Health inspection·December 10, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interview, the facility failed to adequately monitor Resident #85's condition including bowel and bladder elimination to timely identify and treat infection and constipation. This affected one resident (#85) of three residents reviewed for change in condition. The facility census was 80. Actual harm occurred on 06/25/25 after Resident #85 who had cystitis (inflammation of the bladder), reflux, diabetes, impaired cognition and mobility, a high risk for constipation and infection, and a history of sepsis (a life-threatening response to an infection) failed to receive sufficient monitoring to timely treat constipation and infection. The resident developed progressive symptoms throughout the day including an upset stomach, diaphoresis (heavy sweating), vomiting fecal matter, a firm and distended abdomen, hypoxemia (low blood oxygen), a change in mental status, a high heart rate and pallor before being transferred to the hospital and admitted with aspiration pneumonia and a possible small bowel obstruction. Findings include:Review of the closed medical record for Resident #85 revealed an admission date of 04/21/21. The resident was discharged to the hospital on [DATE]. Resident #85 had diagnoses including diabetes, hemiplegia, reflux, epilepsy, aphasia, cystitis, and schizophrenia.Review of the plan of care dated 04/29/21 revealed Resident #85 was at risk for constipation related to decreased mobility. Interventions included to administer medications as ordered, consult dietary for assistance in meeting dietary needs, encourage exercise as tolerated, and encourage fluids if diet and medical diagnosis permit. The care plan identified the resident's risk of infection which was initiated on 06/05/23 for a history of urinary tract infection, but it did not include the risk of infection from diagnoses of reflux, cystitis or a history of sepsis. Interventions included assessments for signs and symptoms of infection including foul smelling or cloudy urine, urine sediment, and decreased urine output, and report findings to the physician, educating on techniques to prevent infection, encouraging fluids, and obtaining labs as ordered.Additional review of the medical record revealed on 02/04/25, Resident #85 completed a kidney ultrasound prior to a urology appointment on 03/11/25. Thereafter on 04/18/25, the resident received a cystoscopy with visual internal urethrotomy (a procedure to open a stricture or scar tissue in the urethra). After the procedure, Resident #85 had an indwelling urinary catheter for three weeks and received a course of oral antibiotics. The catheter was to be removed in the urologist's office at a follow-up appointment scheduled on 05/13/25.Review of a nurse's note dated 05/13/25 at 5:27 A.M. revealed Resident #85 was sent to the hospital for evaluation due to a high heart rate and elevated temperature. The resident complained of feeling chills and was very shaky.Review of a nurse's note dated 05/13/25 at 8:33 A.M. revealed Resident #85 was admitted to the hospital for sepsis and tachycardia (an elevated heart rate).Additional review of the medical record revealed Resident #85 returned to the facility on [DATE] at 8:11 P.M. There was no evidence of comprehensive assessments for infection monitoring as identified in the resident's plan of care after returning from the hospital on [DATE].Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/21/25, revealed Resident #85 had impaired cognition, and was dependent on staff for toileting and transfers. The assessment revealed the resident used a wheelchair for mobility and was occasionally incontinent of bowel and bladder.Review of the Medication Administration Record (MAR) from April to May 2025 revealed Resident #85 had active as needed (PRN) orders related to a risk of constipation which included oral Milk of Magnesia if no bowel movement (BM) after three days (step one), a Dulcolax suppository if no results from Milk of Magnesia (step two) and an enema (step three) if still no results. The records indicate no history of recurrent constipation as evidenced by the unused PRN suppository and enema. Record review revealed the oral laxative, milk of Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few magnesia was administered once on 04/05/25.Review of Resident #85's physician orders effective June 2025 revealed an order to straight catheterize the resident for possible urine retention, and if no bowel movement (BM) after following steps one, two and three to notify the physician. Review of Resident #85's MAR and bowel tracking record for June 2025 revealed Resident #85 had no BM on 06/21/25, 06/22/25, 06/23/25 or 06/24/25. There were no PRN interventions administered