Inspection visit
Inspection
21 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 21 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
the medical record for Resident #193 revealed admission date 12/30/22. Diagnoses include malignant
neoplasm of esophagus, severe-protein calorie malnutrition, dysphagia, atrial fibrillation, hypertension,
bradycardia, abnormal weight loss, dementia, adult failure to thrive, anxiety disorder, renal insufficiency,
and slow transit constipation.
Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #193 Brief Interview for
Mental Status (BIMS) scored 99 which indicated the resident was unable to complete the interview. Staff
assessed Resident #193 with long and short term memory problem. Physical behavioral symptoms directed
towards others occurred one to three days. Verbal behavioral symptoms directed towards others occurred
one to three days. Behaviors significantly interfere with the resident's participation in activities or social
interactions. Rejection of care occurred one to three days and wandering occurred four to six days.
Resident #193 required extensive two plus person assistance for bed mobility, transfers, dressing, and toilet
use. The resident required extensive one person assistance for walk in room, and locomotion off unit,
personal hygiene and eating. Resident #193 was frequently incontinent of bladder and occasionally
incontinent of bowel. Resident #193 had a condition or chronic disease that may result in a life expectancy
of less than six months. The resident had recent surgery requiring skilled nursing facility care, involving the
gastrointestinal or abdominal contents from the esophagus to the anus, (including creation or removal of
ostomies). The resident had a feeding tube.
Review of the plan of care for Resident #193 revealed the care plan was initiated on 01/09/23.
Interview on 01/11/23 at 1:37 P.M. SSD #160 stated Resident #193 did not have a baseline care plan when
she conducted the care conference dated 01/03/23.
Interview on 01/11/23 at 1:41 P.M. MDS Nurse/Licensed Practical Nurse (LPN) #170 stated the 48
hour/baseline care plan should be completed by the unit nurse, unit manager, or nurse that does the
admission.
Review of the facility's policy titled Care Plan Policy and Procedure dated revised 2019 revealed the facility
will develop and implement a baseline care plan within 48 hours. The baseline care plan will be developed
within 40 hours of a resident's admission and a copy should be provided to the resident within the first 72
hours of admission.
Based on medical record review, staff and resident interviews, and review of facility policy, the facility failed
to complete baseline care plans for residents. This affected three (#4, #193, and
(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 10
Event ID:
365566
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0655
#243) of 14 residents in the sample. The census was 39.
Level of Harm - Minimal harm
or potential for actual harm
Findings include:
Residents Affected - Few
1. Review of Resident #243's medical record revealed an admission date of 01/05/23. Diagnoses listed
included fracture of the left femur, cerebral ataxia, chronic obstructive pulmonary disease, epilepsy, and
osteoarthritis.
A comprehensive Minimum Data Set (MDS) assessment had not yet been completed.
Further of Resident #243's revealed no documentation of a baseline care plan being completed.
The Director of Nursing (DON) confirmed during an interview on 01/11/23 at 1:55 P.M. that a baseline care
plan was not completed for Resident #243.
During an interview on 01/11/23 at 2:00 P.M. Resident #243 stated he did not remember receiving any
baseline care plan upon admission to the facility.
2. Review of the medical record for Resident #4 revealed admission date of 12/07/22 with diagnoses
including but not limited to chronic respiratory failure with hypoxia, pneumonia due to Coronavirus Disease
2019 (COVID-19), chronic obstructive pulmonary disease, atrial fibrillation, anemia, insomnia, depression,
anxiety, and hypertension.
Review of admission MDS dated [DATE] for Resident #4 revealed a BIMS score of 13 which indicated
cognitively intact. Resident #4 required extensive assistance of two for bed mobility, transfers, and toileting.
Resident #4 required extensive assist of one for dressing and personal hygiene.
Further review of medical record for Resident #4 revealed no evidence of baseline care plan.
Review of Care Plan for Resident #4 revealed comprehensive care plan was initiated on 12/19/22.
