Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carecore At Mentor during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain its heating units and thermostats in good repair, leading to a smoking blower motor belt in a conference room heater that generated excessive heat and activated the fire alarm. A subsequent inspection identified numerous malfunctioning thermostats in multiple resident rooms, affecting many residents’ room temperatures. This was inconsistent with the facility’s own policy requiring a safe, clean, comfortable environment with safe and comfortable temperatures.
A resident with multiple risk factors, including impaired cognition, mobility issues, and a history of infection, did not receive timely monitoring or interventions for bowel and bladder elimination as required by physician orders and facility protocol. Despite several days without a bowel movement, staff did not follow the bowel protocol or promptly notify the physician, resulting in the resident developing severe symptoms and requiring hospital transfer, where the resident was diagnosed with aspiration pneumonia and possible small bowel obstruction, and later died from sepsis.
A resident with quadriplegia and multiple comorbidities was admitted with two Stage IV pressure ulcers that deteriorated due to the facility's failure to implement a comprehensive pressure ulcer prevention program and delays in obtaining and processing wound cultures. Despite care plans and physician orders, inconsistent documentation, lack of timely interventions, and absence of a wound culture policy led to wound infection, osteomyelitis, and hospitalization.
A resident with multiple chronic conditions was transferred to the hospital after calling 911 due to feeling scared. Although the spouse was notified of the transfer, the POA, who was the primary emergency contact, was not informed, and no change of condition form was completed. The DON confirmed these omissions during the investigation.
A resident with multiple health conditions experienced increased confusion, leading to a family request for a urinalysis to check for a UTI. Staff did not promptly collect the urine sample or initiate antibiotic treatment, resulting in an eight-day delay from the initial request to the start of therapy. The DON confirmed the delays in both sample collection and treatment initiation.
The facility failed to ensure proper kitchen sanitation and staff hair covering practices. An unclean ice machine filter was observed, and a dietary staff member was seen preparing food with unsecured braids, contrary to facility expectations. This affected all residents receiving food, except two with orders for nothing by mouth.
The facility failed to maintain the walk-in freezer in proper working condition, affecting all residents receiving food from the kitchen, except for two with orders for nothing by mouth. Ice buildup was observed due to a malfunctioning door seal, known to maintenance since May. A repair quote was delayed in approval until July, attributed to the Administrator's absence and indecision on repair options.
The facility failed to change nasal cannula oxygen tubing in a timely manner for four residents using oxygen therapy. Observations revealed outdated or undated nasal cannulas, with no documentation of changes in the MAR and TAR for June and July 2024. Interviews with staff confirmed these findings, and the facility's policy requiring weekly changes and dating of tubing was not followed.
A facility failed to accurately document a resident's dialysis treatment in the MDS assessments. Despite having clear documentation and physician orders for dialysis three times a week, the MDS assessments did not reflect this treatment. The DON confirmed the oversight, acknowledging that the resident was an established dialysis patient and the assessments should have captured this information.
A facility failed to develop and implement a care plan for a resident's use of psychotropic medications. The resident, diagnosed with schizophrenia, insomnia, and anxiety, received an antipsychotic and antidepressant, but the care plan did not address these medications. The DON confirmed the absence of a care plan, despite facility policy requiring comprehensive person-centered care plans.
A facility failed to securely administer medications to a resident with multiple diagnoses, including COPD and depression. The resident was observed self-administering a Fluticasone inhaler and had several medication bottles at her bedside without proper orders or a self-administration assessment. She reported ordering her own medications due to stock issues and self-medicating with an additional dose of Desvenlafaxine. An LPN confirmed these findings.
A resident was observed self-administering medication without an order, contributing to a medication error rate of 14.8%. The resident, with multiple diagnoses, reported ordering her own medications due to facility errors. An LPN failed to administer all prescribed medications, and the facility's policy on medication administration was not followed.
A resident with chronic kidney disease was administered a diuretic medication despite orders to hold it, leading to severe dehydration and hospitalization. The facility failed to communicate effectively with the primary care physician and nephrologist, resulting in a significant medication error.