for either step one, two or three. On 06/25/25, the resident received a step two suppository, and thereafter had a medium sized loose BM. Per staff stated protocol (interview with Assistant Director of Nursing [ADON] #269 on 09/30/25) and physician orders, step one was not administered on day three of no BM (on 06/23/25), followed by step two if no result and additionally step three if still no result. Review of a nurse's note dated 06/24/25 at 11:01 P.M. revealed Resident #85 was medicated with the analgesic acetaminophen PRN for pain. Review of a nurse's note dated 06/25/25 at 6:33 A.M. revealed Resident #85 complained of stomach upset. Ginger ale was offered and the resident expressed some relief after drinking it. Resident #85's stomach was visibly distended, and the resident could not recall the last time he had a BM, so the nurse administered a PRN laxative to encourage a BM. Review of the nurse's note dated 06/25/25 at 8:34 A.M. revealed Resident #85 was diaphoretic while in the dining room, so Licensed Practical Nurse (LPN) #305 and other unnamed aides assisted him to bed as the resident requested. The nurse documented vitals were completed with an abnormal heart rate elevated at 111, and a firm abdomen with a denial of pain. Bowel protocol was given as ordered, and all morning medications were taken without difficulty. There was no physician notification at this time. Review of the nurse's note dated 06/25/25 at 10:01 A.M. revealed staff documented Resident #85 had a BM (medium sized and loose). Review of the nurse's note dated 06/25/25 at 11:20 A.M. revealed an unnamed nurse and unit manager observed Resident #85 as diaphoretic while resting on the bed. The resident denied pain or discomfort, but the abdomen was firm and distended. Resident #85 had an emesis (vomited). Vitals signs were within normal limits except for an elevated heart rate of 127 and elevated glucose reading of 194. The physician ordered stat (urgent) tests for a KUB (kidney, ureter, and bladder) x-ray, a CBC (complete blood count) and CMP (complete metabolic panel) lab work, and to straight catheterize for urine. Additional review of Resident #85's physician orders for 06/25/25 revealed orders were entered at 11:30 A.M. for stat lab work of a CBC and CMP due to a change in mental status which was not reflected in the nurse's note dated 06/25/25 at 11:20 A.M., and a stat x-ray KUB due to a firm and distended abdomen.Review of the nurse's note dated 06/25/25 at 12:30 P.M. revealed an unnamed nurse and unit manager attempted multiple times to straight catheterize the resident with no urine return. The resident's abdomen remained distended and firm. He continued to have emesis and was pale in color. Vital signs were completed which revealed abnormal oxygenation of 66 percent, so oxygen was administered via nasal cannula. The physician was notified at this time and ordered to send the resident to the hospital immediately. Resident #85 was alert to name and situation. Emergency medical services (EMS) were called and arrived within minutes. The resident had advanced directives for a DNRCC (Do Not Resuscitate Comfort Care) which was provided to EMS upon transport to the hospital. Review of the nurse's note dated 06/25/25 at 5:31 P.M. revealed Resident #85's mother informed the facility of the resident being transferred to another hospital's intensive care unit (ICU). He was placed on a ventilator and had unstable low blood pressure. Review of the physician's note dated 06/25/25 at 9:20 P.M. revealed upon being contacted regarding Resident #85's change in condition, the facility was advised to obtain a KUB, lab work, and start intravenous fluid (this was not reflected in the physician orders), but within the hour the resident's condition worsened. Resident #85 was vomiting what appeared to be fecal material, so the resident was transferred to the hospital emergency room. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician came to the facility as soon as possible, but the resident was already on his way to the hospital. Interviews on 09/23/25 from 12:33 P.M. until 1:12 P.M. with LPN #241 and LPN #255 revealed bowel movements were tracked on all residents. The aides recorded bowel movements in the electronic plan of care. The nurses then checked the dashboard for a warning which popped up if a resident had no BM after three days. Although the aides were supposed to chart all bowel movements, the LPNs were now also going around and asking the residents. Interviews on 09/23/25 from 1:52 P.M. to 2:19 P.M. with Certified Nursing Assistants (CNAs) #210, #213, #218 and #239 revealed the CNAs recorded resident BMs in the electronic medical record. If residents were independent they asked the residents. Interview on 09/23/25 at 2:19 