Interview on 01/11/23 at 3:27 P.M. with Social Service Director (SSD) #160 verified Resident #4 did not
have a baseline care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 2 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on record review, staff and resident interviews and policy review, the facility failed to initiate a
comprehensive care plan for smoking. This affected two (#34 and #9) of two residents reviewed for
smoking. Facility census was 39.
Findings include:
1. Review of medical record for Resident #34 revealed admission date of 09/06/22 with diagnoses including
but not limited to dementia, cannabis abuse, major depressive disorder, post-traumatic stress disorder, and
anxiety.
Review of Quarterly Minimum Data Set (MDS) for Resident #34 dated 11/11/22 revealed Brief Interview of
Mental Status (BIMS) score of 13 which indicated cognitively intact. Resident required supervision with set
up help for activities of daily living (ADL's).
Review of smoking assessment for Resident #34 dated 09/26/22 revealed the resident had cognitive loss,
visual deficit, and no dexterity problem. Smoked two to five cigarettes daily in the morning, afternoon, and
evenings. Resident can light own cigarette, required supervision, and facility to store lighter and cigarettes.
Plan of care is used to assure resident is safe with smoking.
Review of care plan for Resident #34 revealed resident at risk for injury related to smoking was initiated on
01/10/23.
Interview on 01/09/23 at 9:40 A.M. with Resident #34 stated the residents who smoke at the facility go out
to smoke at specific times. Resident #34 stated the facility holds their cigarettes, lighters, and supervised
smoking in the smoking area. Resident #34 confirmed he/she smokes.
Interview on 01/10/23 at 1:53 P.M. with Administrator verified Resident #34's care plan for smoking was
completed on 01/10/23.
Interview on 01/11/23 at 1:45 P.M. with MDS Nurse #170 verified she added a smoking care plan on
01/10/23. MDS Nurse #170 stated she was made aware on 01/10/23 that Resident #34 needed a care plan
for smoking.
2. Review of medical record for Resident #9 revealed admission date of 11/28/22 with diagnoses including
but not limited to nicotine dependence cigarettes, cognitive communication deficit, hypertension,
hyperlipidemia, paranoid schizophrenia, bipolar disorder, and unspecified psychosis not due to substance
or known physiological condition.
Review of Quarterly MDS for Resident #9 dated 12/13/22 revealed BIMS score of 13 which indicated
cognitively intact. Resident #9 required supervision for bed mobility, transfers, ambulation, and eating.
Resident #9 required extensive assist of one for toileting and limited assistance of one for personal hygiene.
Review of smoking assessment for Resident #9 dated 10/29/22 revealed resident did not have cognitive
loss, visual impairment, or dexterity problem. Resident smoked two to five cigarettes per day in the
morning, afternoon, evenings, and nights. Resident can light own cigarettes and required one on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 3 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
one assistance. Facility to store lighter and cigarettes. Plan of care used to assure resident is safe while
smoking.
Review of care plan revealed Resident #9 at risk for injury related to smoking was initiated on 01/10/23.
Interview on 01/10/23 at 10:18 A.M. with Resident #9 stated the residents who smoke at the facility go out
to smoke once in awhile. Resident #9 confirmed he/she is smokes.
Interview on 01/10/23 at 1:53 P.M. with Administrator verified care plan for smoking was completed on
01/10/23.
Interview on 01/11/23 at 1:45 PM with MDS #170 verified she added Resident #9's smoking care plan on
01/10/23. MDS Nurse #170 stated she was made aware on 01/10/23 that Resident #9 needed a care plan
for smoking.
Review of policy titled Smoking Policy- Residents revised July 2017 revealed any smoking-related
privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care
plan, and all personnel caring for the resident shall be alerted to these issues.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 4 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were
free from unnecessary psychotropic medications when the facility failed to ensure as needed (PRN)
antipsychotic medications was not ordered for longer than 14 days. This affected one (#14) of six residents
reviewed for unnecessary medications. The census was 39.