The facility failed to ensure a resident's medical record was complete and accurate, lacking documentation on the resident's assessment, condition, and reason for hospital transfer. The nurse on duty could not recall the details, and the Director of Nursing confirmed the record was incomplete, violating the facility's documentation policy.
The facility failed to provide adequate wound care for two residents, resulting in one resident developing a severe infection and requiring hospitalization. The facility did not follow its policies on skin breakdown and pain management, leading to significant harm.
A resident with multiple medical conditions experienced a severe weight loss of 14.5% over 56 days due to the facility's failure to provide prescribed nutritional supplements and to monitor the resident's weight as required. Interviews confirmed that the resident often did not receive the supplements, and the facility did not promptly address the weight loss.
The facility failed to provide sufficient tracheostomy care for two residents, leading to significant health issues, including multiple hospital admissions and severe health complications. The lack of care included failing to administer oxygen, monitor oxygenation levels, perform suctioning, change the cannula, and clean the tracheostomy site as ordered. Interviews with the family and staff confirmed the inadequate care and visibility issues of the care orders for the nursing staff.
The facility failed to implement required enhanced barrier precautions for two residents with tracheostomies, improperly handled soiled linen and paper towels during tracheostomy care for another resident, and did not perform proper hand hygiene during wound care for a resident with multiple medical conditions.
The facility failed to maintain a clean and homelike environment, with observations of unused incontinence briefs, soiled socks, and dirty meal trays in resident hallways, as well as an overfilled trash can in the shower room. These issues were confirmed by an STNA and an LPN.
The facility failed to conduct thorough and accurate fall investigations for three residents, leading to deficiencies in accident prevention and supervision. One resident was found on the floor but was later revealed to have been placed in a sitting position by STNAs. Another resident's fall intervention was not implemented, and a third resident's fall was not thoroughly documented or investigated.
The facility failed to obtain orders for and provide sufficient urinary catheter-related care for a resident with multiple diagnoses, including diabetes and chronic kidney disease. Despite having a urinary catheter in place from January to April 2024, there were no physician orders or documented care for the catheter. The DON confirmed the lack of orders and care, which was against the facility's policy on urinary incontinence.
Failure to Maintain Heating Units and Thermostats in Good Repair
Penalty
Summary
The deficiency involves the facility’s failure to maintain heating units in good repair, resulting in malfunctioning thermostats and an overheating incident. A fire department incident report documented that a blower motor belt in the conference room heating unit began smoking and generating excessive heat, which triggered the facility’s fire alarm system. The Administrator reported that the motor on this heating unit had frozen, causing the belt to smoke and produce excessive heat. Subsequent review of facility documentation titled "Monitoring of Heaters" showed that 18 thermostats were not functioning correctly in identified resident rooms, affecting 20 residents. A service quote confirmed that 21 thermostats in the building required replacement, including two in non-resident areas. The Administrator confirmed that the rooms listed on the monitoring document were resident rooms identified during a heating unit inspection. The facility’s own "Quality of Life – Homelike Environment" policy stated that residents are to be provided a safe, clean, comfortable environment with comfortable and safe temperatures, which was not met due to the malfunctioning heating equipment.
