Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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]. Resident #330 had diagnoses including polyneuropathy, muscle weakness, difficulty
walking, cognitive communication deficit, acute cystitis with hematuria (bladder inflammation with blood in
the urine), metabolic disorder, unspecified dementia with behavioral disturbance, atrial fibrillation (irregular
fast heartbeat), peripheral vascular disease, hypertensive heart disease and malignant neoplasm (cancer)
of prostate.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had
severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of three. Resident #330
required extensive assistance of two staff members for transfers and personal hygiene, extensive
assistance of one staff member for bed mobility, dressing and toileting. The assessment revealed the
resident exhibited verbal and physical behaviors. Further review of the MDS 3.0 assessment revealed a
significant change MDS, dated [DATE] with Resident #330 being started on Hospice services.
Record review revealed no evidence of advance directives being in place for the resident.
On [DATE] at 1:28 P.M. interview with Unit Manager Registered Nurse (RN) #258 verified the lack of
documentation of the resident's advance directives/code status in the electronic medical record. RN #258
also verified there was not a signed State of Ohio Do Not Resuscitate (DNR) form in the resident's chart.
Review of the physician's orders revealed an order, dated [DATE] (after the surveyor spoke with RN #258)
for advance directives, a Do Not Resuscitate-Comfort Care (DNRCC) order. This meant standard medical
treatments would be provided until the time the resident's heart or breathing stopped; at which time no
further life saving measures would be provided including cardiopulmonary resuscitation (CPR). A State of
Ohio DNR form was also signed by the Hospice physician on [DATE] at 1:49 P.M. via fax.
Review of the undated facility policy titled Advanced Directives revealed the facility would inform
(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 14
Event ID:
366015
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0578
Level of Harm - Minimal harm
or potential for actual harm
the resident about initiating an advance directive and the facility would maintain written standards and
practice guidelines regarding advanced directives to assure the resident's wishes were honored. The facility
would document in the clinical record whether or not the resident had executed and advance directive.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 2 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
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.
Review of a nursing progress note, dated 03/29/22 revealed Resident #31's blood sugar was running high,
reading 548 and the physician was notified.
Review of the physician's orders for Resident #31 revealed an order, dated 03/29/22 to obtain a hemoglobin
A1C laboratory (lab) test on 03/30/22.
On 03/30/22 at 9:37 A.M. Lab Technician #259 was observed drawing blood from Resident #31 at the
nurse's station on the 100 and 200 halls.
On 03/30/22 at 9:39 A.M. interview with Lab Technician #259 confirmed she did draw the blood work from
Resident #31 at the nurse's station. Lab Technician #259 reported she knew she could not draw labs
outside of a private area but stated sometimes the residents were in a hurry.
On 03/30/22 at 9:41 A.M. interview with Resident #31 confirmed her blood was drawn at the nurse's station.
The resident reported she would have gone back to her room to have it done.
Review of the undated facility policy titled Resident Rights revealed the facility would assure the resident's
personal dignity, well-being and self determination was maintained to assure the residents were
knowledgeable to their rights and responsibilities in this regard.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 3 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0606
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Level of Harm - Potential for
minimal harm
Based 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.
Residents Affected - Many
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.
Review of the personnel file for State Tested Nursing Assistant (STNA) #249 revealed a hire date of
09/01/21. The printed evidence of STNA #249 being checked against the NAR was not completed until
10/21/21.
On 03/29/22 at 1:57 P.M. interview with Corporate Human Resources #260 confirmed screening/checking
employees through the Ohio Nurse Aide Registry for abuse, neglect, exploitation, and misappropriation was
not completed for SS #245, Admissions #204 or STNA #249 prior to or on the first date of 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.
Review of the facility policy titled Abuse, Neglect, and Exploitation of Residents and Misappropriation of
Property, dated May 2018 revealed the goal of the facility was to protect residents from abuse, neglect,
exploitation, and misappropriation. The policy indicated all potential employees would be screened starting
with the application for employment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 4 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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].
Resident #78 was discharged [DATE].
Resident #79 was discharged [DATE].
Resident #80 was discharged [DATE].
Resident #81 was discharged [DATE].
