Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation, and record review the facility did not ensure a safe, functional, sanitary, and
comfortable shower room. This affected two residents (#42 and #82) out of two residents reviewed for the
accommodation of showers and had the potential to affect all 17 residents (#2, #12, #23, #32, #34, #39,
#41, #42, #47, #60, #61, #62, #71, #77, #78, #79, #82) residing on the secured unit. The facility census was
93.
Findings included:
1. Review of the medical record for Resident #82 revealed an admission date of 10/17/23 with diagnoses
including traumatic brain injury with loss of consciousness, dementia, psychosis, history of falling, and
intellectual disabilities.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had
impaired cognition. He was dependent on staff assistance with his showers.
Review of the care plan dated 10/17/23 revealed Resident #82's bathing preference was to have a shower.
Interventions included encourage him to voice his personal preferences, to request changes as needed,
and provide a shower.
Observation on 01/03/24 at 8:55 A.M. revealed State Tested Nursing Assistant (STNA) #608 and STNA
#613 assisted Resident #82 with his shower in the secured unit shower room. They started the water and
proceeded to transfer him from his wheelchair to a shower chair and undressed him. STNA #608
proceeded to wash Resident #82's body and hair. During the shower the water was observed to rise on the
floor, move towards the hallway, and not drain properly. STNA #608 continued to bathe Resident #82 as he
stood in tennis shoes in approximately one inch of water (dirty). STNA #608 verified, at least an inch I feel
sometimes gets higher that he had to stand in while showering residents. After the shower they proceeded
to use bath blankets to soak up the excess water that was standing on the floor.
2. Review of the medical record for Resident #42 revealed an admission date of 08/10/23 with diagnoses
including psychosis, mood disorder, and bipolar disorder.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had intact cognition. She
required supervision/ touching assistance with her showers and was independent with dressing.
Review of the care plan dated 10/26/23 revealed Resident #42's bathing preference was to have a shower.
Interventions included encouraging the resident to voice her personal preferences, to request
(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:
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
01/03/2024
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 0921
changes as needed, and provide a shower.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 01/03/24 at 9:09 A.M. with Resident #42 revealed she takes showers independently in the
shower room on the secured unit as she does not want staff to assist her. She revealed she stood in water
during her showers, it is a mess, does not drain right.
Residents Affected - Some
Interview on 01/03/24 from 7:58 A.M. to 8:04 A.M. with Licensed Practical Nurse (LPN) #609 and STNA
#608 verified Resident #42 independently takes her showers in the shower room on the secured unit. STNA
#608 verified it was a fall risk for Resident #42 to independently be in the shower room due to the water not
properly draining, but Resident #42 refused to have staff assistance.
3. Interview on 01/03/24 at 5:12 A.M. with STNA #603 revealed when she provided showers on the secured
unit the water gets all over the floor and comes into the hallway. She revealed if staff assist with providing a
shower, they must stand in inches of water as the drain does not drain correctly. She revealed, I feel the
drain is not big enough or something. She revealed it had been like that since September 2023 when she
started at the facility.
Interview on 01/03/24 at 7:58 A.M. with STNA #608 revealed the secured unit shower room flooded all the
time. He revealed he had to put down bath blankets for the water not to come out into the hallway. He
revealed it was standing water that does not go down the drain properly. He revealed it was a safety issue,
and it had been like that for several months. He revealed he stands in water when he provides a shower,
and his shoes get soaked with the dirty water causing concerns with infection control. He revealed he had
reported it to the Administrator and Maintenance Director #612 multiple times who always replied, too
expensive to fix. He revealed Maintenance Director #612 stated the shower room had been like that for a
long time, and he refused to fix it.
Interview on 01/03/24 at 8:04 A.M. with LPN #609 verified she had witnessed the shower room flood many
times when staff gave showers as she had seen water come out into the hallway from the shower room.
Interview on 01/03/24 at 10:05 A.M. with Maintenance Director #612 revealed the secured unit shower
room had drained like that for years. He revealed when they built the shower room they did not pitch (angle)
the floor correctly towards the drains as the floor does not slope causing the water to accumulate and not
drain properly. He verified he had seen the water a few inches high and the water flow towards the hallway.
He verified staff had brought it to his attention several times, but he stated, I do not have a solution for it. He
revealed unless the facility breaks up the concrete and re-does the floors to slant them correctly, which he
stated they were not going to do, there really was nothing that could be done.
Interview on 01/03/24 at 11:45 A.M. with the Administrator verified she was notified approximately three
weeks prior regarding the shower not draining properly in the secured unit shower room. She revealed she
had a company come out and gave the facility a quote to correct the issue. She verified she had not placed
any interventions regarding the safety/ fall risk for staff/ residents including Resident #42 who
independently showers in the secured unit shower room. She also verified she had not implemented any
interventions regarding the standing water potentially causing an infection control concern.
Review of the facility policy labeled, Accommodation of Needs, dated March 2021, revealed the facility's
environment and staff behaviors were directed toward assisting residents in maintaining and/
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
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
366015
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2024
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 0921
or achieving safe independent functioning, dignity, and well-being.
Level of Harm - Minimal harm
or potential for actual harm
This deficiency represents non-compliance investigated under Complaint Number OH00149152.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366015
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.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the January 3, 2024 survey of CARECORE AT MENTOR?
This was a inspection survey of CARECORE AT MENTOR on January 3, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARECORE AT MENTOR on January 3, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public."
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.