Failure to Monitor and Timely Treat Constipation and Infection
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor a resident's condition, specifically regarding bowel and bladder elimination, which resulted in a delay in identifying and treating infection and constipation. The resident had multiple risk factors, including diabetes, impaired cognition and mobility, cystitis, a history of sepsis, and was at high risk for both constipation and infection. The care plan included interventions for constipation and infection, but did not comprehensively address all infection risks related to the resident's diagnoses. After returning from a hospital stay for sepsis, there was no evidence of comprehensive infection monitoring as outlined in the care plan. The resident had physician orders and a bowel protocol in place, which required administration of specific medications if no bowel movement occurred after three days, escalating to physician notification if interventions were unsuccessful. Despite documentation showing no bowel movement for four consecutive days, the required interventions were not administered in a timely manner according to the protocol. Staff interviews confirmed that the bowel protocol was not followed as ordered, and there was a lack of timely physician notification and assessment when the resident's condition changed. On the day of the incident, the resident exhibited progressive symptoms including stomach upset, diaphoresis, vomiting fecal matter, a firm and distended abdomen, hypoxemia, change in mental status, elevated heart rate, and pallor. Although some interventions were eventually initiated, there was a delay in both the administration of bowel protocol steps and in notifying the physician. The resident was ultimately transferred to the hospital with diagnoses of aspiration pneumonia and possible small bowel obstruction, and subsequently passed away with sepsis listed as the cause of death.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Timely Infection Management
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident admitted with two Stage IV pressure ulcers. Despite being identified as at high risk for impaired skin integrity due to multiple diagnoses including quadriplegia, malnutrition, and prior osteomyelitis, the resident experienced a deterioration in wound status, including increased wound size and signs of infection such as green drainage. Although wound cultures were ordered when infection was suspected, there were significant delays in obtaining and processing these cultures, with a two-week gap between the initial failed culture and the subsequent successful collection. During this period, the wounds continued to worsen, and appropriate interventions were delayed. The resident's care plan included interventions such as use of barrier creams, pressure reduction devices, repositioning, and wound care per physician orders. However, documentation and interviews revealed inconsistent implementation and monitoring of these interventions. Staff interviews indicated that the resident was sometimes non-compliant with off-loading and repositioning, but there was insufficient documentation of educational efforts or follow-up regarding non-compliance. Additionally, the facility lacked a policy on wound cultures, contributing to the delay in obtaining necessary diagnostic information and initiating timely treatment for infection. As a result of these failures, the resident's wounds became infected, with cultures eventually revealing multiple bacteria including MRSA and carbapenem-resistant organisms. The resident developed osteomyelitis and required hospitalization after experiencing confusion, lethargy, and overall decline. The deficiency was substantiated by medical record review, staff interviews, and the absence of timely and effective wound management practices.
Failure to Notify POA of Resident Hospitalization
Penalty
Summary
The facility failed to timely notify the appropriate family member, specifically the resident's Power of Attorney (POA), regarding a resident's hospitalization. The resident, who had diagnoses including COPD, a displaced fracture of the left femur, an open wound to the left hip, diabetes, a left artificial hip, and peripheral vascular disease, was admitted to the facility and later transferred to the hospital after calling 911 due to feeling scared. Emergency Medical Services (EMS) responded and, at the resident's request, transported her to the hospital for evaluation. Documentation showed that the resident's spouse was notified of the transfer, but there was no evidence that the POA, listed as the primary emergency contact, was informed. Additionally, the medical record review revealed that no change of condition form was completed for this event. The Director of Nursing (DON) confirmed during an interview that the required notification to the POA was not made and that the change of condition form was not filled out. This deficiency affected one resident out of three reviewed for change in condition, in a facility with a census of 80.
Delay in Urine Sample Collection and UTI Treatment
Penalty
Summary
A deficiency occurred when staff failed to timely collect a urine sample and initiate antibiotic treatment for a resident who exhibited signs of a possible urinary tract infection (UTI). The resident, who had multiple diagnoses including COPD, diabetes, and a recent hip fracture, was noted to have increased confusion, prompting a request from the resident's daughter for a urinalysis with culture and sensitivity (UA C&S). Although the need for a urine sample was communicated between nursing shifts, the sample was not collected promptly, as the resident had just used the restroom when the nurse attempted collection, and the task was passed to the oncoming nurse. Despite documentation of the UA C&S order and ongoing family inquiries about the results, there was a significant delay in both obtaining the urine sample and starting antibiotic therapy. The positive urinalysis was noted several days after the initial request, and the antibiotic order was not placed until eight days after the family first raised concerns. The DON confirmed that both the urine sample collection and the initiation of antibiotic treatment were not completed in a timely manner.
Kitchen Sanitation and Hair Covering Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the kitchen, specifically regarding the ice machine filter and staff hair covering practices. During an initial tour of the kitchen, it was observed that the ice machine filter was not clean and had accumulated a layer of dust. This was confirmed by a dietary staff member who acknowledged that the filter was supposed to be cleaned monthly. Additionally, a dietary staff member was observed preparing food with long braids that were not secured or covered by a hairnet, contrary to the facility's expectations for hair covering. The facility's policy on kitchen sanitation, dated 2010, indicated that the ice machine should be cleaned regularly to ensure sanitary conditions. The deficiency had the potential to affect all residents receiving food from the kitchen, except for two residents who had orders for nothing by mouth. The facility census at the time was 84.