Resident #82 was discharged [DATE].
Resident #83 was discharged [DATE].
Resident #84 was discharged [DATE].
Resident #85 was discharged [DATE].
Resident #87 was discharged [DATE].
Resident #89 was discharged [DATE].
Resident #90 was discharged [DATE].
Resident #91 was discharged [DATE].
Resident #92 was discharged [DATE].
Resident #93 was discharged [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 5 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0623
Resident #94 was discharged [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Resident #280 was discharged [DATE].
Resident #281 was discharged [DATE].
Residents Affected - Some
Resident #282 was discharged [DATE].
Resident #283 was discharged [DATE].
Resident #284 was discharged [DATE].
Resident #285 was discharged [DATE].
Resident #286 was discharged [DATE].
Resident #287 was discharged [DATE].
Resident #288 was discharged [DATE].
Resident #289 was discharged [DATE].
Resident #290 was discharged [DATE].
Resident #291 was discharged [DATE].
Resident #292 was discharged [DATE].
Resident #293 was discharged [DATE].
Resident #294 was discharged [DATE].
Resident #295 was discharged [DATE].
Resident #296 was discharged [DATE].
Resident #297 was discharged [DATE].
Resident #298 was discharged [DATE].
Resident #283 was discharged [DATE].
Resident #299 was discharged [DATE].
Resident #300 was discharged [DATE].
Resident #301 was discharged [DATE].
Resident #302 was discharged [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 6 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0623
On 03/30/22 at 9:07 A.M. interview with the Administrator verified the State Ombudsman was not notified of
the above resident transfers/discharges as required.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 7 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident
#19 was admitted to the facility on [DATE] with diagnoses including hemiplegia, history of falling,
depression, psychosis, schizophrenia, anxiety disorder and aphasia.
Residents Affected - Some
Review of this resident's MDS 3.0 assessment, dated 01/19/22 revealed the resident had severe cognitive
impairment, required extensive assistance from one to two staff for bed mobility, transfers, dressing, toilet
use and personal hygiene.
The resident's plan of care, last updated on 03/22/22 revealed the resident preferred showers every
Monday and Thursday during the day.
On 03/29/22 at 9:30 A.M. interview with Resident #19 revealed concerns he was not consistently getting his
showers twice a week. When asked when the resident last got a shower, he stated about one month ago.
He also revealed he wanted to take a shower and not have a bath.
On 03/29/22 at 11:15 A.M. interview with Licensed Practical Nurse (LPN) #265 revealed she checks on her
residents during medication administration and treatments to ensure they were getting their shows as
scheduled/assigned. She further stated the shower book at the nurse's station listed the days of each
residents showers. When asked about Resident #19, the LPN revealed the resident had not received a
shower on this date.
Review of the shower sheets for Resident #19 revealed in the past three months the resident had not
received a shower on 02/17/22, 02/21/22, 03/03/22 or 03/17/22 as scheduled/planned.
Review of the corresponding nursing progress for the above days revealed no evidence the resident had
refused a shower.
On 03/30/22 at 3:20 P.M. interview with LPN #265 revealed the direct care staff were to complete a shower
sheet and place it in a binder once a shower was given. At the end of the shift, the shower sheets were
taken out of the binder and given to the Assistant Director of Nursing (ADON). When asked about missing
shower sheets for the above listed days, LPN #265 revealed the resident probably did not get a shower on
those days.
Based 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.
Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/16/22 revealed the resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 8 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed
Resident #332 required extensive assistance from two staff members for personal hygiene and bathing and
extensive assistance from one staff member for dressing, toileting and transfers.
On 03/29/22 at 11:58 A.M. observation and interview with Registered Nurse (RN) #239 revealed Resident
#332's toenails were visible and extremely long. RN #239 revealed she had not noticed the length of the
resident's toenails prior to this interview and indicated she would request a podiatry consult per the
resident's request. There was no evidence provided that the care needed could not be performed by facility
staff or that the resident's toenails could only be cut/cared for by a podiatrist.