Findings include:
Review of Resident #14's medical record revealed an admission dated of 08/24/21. Diagnoses listed
included dementia without psychotic disturbance, atrial fibrillation, tachycardia, and dorsalgia.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was
moderately cognitively impaired and required supervision to limited assistance with activities of daily living
(ADL's).
Review of physician orders revealed an order dated 11/07/22 for Haloperidol (antipsychotic medication)
tablet 0.5 milligrams (mg), give one tablet by mouth every four hours PRN for
nausea/vomiting/agitation/delirium and give two tablets by mouth every four hours PRN for
nausea/vomiting/agitation/delirium per Hospice order. The order for Haloperidol did not have and end date.
During an interview on 01/10/23 at 4:35 P.M. the Director of Nursing (DON) confirmed that Resident #14's
PRN Haloperidol was ordered for longer than 14 days and did not have an end date.
Review of the facility's policy titled Antipsychotic Medication Use dated revised December 2016 revealed
PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare
practitioner has evaluated the resident for the appropriateness of that medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 5 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff interview, review of facility policy, and review of manufacturer
guidelines, the facility failed to ensure staff primed insulin pen devices (insulin pens) before insulin
administration resulting in a significant medication error. This affected one (#18) of five residents observed
for medication administration. The census was 39.
Residents Affected - Few
Findings include:
Review of Resident #18 medical record revealed an admission date of 03/14/22. Diagnoses listed included
chronic kidney disease, osteoarthritis, morbid obesity, and type two diabetes mellitus.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was
cognitively intact with a brief interview for mental status (BIMS) score of 14 and required extensive
assistance with activities of daily living (ADL's).
Review of physician orders revealed an order dated 03/14/22 for Novolog Flexpen (insulin pen) 100 units
per milliliter (units/ml). Inject 16 units subcutaneously (SQ) two times a day for diabetes mellitus.
Observation on 01/10/23 at 7:48 A.M. revealed Licensed Practical Nurse (LPN) #109 preparing an insulin
pen for Resident #18. LPN #109 prepared a Novolog FlexPen 100 units/ml by connecting a new needle and
dialing the insulin pen to 16 units. LPN #109 did not prime the insulin pen/needle.
Observation on 01/10/23 at 7:50 A.M. revealed LPN #109 administered the Novolog Flexpen 16 units to
Resident #18. Observations revealed LPN #109 did not prime the insulin pen/needle.
Interview with LPN #16 on 01/10/23 at 7:53 A.M. confirmed she had not primed Resident #18's Novolog
Flexpen needle before dialing up the required dose of insulin.
Review of the facility's undated policy titled How to Use an Insulin Pen revealed it is important to do a safety
test (prime the pen) before every injection. The safety test makes sure the insulin pen and needle are
working correctly. It also removes air bubbles and fills the needle with insulin so you get your full dose.
Review of manufacturer instructions for the Novolog Flexpen before each injection small amounts of air may
collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dose
selector to select 2. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with
your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing
upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should
appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you
do not see a drop of insulin after six times, do not use the NovoLog FlexPen and contact the manufacturer.
A small air bubble may remain at the needle tip, but it will not be injected.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 6 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and policy review, the facility failed to ensure open food products in
the refrigerator and/or freezer were dated after opening. This had the potential to affect 37 out of 39
residents residing in the facility who receive their meals from the kitchen, the facility identified two (#22 and
#193) resident who did not receive meals from the kitchen. Facility census was 39.
Findings include:
Observation on 01/09/23 from 8:30 A.M. to 8:45 A.M. of the kitchen revealed reach-in refrigerator had one
package of Canadian ham in Ziploc bag, one ranch dressing tub, and two bowls of food which were not
dated. Observations in the walk-in freezer revealed one Ziploc bag of mixed vegetables undated.
Observations in the walk-in refrigerator revealed seven pureed meats in individual Styrofoam bowls were
undated.