Delayed Repair of Walk-In Freezer Door
Penalty
Summary
The facility failed to maintain the walk-in freezer in proper working condition, which had the potential to affect all residents receiving food from the kitchen, except for two residents who were identified as having orders for nothing by mouth. The issue was identified through observations of ice buildup inside the freezer, including ice on the floor and on boxes of food items. Interviews with dietary staff confirmed that the freezer door did not seal properly, causing the ice buildup, and that maintenance was aware of the issue but had not yet repaired it. The facility received a repair quote on 05/13/24, but the repair was not approved until 07/10/24. The delay in addressing the malfunction was attributed to the Administrator being out of the office for three weeks and the facility's indecision on whether to replace the broken part or the entire door. Despite the freezer maintaining an appropriate temperature, the lack of timely action to repair the door resulted in continued ice accumulation, as confirmed by multiple observations and interviews with facility staff.
Failure to Timely Change Nasal Cannula Oxygen Tubing
Penalty
Summary
The facility failed to change nasal cannula oxygen tubing in a timely manner for four residents who were utilizing oxygen therapy. Resident #32, diagnosed with chronic obstructive pulmonary disease, had no documentation of nasal cannula changes in their Medication Administration Records (MAR) and Treatment Administration Records (TAR) for June and July 2024. An observation on July 8, 2024, revealed no date on the nasal cannula, and the resident was unsure when it was last changed. Similarly, Resident #64, with chronic respiratory failure, had a nasal cannula dated May 23, 2024, with no subsequent changes documented in the MAR and TAR for the same period. An interview confirmed the outdated nasal cannula. Resident #69, with atherosclerotic heart disease and impaired cognition, also had no documentation of nasal cannula changes in their records for June and July 2024. An observation on July 8, 2024, showed no date on the nasal cannula. Resident #22, with chronic obstructive pulmonary disease and mild cognitive impairment, similarly lacked documentation of nasal cannula changes, and an observation confirmed the absence of a date on the nasal cannula. Interviews with staff verified these findings, and a review of the facility's policy indicated that oxygen tubing and nasal cannulas should be changed weekly and dated, which was not adhered to in these cases.
Failure to Accurately Capture Dialysis in MDS Assessments
Penalty
Summary
The facility failed to accurately capture the health status of a resident undergoing dialysis during the Minimum Data Set (MDS) assessments. The resident, who was admitted with diagnoses including intraductal carcinoma of the left breast and end-stage renal disease, was dependent on renal dialysis. Despite having physician orders for dialysis three times a week and documentation from the admitting hospital and facility indicating the resident's dialysis schedule, the MDS assessments did not reflect dialysis as a treatment. This oversight was identified during a review of the admission and 5-Day MDS assessments, as well as the quarterly and modified quarterly MDS assessments. The Director of Nursing (DON) confirmed that the resident was an established dialysis patient and acknowledged that the MDS assessments should have accurately captured this treatment. The facility's policy on comprehensive assessments, revised in October 2023, stated that MDS assessments should be conducted to develop person-centered care plans through direct observations and communication with residents and staff. However, the facility failed to communicate effectively to complete the MDS assessments accurately, leading to the deficiency.
