Inspection·April 19, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and staff interviews, the facility failed to ensure the laundry room wall was in good repair without missing drywall or black substance on wall and around the window. This had the potential to affect 55 residents who have their laundry washed at the facility, the facility identified three (#20, #21 and #25) residents who do not have their laundry washed by the facility. The facility census was 58. Findings include: Interview on 04/19/24 at 8:50 A.M. with Laundry Aide #123 stated the wall near the folding table in the laundry room had several areas of black substance on the wall below the window, around the window and under the air conditioning (AC) unit which was above the window. Laundry Aide #123 stated the wall had been missing part of the drywall for over one year and there had not been a change in the appearance of the black substance around the window and AC unit. Observation on 04/19/24 at 9:05 A.M. revealed a window and wall near the folding table in the laundry room to be missing part of the drywall under the window, window ledge deteriorated with part of the ledge missing, and black substance noted on several areas of the wall below the window, around the window, and around the air conditioning unit above the window. Interview on 04/19/24 at 9:10 A.M. with Administrator confirmed the wall located in the laundry room near the folding table had drywall missing from below the window and there was black substance noted on several areas on wall below the window, around the window and under the AC unit above the window. Administrator denied any recent concerns with water or roof issues in that area. Interview on 04/19/24 at 9:15 A.M. with Laundry Aide #117 stated she had worked in the laundry room for over one year. Laundry Aide #117 confirmed the wall under the window near the folding table in the laundry room was missing part of the drywall, the window ledge was deteriorated and missing part of the ledge, and the wall under the window, around the window, and under the AC unit above the window had several areas of black substance. Laundry Aide #117 stated the wall had looked like that for over one year and had not changed. Interview on 04/19/24 at 9:25 A.M. with Maintenance Director #121 confirmed the wall located near the folding table in the laundry room was missing part of the drywall, the window ledge was deteriorated and missing part of the ledge, and the wall below the window, around the window, and under the AC unit located above the window had several areas of black substance. Maintenance Director #121 stated he was not aware of any leaks around the window or roof in that area. Maintenance Director #121 stated he has had to replace the AC unit above the window two times because of water leaking down the (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: 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 04/19/2024 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)