P.M. with CNA #213 revealed caring for Resident #85 on 06/25/25. On that morning, the resident was pale and it was reported to an agency nurse. The resident complained that his stomach hurt but did not talk well which may be why he did not express as much. Interview on 09/30/25 at 2:57 P.M. with ADON #269 revealed Resident #85 was alert and oriented and he did not usually have any bowel concerns. The ADON revealed if residents did not have BMs it triggered on the dashboard to start the bowel protocol. The bowel protocol was if a resident did not have a BM on the third day then Milk of Magnesia was given. If no results then it was followed by a Dulcolax suppository, and if still no results then an enema was given. If all intervention did not work, the nurse called the physician to get an order for a KUB and did a bowel assessment. ADON #269 stated she called the physician to get a KUB. When they put Resident #85 back to bed his stomach got bigger and then he was sent out. Interview on 12/04/25 at 1:58 P.M. with Attending Physician #306 revealed Resident #85 was well known to the physician. The physician revealed the resident had improved significantly overall during his stay at the facility. He had past urinary issues had had been admitted to the hospital previously with urosepsis. The resident was being followed for his bladder issues. On 06/25/25, the resident was admitted with hospital diagnoses of aspiration pneumonia and a possible small bowel obstruction. The resident subsequently passed away with the cause of death listed as sepsis. However, during the interview Attending Physician #306 did not feel the constipation was the cause of the possible small bowel obstruction or death. This deficiency represents non-compliance investigated under Complaint Number 2595860 and 2568156. Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to promote healing and to prevent a decline and infection in pressure ulcers. This affected one resident (#87) of three residents reviewed for pressure ulcers. The facility census was 80.Actual harm occurred beginning on 04/30/25 when Resident #87, who was admitted to the facility with two Stage IV (a severe open sore that has penetrated through all layers of the skin and underlying tissue exposing muscle, tendon or bone) pressure wounds was noted to have a deterioration in wound status (green drainage indicative of infection and increase in size). Wound cultures were not obtained until 05/15/25. On 06/06/25 Resident #87 requested to go to the hospital due to complaints of not feeling well (the resident's family had identified the resident had experienced new onset confusion and lethargy during the week prior). The resident was admitted to the hospital for treatment of osteomyelitis. Findings include:Review of the closed medical record for Resident #87 revealed an admission date of 12/17/24 with diagnoses including unspecified injury at C7 level of the cervical spinal cord, injury at C5 level of the cervical spinal cord, chronic obstructive pulmonary disease, quadriplegia, protein-calorie malnutrition, emphysema, neuromuscular dysfunction of the bladder, osteomyelitis (06/04/25), fusion of the spine, contracture of the muscle, and neurogenic bowel. The resident was transferred to the hospital on [DATE] and did not return to the facility. Review of the admission nursing assessment dated [DATE] identified Resident #87 was admitted with a wound with depth on the right buttock and an open wound with depth on the left buttock.Review of the plan of care dated 12/18/24 revealed Resident #87 was at risk for impaired skin integrity/pressure ulcers related to altered sensations, fragile skin, and quadriplegia. Interventions included to apply barrier cream/ointment after each incontinent episode as needed, to elevate heels off the mattress, encourage fluids, encourage to be out of the wheelchair at least two hours daily as tolerated, the nurse to ensure the resident goes to bed timely just before or after dinner, to inspect the skin during routine daily care, peri care after each incontinent episode, pressure reduction devices as ordered, and treatments per order.Review of the plan of care dated 12/19/24 revealed Resident #87 had an actual pressure ulcer, Stage IV right ischium and Stage IV left ischium. Interventions included administering medications per physician orders, explaining all procedures prior to care, monitoring for signs and symptoms of infection, notifying the physician of wound deterioration, providing wound care per physician orders, and referring to the wound physician as needed.