On 03/30/22 at 12:54 P.M. interview with Licensed Social Worker (LSW) #245 revealed skilled residents
who were admitted for a short-term stay (like Resident #332) were not asked if they would like ancillary
services, such as podiatry care. She verified Resident #332 did not have a signed consent or refusal for
podiatry services in his medical record and revealed the resident had not been offered any ancillary
services.
Review of facility policy titled Foot Care, revised 10/2018 revealed the facility would provide foot care to all
residents to provide comfort, prevent skin breakdown and promote healing. Toenail care for diabetic
residents should be provided by the nurse.
On 03/31/22 at 10:06 A.M. during a follow up interview with LSW #245, the LSW revealed the facility
utilized an outside service to provide ancillary services, such as podiatry to residents.
2. Review of medical record for Resident #11 revealed an admission date of 05/12/16 with diagnoses
including chronic obstructive pulmonary disease, anemia and heart failure.
Review of quarterly MDS 3.0 assessment, dated 11/07/21 revealed Resident #11 had moderate cognitive
impairment, required extensive two person physical assistance for bed mobility, limited one person physical
assistance for transfers, supervision set up help only for eating and extensive one person physical
assistance for toilet use and personal hygiene. The assessment revealed Resident #11 was always
continent of urine and bowel.
Review of the care plan, dated 01/25/22 revealed Resident #11 had a preference for showers every
Monday and Thursday in the early morning.
Review of shower sheets for Resident #11 revealed from 01/01/21 to 03/28/22 revealed Resident #11 did
not receive a shower as scheduled on 02/01/22, 03/10/22 or 03/14/22.
On 03/28/22 at 8:29 A.M. interview with Resident #11 revealed she was not getting her showers regularly.
The resident revealed her son had also complained about her not getting showers to the facility and they
had a meeting about it.
On 03/31/22 at 9:10 A.M. interview with Licensed Practical Nurse (LPN) #257 confirmed there was no
evidence of Resident #11 receiving showers as planned on the days noted above.
3. Review of medical record for Resident #13 revealed an admission date of 02/03/21 with diagnoses
including chronic obstructive pulmonary disease, displaced transverse fracture of the shaft of the right
femur and major depressive disorder.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 9 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Review of the quarterly MDS 3.0 assessment, dated 12/31/21 revealed Resident #13 had moderate
cognitive impairment, required limited one person physical assistance for bed mobility, supervision one
person physical assistance for transfers and limited one person physical assistance for bed mobility,
dressing, toilet use and personal hygiene. The assessment revealed the resident was frequently incontinent
of urine and occasionally incontinent of bowel.
Residents Affected - Some
Review of the care plan, dated 01/31/22 revealed Resident #13 preferred a shower two times a week.
Review of shower sheets for Resident #13 from 01/01/22 to 03/28/22 revealed the resident did not receive
a shower on 01/25/22, 02/23/22 or 03/15/22 as scheduled.
On 03/28/22 at 12:25 P.M. interview with Resident #13 revealed she had not been getting a shower
regularly.
On 03/31/22 at 9:10 A.M. interview with Licensed Practical Nurse (LPN) #257 confirmed there was no
evidence of Resident #13 receiving showers as planned on the days noted above.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 10 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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
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.
Record review revealed on 12/11/21 an order was received for the antipsychotic medication, Haldol Lactate
5 milligrams per milliliter inject two milligrams (mg) intramuscularly every four hours as needed for
combative behavior.
Review of a pharmacy recommendation, dated 01/28/22 revealed as needed (PRN) psychotropic orders
cannot exceed 14 days with the exception that the prescriber documented their rationale in the resident's
medical record and indicated the duration for the PRN order. The pharmacist recommended the physician
place a new order for PRN Haldol two mg intramuscularly every four hours as needed that had to be
renewed every 14-days. The physician signed in agreement on 02/14/22.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 3/12/2022 revealed the resident
had severely impaired cognition.
Review of the medication administration records (MAR) for 03/2022 revealed the PRN order remained as a
current order for the resident. Record review revealed the resident received nine doses of the PRN
medication which included doses on 12/11/21, 01/24/22, 01/27/22, 01/30/22, 03/21/22, 03/26/22, 03/28/22,
03/29/22 and 03/30/22.