Failure to Implement Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement a care plan for the use of psychotropic medications for Resident #72. The resident was admitted with diagnoses including schizophrenia, insomnia, and anxiety. A review of the quarterly Minimum Data Set (MDS) Assessment indicated that the resident received an antipsychotic and antidepressant during the seven-day lookback period. However, the comprehensive care plan, last reviewed on 04/19/24, did not include a plan for the use of these medications. Physician's orders for July 2024 included Invega Sustenna, an antipsychotic, and Trazodone Hydrochloride, an antidepressant, but there was no corresponding care plan. The Director of Nursing confirmed the absence of a care plan for the psychotropic medications. The facility's policy required a comprehensive person-centered care plan with measurable objectives and timetables to meet the resident's needs, which was not developed or implemented in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to securely administer medications according to the needs of a resident, affecting one of five residents reviewed for medications. The resident, who had diagnoses including COPD, diabetes, visual hallucinations, major depressive disorder, and bipolar disorder, was observed self-administering a Fluticasone inhaler without a self-administration assessment. The resident had multiple medication bottles at her bedside, including acetaminophen, Turmeric, Alrex, Desvenlafaxine, and Fluticasone, despite not having orders to keep these medications at her bedside, except for nasal spray. The resident reported that the facility often did not have her medications in stock, prompting her to order her own and self-medicate with an additional dose of Desvenlafaxine beyond the facility-administered dosage. An LPN confirmed these findings during an interview.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 14.8% during a medication administration observation. This deficiency affected one resident, who was observed self-administering a Fluticasone inhaler without an order to do so. The resident had multiple pill containers at her bedside, including Desvenlafaxine, which she took in a dosage not prescribed by the facility. The Licensed Practical Nurse (LPN) responsible for administering medications did not provide the resident with all her prescribed medications, as the artificial tears and FiberCon were not found or administered. The resident, who had diagnoses including COPD, diabetes, and major depressive disorder, reported frequently ordering her own medications due to the facility's failure to provide the correct ones. The LPN confirmed that the resident had no orders to self-administer medications and acknowledged the missing medications. The facility's medication administration policy requires medications to be given according to prescriber orders and only allows self-administration if deemed safe by the attending physician and care team, which was not the case here.
Failure to Hold Diuretic Medication Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, leading to actual harm. Resident #91, who had a history of chronic kidney disease, diabetes, and other conditions, was ordered by her primary care physician (PCP) to hold her diuretic medication, Torsemide, due to worsening kidney function. Despite this order, the facility administered the medication without a physician's order, resulting in a significant change in the resident's condition and an unplanned hospitalization. The resident's creatinine levels, which indicate kidney function, continued to rise, and she showed signs of severe dehydration and renal failure. On 03/29/24, the PCP ordered to hold the Torsemide due to abnormal lab results, but the facility restarted the medication on 04/01/24 without a physician's order. The facility was unable to contact the nephrologist regarding the increased creatinine levels until 04/03/24. During this period, the resident continued to receive the diuretic, which exacerbated her condition. The resident was eventually sent to the hospital, where she was found to be severely dehydrated and at risk of requiring dialysis. Interviews with facility staff and the resident's husband revealed that there was a lack of communication and documentation regarding the resident's medication and lab results. The Director of Nursing confirmed that the Torsemide should not have been restarted and that the facility failed to contact the PCP when they were unable to reach the nephrologist. The facility's policy on administering medications was not followed, leading to the resident's deterioration and hospitalization.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to ensure that Resident #91's medical record was complete and accurate. Resident #91, who had diagnoses including partial amputation of her right foot, diabetes, chronic kidney disease, lymphedema, and osteomyelitis, was transferred to the hospital on 04/03/24. However, the medical record lacked documentation regarding the resident's assessment, condition, who ordered the hospital transfer, and the reason for the transfer. This deficiency was identified during a review of the medical records, facility policy, and interviews with staff members, including RN #601 and the Director of Nursing. RN #601, who was on duty at the time of the transfer, could not recall the details of why Resident #91 was sent to the hospital and admitted that she did not document the necessary information. The Director of Nursing confirmed that the medical record was incomplete and that RN #601 should have documented the resident's assessment, condition, and the reason for the hospital transfer. The facility's policy on charting and documentation, dated July 2017, requires that all services provided to the resident and any changes in the resident's condition be documented in the medical record. This deficiency was investigated under Complaint Number OH00152934.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to provide comprehensive, individualized, and sufficient wound care for two residents, resulting in actual harm to one of them. Resident #28, who was admitted for wound care, experienced a significant decline in their condition due to inadequate monitoring and treatment. Despite being admitted with a wound that required specific care, the facility did not initiate the necessary treatment until several days after admission. This delay led to the resident developing a foul-smelling, pus-draining, and painful wound, which was later diagnosed as cellulitis/infection, necessitating hospital admission. The resident reported that the dressing was supposed to be changed twice daily but was only changed four times in ten days, contributing to the infection and increased pain. The Director of Nursing (DON) confirmed that the wound was not treated promptly and that the resident had to contact emergency services due to the lack of care and increased pain. Additionally, the facility's records showed discrepancies, with treatments being signed off as completed even when the resident was not in the facility. The facility's policies on skin breakdown and pain management were not followed, leading to the resident's condition worsening and requiring hospitalization. Resident #95 also did not receive the ordered wound care on multiple occasions, as confirmed by the DON. The resident's treatment administration record showed that wound care was not completed as ordered on several dates, indicating a pattern of neglect in providing necessary wound care. This deficiency represents non-compliance investigated under Complaint Number OH00152133 and Complaint Number OH00152075.