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #87 had two Stage IV pressure ulcers/wounds which were present on admission. Review of the plan of care dated 01/27/25 revealed Resident #87 was non-compliant related to wound care and supplements for wound healing, non-compliant with a preventative pressure reduction mattress, and non-compliant with off-loading the buttocks from the wheelchair throughout the day. Interventions included to document educational attempts made with resident in relation to compliance, and educate the resident, family or responsible party on negative outcomes related to non-compliance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #87 dated 03/26/25 revealed the resident was cognitively intact. The resident used a wheelchair and was assessed to have limited range of motion (ROM) on both sides. The assessment revealed the resident required substantial (staff) assistance with oral hygiene, dressing, personal hygiene, rolling left and right, and sitting to lying. The resident was dependent on staff for toileting, bathing, sitting to standing, chair to bed transfers, and toilet transfers. The assessment indicated the resident had two Stage IV pressure ulcers present on admission. Review of Resident #87's physician orders from Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few admission through March 2025 revealed to encourage floating heels off the mattress when in bed, a pressure reducing mattress to bed, encouraging oral fluids, heel protection boots while in bed or as needed, encouraging to be out of the wheelchair at least two hours daily as tolerated, and the nurse to ensure resident goes to bed timely just before or just after dinner. Review of Resident #87's treatment orders revealed on 04/09/25 the right and left ischium were dressed with collagen silver calcium alginate (used for managing moderate to heavy draining wounds with antimicrobial protection) followed by a bordered foam dressing daily and as needed (PRN). Review of Nurse Practitioner (NP) #307's wound note dated 04/14/25 revealed the status of both Resident #87's wounds, the right and left ischium, were stable with both measuring 1.0 centimeters (cm) length (L) by 2.0 cm width (W) by 1.0 cm depth (D) for a calculated area of 2.0 square (sq) cm. Review of the NP #307's wound note dated 04/23/25 revealed the status of both Resident #87's wounds, the right and left ischium, stalled with the right ischium having increased in size to 4.5 cm L by 3.0 cm W by 0.8 cm D for a calculated area of 13.5 sq cm, and the left ischium size unchanged. Surgical wound debridement was completed on the right ischium wound.Review of the NP #307's wound note dated 04/30/25 revealed Resident #87's right ischium wound status remained stalled with the wound further increased in size to 5.0 cm L by 4.0 cm W by 0.8 cm D for a calculated area of 20.0 sq cm. There was a moderate amount of green exudate, so the NP recommended a wound culture of the right ischium due to evidence of infection, wound deterioration, increased size, increased drainage, tissue degradation, and stalled healing. A wound culture was taken at the time of the assessment.Review of Resident #87's physician orders for 04/30/25 revealed an order for wound culture for wound care. The wound treatment orders were changed to dress the right and left ischium with silver calcium alginate (used for managing moderate to heavy draining wounds, controlling infection and promoting healing) followed by a bordered foam dressing daily and PRN.Review of the nurse's note dated 05/02/25 at 6:49 P.M. revealed Resident #87's wound culture needed recollected due to integrity. The physician was aware of a new order placed to recollect on the next scheduled lab day (05/05/25). Review of Resident #87's physician orders for 05/06/25 revealed an order for wound culture for wound care.Review of the NP #307's wound note dated 05/07/25 revealed Resident #87's right ischium wound status remained stalled. The wound measured 4.5 cm L by 4.0 cm W by 0.8 cm D for a calculated area of 18.0 sq cm. A moderate amount of green exudate remained present. The left ischium wound status was also stalled with no change in measurements and a moderate amount of serosanguineous (a thin discharge which contains blood and serious fluid). The note indicated the wound culture taken on the last visit by NP #307 per the facility's wound nurse was not completed and sent to the lab. Another order for another culture was pending.Review of Resident #87's physician orders for 05/13/25 revealed an order for wound culture for wound care for two days. The right ischium wound treatment was changed to day shift in lieu of night shift and the left ischium wound treatment was changed to dress with collagen with silver followed by a bordered foam dressing daily and PRN on day shift in lieu of night shift.Review of the NP #307's wound note dated 05/15/25 revealed Resident #87's right ischium wound status