/14/21. Resident #31 had diagnoses including hemiplegia affecting left non dominant side, type two diabetes mellitus and cerebral infarction. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/12/22 revealed Resident #31 was cognitively intact, required extensive one person physical assistance for bed mobility, dressing and personal hygiene, set up assistance only for eating and was totally dependent on one person for toileting. [...]

Inspectors wroteBased on record review and interview the facility failed to follow through with a physician approved pharmacy recommendation related to the use of as need (PRN) psychoactive medication (Haldol) for Resident #1 and failed to ensure the PRN medication order was limited to 14 days or included a physician rationale for a longer ordered duration. This affected one resident (#1) of five residents reviewed for unnecessary medication use. Findings Include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, restlessness and agitation, delusional disorders, visual hallucinations, insomnia, suicidal ideations, major depressive disorders, and adjustment disorders with anxiety. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property as required. This had the potential to affect all 77 residents residing in the facility. Findings Include: Review of the personnel file for Social Services (SS) #245 revealed a hire date of 01/25/22. The printed evidence of SS #245 being checked against the NAR was not completed until 03/28/22. Review of the personnel file for Admissions #204 revealed a hire date of 03/10/22. The printed evidence of admission #204 being checked against the NAR was not completed until 03/16/22. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations were documented, communicated to the doctor, and acted on appropriately. This affected one (Resident #96) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were administered with an error rate of less than 5%. This affected one (Resident #87) of five residents observed for medication administration. There were three errors observed out of a possible 25 opportunities for an error rate of 12%. The facility census was 113.