Interview on 01/09/23 at 8:43 A.M. with [NAME] #146 verified pureed meat, mixed vegetables, ham, ranch
dressing, and bowls were not dated. [NAME] #146 verified food was to be dated when opened. The facility
confirmed 37 out of 39 residents residing in the facility receive their meals from the kitchen and there were
currently two (#22 and #193) residents who did not receive meals from the kitchen.
Review of policy titled Dietary: Food Storage not dated revealed facility to date food items when they are
opened.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 7 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations, staff interview, and review of facility policy, the facility failed to ensure staff
appropriately disinfected a glucometer device after use. This affected one (#13) of one residents observed
for blood sugar checks. The census was 39.
Residents Affected - Few
Findings include:
Review of Resident #13's medical record revealed an admission date of 05/17/21. Diagnoses listed
included convulsions, major depressive disorder, chronic kidney disease, overactive bladder, and type two
diabetes mellitus.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was
cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and required extensive
assistance with activities of daily living (ADL's).
Review of physician orders revealed an order dated 09/27/22 to obtain and record Accu-check blood sugar
(finger stick blood glucose) before meals and at bedtime without insulin coverage.
On 01/10/23 at 6:37 A.M. Licensed Practical Nurse (LPN) #107 was observed obtaining an Accu-check on
Resident #13 using a glucometer from the medication cart. After obtaining the Accu-check LPN #107
returned to the cart with the glucometer. LPN #107 wiped down the glucometer with a small square alcohol
pad and place in back in a top drawer of the medication cart. Observations revealed the top drawer of the
medication cart was a general storage area and was not assigned to Resident #13.
During an interview on 01/10/23 at 6:39 P.M. LPN #107 confirmed she had wiped the glucometer with an
alcohol pad. LPN #107 stated alcohol pads are what is used to sanitize glucometer's after use in the facility.
LPN #107 confirmed the glucometer was stored in the top drawer of the medication cart which was a
general storage area and was not specifically for Resident #13. LPN #107 confirmed the glucometer could
be retrieved from the top drawer of the medication cart and used on any resident requiring a blood sugar.
Review of a facility provided list revealed Resident #13 was the only resident currently using the glucometer
in the medication cart.
Review of the facility's untitled and undated policy about glucometer sanitation revealed it is the policy of
the facility that glucometer's are cleaned and disinfected between each use per manufacture's instruction to
maintain infection control. If no visible soiling is present, or after cleaning off visible soiling, the surfaces will
be disinfected by wiping with a bleach product such as the PDU Super Sani Cloth: Germicidal Disposable
Wipes, or a product recommended by the manufacturer. Alcohol is not an acceptable product for this
purpose and should not be used to disinfect glucometer's.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 8 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interviews, review of facility policy and review of Centers for Disease Control
and Prevention (CDC) Guidelines, the facility failed to offer residents the pneumonia vaccinations per CDC
Guidelines. This affected four (#16, #12, #35, and #39) of five residents reviewed for immunizations. The
census was 39.
Residents Affected - Some
Findings include:
1. Review of the medical record for Resident #12 revealed admission date 01/26/22. Diagnoses included,
but not limited to, Diabetes Mellitus Type 2 (DM 2), chronic ischemic heart disease, and essential
hypertension. Resident #12 was [AGE] years old or older.
Further review of Resident #12's medical record revealed there was no evidence the Pneumococcal
immunization was offered or administered.
2. Review of the medical record for Resident #16 revealed admission date 03/24/22. Diagnoses included,
but not limited to, chronic systolic heart failure and DM 2. Resident #16 was adult 19 through 64 with
certain medical conditions.
Further review of Resident #16's medical record revealed there was no evidence the Pneumococcal
immunization was offered or administered.
3. Review of the medical record for Resident #35 revealed admission date 08/11/22. Diagnoses included,
but not limited to, dysphagia, pulmonary fibrosis, chronic respiratory failure, and dependence on
supplemental oxygen. Resident #35 was [AGE] years old or older.
Further review of Resident #35's medical record revealed there was no evidence the Pneumococcal
immunization was offered or administered.