continued to be stalled. The wound measured 5.6 cm L by 4.0 cm W by 0.8 cm D for a calculated area of 22.4 sq cm. The wound now had a moderate amount of purulent (pus containing dead white blood cells, bacteria and tissue debris signaling an active infection that needs prompt medical attention) exudate. The left ischium wound status also remained stalled measuring 2.0 cm L by 3.0 cm W by 3.5 cm D for a calculated area of 6.0 sq cm. The wound continued to have serosanguineous exudate. A wound culture was collected. The previous wound cultures (since 05/07/25) were not completed and/or picked up for the lab so no results were available per the facility nursing staff. Imaging was recommended to rule out osteomyelitis as the right ischium bone was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few exposed and the left ischium bone was covered with fascia (a web of connective tissue).Review of Resident #87's physician orders revealed an order dated 05/16/25 for wound culture for wound care. The NP recommended imaging from 05/15/25; however, this was not ordered until 05/18/25 for Magnetic Resonance Imaging (MRI) to rule out osteomyelitis due to bone being exposed in the right ischium wound and the left ischium bone covered with fascia in the wound. It was not until 05/22/25 when the MRI appointment was ordered for 06/06/25 at 10:30 A.M. via scheduled transport.Review of the nurse's note dated 05/16/25 at 5:28 P.M. revealed Resident #87's wound culture was still pending as of this date.Review of the wound culture results dated 05/19/25 for the specimen collected 05/16/25 revealed it was positive for heavy growth of multiple bacteria.Review of the lab note dated 05/19/25 at 7:49 P.M. revealed Resident #87's labs were reported to the physician and new orders were given.Review of Resident #87's physician orders for 05/19/25 revealed an order for the antibiotic Doxycycline 100 milligrams (mg) orally twice daily for wound infection for 14 days and to make an appointment with infectious disease specialist for the wounds.Review of the medication administration note dated 05/19/25 at 11:49 P.M. revealed Resident #87 received the initial dose of the ordered antibiotic Doxycycline.Additional review of Resident #87's physician orders revealed on 05/20/25 an infectious disease specialist appointment was scheduled for 06/04/25 with a one-time only wound culture and facility staff were to accompany the resident. Review of NP #307's wound note dated 05/22/25 revealed Resident #87 started on contact isolation as of 05/20/25 secondary to the right ischium wound culture results of heavy growth of the bacteria klebsiella pneumoniae and moderate growth of pseudomonas aeruginosa which was a CRPA (Carbapenem resistant Pseudomonas), heavy growth of streptococcus agalactiae group B, heavy growth of probable non-hemolytic streptococcus with no sensitivity done, and moderate growth of diphtheroid bacillus. Doxycycline 100 mg was started on 05/19/25 with an end date of 06/02/25 to be given orally twice daily for the wound infection for 14 days. Imaging to be completed to rule out osteomyelitis. The MRI appointment was scheduled for 06/06/25. The status of both wounds continue to be stalled. The right ischium measured 2.2 cm L by 5.2 cm W by 3.5 cm D for a calculated area of 11.44 sq cm and had moderate amounts of serosanguineous exudate. The left ischium measured 2.5 cm L by 2.0 cm W by 2.1 cm D for a calculated area of 5.0 sq cm and had moderate amounts of serosanguineous exudate. New recommendations for Resident #87's right ischium were from cultures resulted an antibiotic was started, an MRI was scheduled and pending completion, and no debridement until all imaging resulted. New recommendations for the resident's left ischium was debridement which the resident agreed upon. Review of Resident #87's physician orders for 05/23/25 revealed the right ischium wound treatment was changed to cleanse with 0.125 percent Dakin's solution (an antiseptic liquid) then apply Dakin's moistened gauze followed by a bordered foam dressing daily and PRN. The left ischium treatment was changed to cleanse with 0.125 percent Dakin's solution then apply medical grade honey, followed by calcium alginate and a bordered foam dressing daily and PRN.Review of the nurse's note dated 05/23/25 at 8:23 P.M. revealed Resident #87 continued antibiotic therapy with isolation precautions maintained. The resident complained of discomfort and non-pharmacological interventions were ineffective, so PRN medication was administered.Review of NP #307's wound note dated 05/30/25 revealed Resident #87's wounds continued to be stalled and increased in size. The right ischium measured 4.0 cm L by 6.5 cm W by 3.5 cm D for a calculated area of 26.0 sq cm. The left ischium measured 