Failure to Provide Nutritional Supplements and Monitor Weight
Penalty
Summary
The facility failed to ensure that a resident received nutritional supplements as ordered, did not develop and implement a comprehensive and effective nutrition program, and failed to obtain re-weights and/or weekly weights when a severe weight loss was noted. This deficiency affected a resident who experienced a severe weight loss of 14.5% over 56 days. The resident's weight loss was not addressed until 23 days after it was first documented, and the resident did not receive the prescribed nutritional supplements consistently during this period. The resident, who had multiple medical conditions including rheumatoid arthritis, diabetes, lupus, emphysema, Bell's palsy, hypertension, hyperlipidemia, schizophrenia, hypothyroidism, and anxiety, was on a consistent carbohydrate diet with mechanical soft texture and thin consistency. Despite the physician's orders for various nutritional supplements, the resident's medical record and Medication Administration Record (MAR) revealed numerous instances where the supplements were not provided. The resident's weight dropped from 111 pounds to 95.4 pounds over the course of two months, indicating a severe weight loss that was not promptly addressed. Interviews with the resident, dietary manager, registered dietitian (RD), and director of nursing (DON) confirmed that the resident often did not receive the prescribed supplements. The facility's policy required immediate notification of the dietitian in case of significant weight loss, but this was not followed. The RD tracked weight loss but did not document a nutrition note until 23 days after the initial weight loss was noted. The facility's failure to provide the necessary nutritional supplements and to monitor the resident's weight as required led to the resident's severe weight loss and the deficiency noted in the report.
Failure to Provide Adequate Tracheostomy Care
Penalty
Summary
The facility failed to provide sufficient tracheostomy care for two residents, leading to significant health issues. Resident #19, who was cognitively impaired and dependent on staff for tracheostomy care, was admitted to the hospital multiple times with acute on chronic respiratory failure, hypoxia, recurrent infection, and the need for mechanical ventilation. Despite having specific physician orders for tracheostomy care, there was no documented evidence that the required care was provided consistently, especially when the respiratory therapist was not present in the facility. This lack of care included failing to administer oxygen, monitor oxygenation levels, perform suctioning, change the cannula, and clean the tracheostomy site as ordered. The resident's condition deteriorated, leading to multiple hospital admissions and severe health complications, including cardiac arrest and respiratory failure due to mucus plugging and infection. Interviews with the family and staff confirmed the inadequate tracheostomy care and the visibility issues of the care orders for the nursing staff. The Director of Nursing (DON) verified these findings, indicating a systemic issue in ensuring the visibility and execution of tracheostomy care orders by the nursing staff when the respiratory therapist was not available. Resident #29, who had no cognitive impairment and was dependent on a respiratory ventilator, also did not receive the required tracheostomy care after re-entering the facility. The resident's medical records showed no evidence of completed tracheostomy care orders, and interviews with the resident and staff revealed a reliance on the respiratory therapist for tracheostomy care. The DON confirmed that the tracheostomy care orders were not visible to the nursing staff, leading to a lack of routine care when the respiratory therapist was not present. This deficiency represents non-compliance investigated under Complaint Number OH00152226.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff used appropriate infection control practices by not implementing required enhanced barrier precautions (EBP) for three residents. Resident #19, who had a tracheostomy and a positive MRSA diagnosis, and Resident #61, who had a tracheostomy and gastrostomy tube, did not have EBP posted or PPE available at their room entrances. Staff members, including an LPN, STNA, and RT, performed various care activities for these residents without wearing the required PPE, such as gowns. The Director of Nursing acknowledged the lack of EBP and PPE, attributing it to recent training that had not yet been disseminated to the staff. Facility policy and CMS guidelines required EBP for residents with wounds or indwelling medical devices, effective from 04/01/24, but these were not followed for Residents #19 