On 04/01/22 at 8:28 A.M. interview with Licensed Practical Nurse (LPN) #257 verified the order for Haldol
had not had a 14-day limit placed on it as recommended during the pharmacy review on 01/28/22 that was
reviewed by the physician on 02/14/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 11 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
medical record for Resident #19 revealed an admission date of 04/21/21 with diagnoses including
schizophrenia, paranoid personality disorder and anxiety disorder. Review of the physician's orders
revealed an order dated 07/15/21 for Depakote Sprinkles 500 milligrams (mg) twice daily related to
paranoid personality disorder.
On 03/31/22 at 7:36 A.M. while walking toward Resident #64's room with Licensed Practical Nurse (LPN)
#257 and Registered Nurse #258 a locked medication cart was observed adjacent to room [ROOM
NUMBER]. No staff member was observed at the medication cart and Resident #51 was observed sitting in
a wheelchair waiting next to the medication cart. On top of the medication cart, the surveyor observed one
medication card of Depakote Sprinkles (anticonvulsant) 500 milligrams (mg) with 26 capsules labeled for
Resident #19. There was no nurse or other facility staff observed near or at the medication cart at the time
of the observation.
Interview at the time of the observation with Resident #51 revealed the nurse had left but the resident
stated she was waiting for the nurse to return to get pain medication. LPN #257 verified Resident #19's
Depakote was improperly left unsecured on top of the medication cart where other residents could access
the medication. LPN #257 further stated a belief LPN #265 (who was the assigned nurse) was utilizing the
restroom.
Review of a notice of corrective action for LPN #265, dated 03/31/22 and given by LPN #257 revealed a
verbal warning for not following proper policy and procedure was issued. LPN #257 indicated on the
corrective action form LPN #265 stated having to use the bathroom, had never left medications on the cart
and knew better.
Based 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. observation of the 300 hall medication cart revealed a Lispro insulin 100
units/milliliter vial was opened with no date marked as to when it was opened. Interview during the time of
the observation with Licensed Practical Nurse (LPN) #263 confirmed the vial was undated.
On 03/30/22 at 11:22 A.M. observation of the 100-200 hall medication storage room revealed a vial of
tubersol 5/0.1 milliliter dated as filled on 12/09/21 was opened with no date marked as to when it was
opened. Interview at the time of the observation with RN #258 confirmed the vial was not dated as to when
it was opened.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 12 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Review of the Medication Administration Record (MAR) for February 2022 revealed Resident #331 was
administered tubersol solution for Mantoux test on 02/12/22.
On 03/30/22 at 11:25 A.M. observation of the 200 hall medication cart revealed Lispro insulin 100
units/milliliter vial dated as filled on 02/24/22 was opened with no date marked as to when it was opened.
Interview during the time of the observation with LPN #225 confirmed the vial was not marked as to the
date it was opened.
Record review revealed Resident #18 and Resident #28 received Lispro insulin from the carts observed
with the undated insulin vials.
Review of the facility policy titled Medication storage dated September 2010, revealed medications and
biologicals were to be stored properly, following manufacturer's or provider pharmacy recommendations to
maintain their integrity and to support safe effective drug administration. Note the date on the label for
insulin vials and pens when first used.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 13 of 14
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at Mentor
8881 Schaefer St
Mentor, OH 44060
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 - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based 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. In the walk-in refrigerator, raw ground turkey was observed stored
above already cooked pureed meat and a bag of pre-made French toast was not closed properly and not
dated.
Interview with DM #216 at the time of the observations verified the above findings.
On 03/31/22 at 8:34 A.M. additional kitchen observations revealed Dietary Aide (DA) #209 and DM #216
were not wearing any type of hair restraint/hair net. Interview with both DA #209 and DM #216 at the time of
the observation verified the lack of hair restraint being worn.
Review of the facility policies and procedures revealed kitchen task assignments included the kitchen
should be cleaned and food should be wrapped, labeled, and dated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
If continuation sheet
Page 14 of 14
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 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.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F606 - The facility must—
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the April 1, 2022 survey of CARECORE AT MENTOR?
This was a inspection survey of CARECORE AT MENTOR on April 1, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARECORE AT MENTOR on April 1, 2022?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
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.