2.6 cm L by 3.4 cm W by 2.1 cm D for a calculated area of 8.84 sq cm. Surgical wound debridement was done on both wounds.Additional review of Resident #87's plan of care revealed it was not revised until 06/05/25 to include an actual infection of Methicillin-resistant Staphylococcus aureus (MRSA). Interventions included administering antibiotic therapy per physician orders, aerosols per physician orders, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few assessing and monitoring vital signs, notifying physician of changes, encouraging fluids, and providing isolation per protocol.There was no documented information included in the medical record regarding Resident #87's appointment with the infection specialist on 06/04/25. However, a diagnosis of osteomyelitis was added and the physician orders for 06/04/25 revealed a change of antibiotic to Piperacillin, 4.5 grams to be infused intravenously every six hours for MRSA infection of stage 4 wound for six weeks until finished, and a PICC (peripherally inserted central catheter) to be placed for infusion. Review of the run reports for transportation dated 06/06/25 revealed Resident #87 attended the scheduled MRI appointment on 06/06/25. The facility was awaiting results.Review of the physician's orders for 06/06/25 revealed the right ischium wound treatment was changed to cleanse with 0.125 percent Dakin's solution then apply Dakin's moistened gauze with calcium alginate over the peri wound area followed by a bordered foam dressing daily and PRN. The left ischium treatment was changed to cleanse with 0.125 percent Dakin's solution, then apply medical grade honey and calcium alginate with silver followed by a bordered foam dressing daily and PRN.Review of the nurse's note dated 06/06/25 at 6:25 P.M. revealed Resident #87 requested to go to the hospital for overall not feeling well. The resident had periods of confusion and lethargy throughout the day. The resident's family also requested Resident #87 be transported to the hospital due to the resident being confused a few times throughout the week, which was not reflected in the medical record.Review of the nurse's note dated 06/06/25 at 7:24 P.M. revealed Resident #87 left by ambulance to the hospital.Review of the nurse's note dated 06/07/25 at 2:42 A.M. revealed Resident #87 was admitted to the hospital. Attempts to obtain hospital records to review as part of investigation were unsuccessful. Interviews on 09/23/25 at 12:33 P.M. with Licensed Practical Nurse (LPN) #241, at 1:12 P.M. with LPN #255, and at 4:37 P.M. with LPN #242 revealed floor nurses completed all wound care, and the wound care nurse came to the facility once weekly to do wound measurements and follow up with wounds.Interview on 09/23/25 at 1:40 P.M. with Assistant Director of Nursing (ADON) #269 revealed Resident #87 had a wound culture ordered on 04/30/25. On 05/02/25, the lab results stated there was a problem with sample integrity. The facility policy was to have a nurse redo the culture. The repeat culture was not completed until 05/16/25. Interview on 09/29/25 at 1:00 P.M. with Senior Director of Nursing (SDON) #300 revealed Resident #87 was admitted on [DATE] with right and left Stage IV pressure ulcers/wounds. SDON #300 revealed a culture was collected on 05/02/25 and a repeat culture was not completed until 05/16/25 because the resident refused it on 05/15/25 (this was not reflected in the medical record). On 05/20/25 the antibiotic, Doxycycline was ordered and was changed to a different antibiotic on 06/04/25, given IV through a PICC. Interview on 09/30/25 at 8:02 A.M. with LPN #255 revealed Resident #87 had bad wounds but was not compliant by staying up in her wheelchair for too long. However, the LPN stated the resident was compliant with wound dressing changes. Interview on 09/30/25 at 8:46 A.M. with Certified Nursing Assistant (CNA) #239 revealed Resident #87 was very particular. She was alert and oriented, and needed her wound dressings changed every time she had a bowel movement. The resident used a motorized wheelchair and was up before lunch and laid down before dinner. The resident had an air mattress, a wedge pillow at her feet and floated her heels but the CNA stated the resident was non-compliant at times about repositioning. Interview on 09/30/25 at 11:31 A.M. with the wound company's Clinical Lead Nurse, Nurse #308 revealed Resident #87 was admitted with pressure ulcers and had a history of osteomyelitis. The right ischium wound was debrided on 04/07/25. An air mattress was used, and it was recommended for the resident to not be up for more than two hours at a time. Both wounds were stable on 04/21/25. By 04/30/25 there was some mild moisture associated skin damage (MASD) and the right ischium wound had stalled