Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, review of a Facility Reported Incident, review of police report, review
of hospital records, and review of policy, the facility failed to ensure a cognitively impaired resident was free
from physical abuse by a facility staff member. This resulted in physical harm when Resident #01 was
forcefully pushed down on to a bed by Certified Nursing Assistant (CNA) #200 causing physical injuries of
bruising, skin impairments and pain. During the incident, Licensed Practical Nurse (LPN) #202 observed
and failed to intervene to protect Resident #01 from abuse. This affected one (#01) of three residents
reviewed for abuse. The facility census was 55. Findings include:Review of the medical record of Resident
#01 revealed an admission date of 11/26/24. Diagnoses include unspecified psychosis, depressive
disorder, Alzheimer's disease, and dementia.Review of the quarterly Minimum Data Set assessment dated
[DATE] revealed Resident #01 was cognitively impaired and required set-up or clean-up assistance for
transfers and personal care. Resident #01 was self-ambulatory.Review of the care plan revealed a focus,
initiated 12/09/24, of delirium, or an acute confusion episode related to acute disease process, dementia,
and Alzheimer's disease with interventions to include engage resident in simple, structured activities, make
eye contact when speaking with him, and if becomes agitated, stop and return. Another focus, initiated
12/09/24, of impaired cognition related to dementia with interventions to keep routine consistent as possible
and cue and re-orient as able. A third focus of potential for behavior problems, initiated 12/09/24, with
interventions to medicate as ordered, approach and speak in a calm voice, and psych/counseling services
as needed. A focus, initiated 04/17/25, revealed Resident #01 resides on the secure unit related to
elopement risk and aggressive behavior. Review of the Facility Reported Incident (262612) dated 07/10/25
revealed an alleged incident occurred on 07/10/25 at approximately 2:00 A.M. involving Resident #01 and
Certified Nursing Assistant (CNA) #200. The alleged incident was reported to the local police by a neighbor.
The police arrived at the facility and conducted an interview with Licensed Practical Nurse (LPN) #202 and
CNA #200. Resident #01 was taken to the emergency room for an evaluation. The report revealed the
neighbor, who lived approximately 500 feet from the facility, witnessed Resident #01 stumbling and a staff
member, with arms extended towards the resident. The report indicated the neighbor was interviewed by
the Administrator and the Regional Director of Clinical Operations #900 and stated he had witnessed
Resident #01 stumble and one staff member (identified by the facility as CNA #200) extend out their arms.
This was taken directly from the FRI. The facility did not substantiate the allegation.Review of the police
report #25-005782 revealed the incident occurred on 07/10/25 between 1:30 A.M. and 2:10 A.M. The report
revealed a phone call was received at approximately 2:14 A.M., from a male. The male (neighbor) reported
witnessing two nurses acting violently towards a resident at the facility. The officer first made contact with
the male, a neighbor, who reported seeing nurses throw the patient onto the bed in an aggressive manner.
The officer arrived at
(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 3
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
07/21/2025
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 0600
Level of Harm - Actual harm
Residents Affected - Few
the facility and informed LPN #202 of the purpose of his visit. LPN #202 reported CNA #200 had been in
the room with Resident #01. LPN #202 stated she had entered the room to observe Resident #01 standing
behind the bathroom door. CNA #200 forcefully placed both hands onto Resident #01's shoulders and
threw him onto the bed. CNA #200 then lifted Resident #01's legs and forcefully positioned them on the
bed. The report indicated LPN #202 expressed concern of CNA #200's handling of Resident #01 appeared
rough. The officer interviewed CNA #200 who denied any use of force. The officer observed bruises on the
right and left pectoral muscles, the left triceps, and a large bruise on the right buttock. The report further
indicated Resident #01 exhibited pain when the left rib cage area was touched, without any visible injuries
or markings. Resident #01 was sent to the local emergency room for potential internal injuries. At this point
in time, no charges have been filed.Review of the hospital record dated 07/10/25 at 5:20 A.M. revealed
Resident #01 was evaluated for alleged assault in the emergency room at the local hospital. The report
revealed a physical examination documented an induration between the webspace of digits one and two of
the right foot, erythema extending upwards from the toe on the dorsal aspect, and the area was warm to
the touch. Resident #01 had four small areas of excoriation located on the right anterior shin without active
bleeding. The areas almost look like insect bites. Resident #01 had a half centimeter circumferential eschar
on the left proximal tibia, anteriorly. Resident #01 had area of ecchymosis in the left lower quadrant, just
lateral to the umbilicus, (without description of color) and two areas of ecchymosis one the anterior chest.