4. Review of the medical record for Resident #39 revealed admission date 09/16/22. Diagnoses included,
but not limited to, atherosclerosis of aorta and chronic kidney disease. Resident #39 was [AGE] years old or
older.
Further review of Resident #39's medical record revealed there was no evidence the Pneumococcal
immunization was offered or administered.
Interview on 01/11/23 at 12:35 P.M. the Administrator stated they were unable to provide/locate pneumonia
vaccination documentation. On 01/12/23 at 10:36 A.M. the Administrator stated the Director of Nursing
(DON) had been here seven weeks and she had been here four months.
Interview on 01/12/23 at 11:16 A.M. the DON stated he was not sure what the process for offering or
documenting pneumonia vaccination prior to his employment. The DON revealed there was a folder with
influenza and Pneumococcal consent forms from the annual influenza vaccinations provided during the fall
of 2022. The DON confirmed there was no evidence Resident #12, #16, #35 or #39 was offered or received
the Pneumococcal immunization.
Review of the of the Centers for Disease Control and Prevention (CDC) Guidelines,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 9 of 10
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
365566
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Minster
24 North Hamilton Street
Minster, OH 45865
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)
F 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html#adults-19-64, revealed risk
factors for adults 19 through 64 included, but not limited to, chronic heart disease, including congestive
heart failure and cardiomyopathies and diabetes mellitus. The CDC recommends for those who have not
previously received any Pneumococcal vaccine, give one dose of Pneumococcal conjugate vaccine (PVC)
15 or PVC20. If PVC15 is used, this should be followed by a dose of Pneumococcal polysaccharide vaccine
(PPSV) 23 at least one year later. The minimum interval is eight weeks and can be considered in adults
with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. If PCV20 is used, a
dose of PPSV23 in not indicated. For those who have received PPSV23, CDC recommends you: May give
one dose of PCV15 or OCV20. The PCV15 or PCV20 dose should be administered at least one year after
the most recent PPSV23 vaccinations. Regardless of it PCV15 or PCV20 is given, an additional dose of
PPSV23 is not recommended since they already received it. For those who have received PVC13 with or
without PPSV23, CDC recommends one dose PPSV23 as previously recommended. For adults 65 years
and older CDC recommends Pneumococcal vaccination for all adults 65 years or older. For adults 65 year
or older who have not previously received any Pneumococcal vaccine, give one dose of PCV15 or PCV20.
If PVC15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum
interval is eight weeks and can be considered in adults with an immunocompromising condition, cochlear
implant, or cerebrospinal fluid leak. If PCV20 is used, a dose of PPSV23 is not indicated. For adults 65
years or older who have only received PPSV23, CDC recommends one dose of PCV15 or PCV20. The
PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 vaccination.
Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they
already received it. For Adults 65 years or older who have only received PVC13, CDC recommends give
PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their
recommended Pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is
not available. If PCV20 is used, their Pneumococcal vaccinations are complete.
Review of facility policy titled Pneumococcal Vaccine, undated, revealed prior to or upon admission,
residents will be assessed for eligibility to receive the Pneumococcal vaccine series, and when indicated,
will be offered the vaccine series within thirty (30) days of admission to the facility unless medically
contraindicated or the resident has already been vaccinated. Assessments of Pneumococcal vaccination
status will be conducted within five (5) working days of the resident's admission if not conducted prior to
admission. Before receiving a Pneumococcal vaccine, the resident or legal representative shall receive
information and education regarding the benefits and potential side effects of the Pneumococcal vaccine.
Provision of such education shall be documented in the resident's medical record.
Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be
documented in each resident's medical record indicating the date of refusal of the Pneumococcal
vaccination.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 10 of 10
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Back to topCitations
21 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0223GeneralS&S Fpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0343GeneralS&S Fpotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the January 12, 2023 survey of CARECORE AT MINSTER?
This was a inspection survey of CARECORE AT MINSTER on January 12, 2023. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARECORE AT MINSTER on January 12, 2023?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.