with healing, so the treatment was changed. A culture was ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete but it was not processed. By 05/07/25 both wounds were stalled and per the nurse, the culture was pending as the resident would not allow testing (this was not reflected in the medical record). On 05/15/25 the treatment was changed and the culture was collected. Imaging was recommended on 05/22/25. The culture came back (reflective of infection) and an antibiotic started for 14 days. The resident had an appointment for an MRI on 06/06/25. On 05/30/25 the wounds remained stalled and were debrided. The nurse revealed staff were to assist the resident with side-to-side turns as tolerated. On 06/04/25 the antibiotic was changed for MRSA. During the interview, Nurse #308 verified the wound culture was not completed timely (resulting in a delay in treatment for infection). Nurse #308 revealed the facility should have called the physician for further advice. Nurse #308 identified the pressures ulcers began to decline on 05/15/25. Interview on 09/30/325 at 12:49 P.M. with Resident #87's attending physician, Medical Doctor (MD) #304 revealed the physician was unaware the resident failed to receive a wound culture for two weeks. Interview on 09/30/25 at 4:12 P.M. with Regional Director of Nursing (RDON) #299 verified Resident #87 had a wound culture completed on 05/02/25 that came back with a sample integrity issue and no further wound cultures were completed until 05/16/25. Interview on 12/09/25 at 2:44 P.M. with Administrator revealed the facility had no policy on wound cultures.This deficiency represents non-compliance investigated under Complaint Numbers 2621314 and 1313686 (OH00167120). Event ID: Facility ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on record review and interview, the facility failed to timely collect a urine sample and start an antibiotic for a urinary tract infection (UTI). This affected one (Resident #84) of three residents reviewed for timely lab work. The facility census was 80.Findings include:Review of the medical record for Resident #84 revealed an admission date of 06/19/25. Diagnoses included chronic obstructive pulmonary disease (COPD), displaced fracture neck of the left femur, open wound to the left hip, diabetes, presence of left artificial hip, peripheral vascular disease. The resident was discharged to another facility on 07/16/25.Review of the Five-Day Minimum Data Set (MDS) assessment, dated 06/23/25, revealed Resident #84 had intact cognition. The resident required partial/moderate assistance for toileting hygiene, upper body dressing, to roll left and right, and sit to laying. The resident required substantial/maximal assistance for lower body dressing, sit to stand, chair to bed to chair transfer, and toilet transfer.Review of the nurse's note dated 07/07/25 at 7:10 A.M. revealed the previous shift nurse notified this nurse that resident's daughter requested a urinalysis for culture and sensitivity (UA C&S) due to increased confusion. Later in shift, this nurse went to answer the resident's call light, and Resident #84 stated she doesn't know what she is doing, and she thought she had lost her mind. The nurse attempted to collect urine at that time, but the resident stated she had just gone to the restroom. The oncoming nurse was made aware to the need to attempt to collect urine.Review of the social service's note dated 07/07/25 at 1:17 P.M. revealed Resident #84 had a UA C&S ordered due to the resident's increased confusion and daughter's concern.Review of the nurse's note dated 07/11/25 at 7:00 A.M. revealed Resident #84 had positive UA results with the C&S pending.Review of the nurse's note dated 07/14/25 at 1:25 P.M. revealed Resident #84's granddaughter called for updates on UA C&S and labs. The nurse made the granddaughter aware the physician had not given any orders at this time but told the granddaughter she would reach out to the physician and call her with an update.Review of the nurse's note dated 07/14/25 at 3:51 P.M. revealed Resident #84's granddaughter was updated regarding new orders for Macrobid (antibiotic) and iron.Review of physician orders identified orders for Macrobid oral capsule 100 milligrams (mg). Give one capsule by mouth two times a day for UTI for seven days. The order was dated 07/15/25 at 7:00 A.M. (It took eight days for treatment to begin after Resident #84's daughter originally requested a UA C&S).Interview on 09/26/25 at 8:52 A.M. with the Director of Nursing (DON) confirmed the urine sample was not obtained timely, and the antibiotic was not ordered timely. This deficiency represents non-compliance investigated under Complaint Number 2572360. Event ID: Facility ID: 366015 If continuation sheet Page 10 of 10