One of the areas was above the nipple and medial, the other was four to six inches above and medial to the
right nipple. An area of ecchymosis was noted to the right buttocks the size of a hand but did not appear to
in the shape of a hand. It is in various stages of healing. Resident #01 appeared to be in no distress, resting
comfortably and hemodynamically stable. Resident #01 was discharged back to the facility with a new order
for an antibiotic for cellulitis in the toe (previously diagnosed and was being treated). Review of the Skin
Assessment dated 07/10/25 at 11:40 A.M. revealed Resident #01 exhibited a right pectoral bruise
measuring three centimeters (cm.) by two cm., a bruise to the left pectoral bruise measuring 10 cm. by 12
cm., a bruise on the right forearm measuring one cm. by half cm., a bruise to right shoulder/top of arm
measuring half cm. round, a bruise on the right antecubital area (inner elbow) measuring two point five cm.
by one point five cm., a skin tear on the left wrist measuring two cm. by one cm., a bruise to the left
posterior upper arm measuring three point five cm. by four cm., a bruise to the right buttock measuring
seven point five cm. by 14 cm., a bruise to the right knee (rear) measuring one cm. by two cm., a skin tear
to the front right thigh measuring half cm. round, a skin tear to the front right upper shin measuring zero
point two cm. round, and a skin tear to the right lower shin measuring one cm. by zero point seven cm. The
report indicated no sign or symptoms of pain during the assessment and medication was available if
needed. During a phone interview on 07/14/25 at 1:00 P.M. with CNA #200 revealed, on 07/10/25 at
approximately 2:00 A.M. Resident #01's call light was activated. As CNA #200 entered his room, Resident
#01 was noted to have the call light in his hand, pulled from the wall, and was urinating on the wall. CNA #
200 allowed him to finish and asked him if he needed the toilet. CNA # 200 opened the bathroom door and
Resident #01 slammed it shut and raised a fist. CNA #200 stated, Resident #01's name, please do not hit
me. At which time the nurse arrived. Resident #01 sat on the bed and CNA #200 bent down to assist with
his legs as they were swollen. Once he was laid down, CNA #200 covered him, turned the lights out and left
the room. During a phone interview on 07/16/25 at 2:08 P.M. with LPN #202 revealed she had been at the
nurses' station at approximately 2:00 A.M. on 07/10/25 and heard CNA #200 and Resident #01 getting
loud. LPN #202 stated she entered Resident #01's room to discover him standing in the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365566
If continuation sheet
Page 2 of 3
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
07/21/2025
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 0600
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
room with a puddle of urine around him. CNA #200 was trying to get him into the bathroom, and he was
resisting. LPN #202 reported CNA #200 forced Resident #01 onto the bed, with more force than she felt
was necessary, and swung his legs up quickly. LPN #202 stated she went to the head of the bed to prevent
him from falling. LPN #202 reported having told CNA #200 she had been rough and had man-handled
Resident #01. LPN #202 reported the incident to the Administrator upon the police arrival. Review of the
undated policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention, revealed the facility will
protect residents from abuse by anyone. The facility will develop policies and protocols to prevent and
identify abuse of residents by ensuring adequate staffing and oversight/support and conduct background
checks on employees.This deficiency represents the noncompliance investigated under Complaint Number
2560552.
Event ID:
Facility ID:
365566
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the July 21, 2025 survey of CARECORE AT MINSTER?
This was a inspection survey of CARECORE AT MINSTER on July 21, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARECORE AT MINSTER on July 21, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.