and #61. Additionally, RT #281 failed to appropriately handle soiled linen and paper hand towels during tracheostomy care for Resident #61, using a visibly soiled roll of paper towels for hand drying multiple times during the procedure, which was against the facility's policy for handling soiled linen and maintaining hygiene standards. The soiled towel and paper roll were not removed promptly, and the RT continued to use them, compromising infection control practices. For Resident #22, who had multiple medical conditions including a tracheostomy and an abdominal wound, LPN #238 did not perform hand hygiene between glove changes during wound care. The LPN also placed clean dressing supplies on an inadequate barrier, contaminating them with the resident's pillow. This was in violation of the facility's hand hygiene policy, which required handwashing after removing gloves, and the use of a clean barrier for wound care supplies. These deficiencies were identified during observations and interviews with staff, and were confirmed by a review of the facility's policies and CMS guidelines.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment within resident hallways and a shower room, affecting eight residents and potentially all 90 residents in the facility. Observations revealed unused incontinence briefs stuffed into handrails, a soiled sock on the floor, and dirty meal trays placed on heating units and wheelchairs. Additionally, a large Starbucks beverage and food package were found within the handrail alongside soiled linen and trash containers. These items were confirmed by a State tested Nursing Assistant (STNA), who indicated uncertainty about the procedure for returning dirty meal trays and admitted to placing her breakfast items in the resident care area due to being from an agency and not knowing where to keep them. Further observations revealed that the 300-hall shower room had an overfilled trash can with no bag, resulting in trash items spilling onto the floor, including paper towels, wadded-up toilet paper, and a candy wrapper. These findings were verified by a Licensed Practical Nurse (LPN). The deficiency was investigated under Complaint Numbers OH00152036 and OH00152394.
Deficient Fall Investigations and Supervision
Penalty
Summary
The facility failed to ensure thorough and accurate fall investigations for three residents, leading to deficiencies in accident prevention and supervision. Resident #97, who had moderately impaired cognition and multiple diagnoses including acute kidney failure and diabetes, was found on the floor by a nurse. The fall investigation lacked witness statements and contained inaccuracies, as later interviews revealed the resident had not fallen but was placed in a sitting position by STNAs. The DON confirmed the investigation was not thorough or accurate. Resident #5, with impaired cognition and diagnoses including COPD and congestive heart failure, was found on the floor near his bed. The fall investigation did not include witness statements, and the intervention of a perimeter mattress was not implemented. The DON confirmed that the resident refused the mattress, but there was no documentation of this refusal. Resident #94, with intact cognition and diagnoses including a femur fracture and dementia, experienced a fall that was not thoroughly documented. The fall investigation lacked detail, did not include neurological checks, and did not address predisposing factors such as poor lighting and incontinence. The DON verified the fall concerns and the lack of thorough investigation.
Failure to Provide Sufficient Urinary Catheter Care
Penalty
Summary
The facility failed to obtain orders for and provide sufficient urinary catheter-related care for Resident #19. The resident, who had multiple diagnoses including diabetes mellitus type II, acute respiratory failure, hemiplegia, and chronic kidney disease, had a urinary catheter in place during various periods from January to April 2024. Despite the presence of the catheter, there were no physician orders to monitor, maintain, or care for it, and the medication and treatment administration records showed no evidence of catheter care being provided. Progress notes indicated the presence of the catheter on specific dates, but there was no consistent documentation of its maintenance or care. An observation on April 3, 2024, revealed that the resident did not have a urinary catheter in place. The Director of Nursing confirmed that the resident had a urinary catheter for urinary retention, which was believed to have been placed on February 5, 2024, and removed after returning from the hospital on April 1, 2024. However, there were no urinary catheter-related orders during the time the catheter was in place, and no evidence of sufficient care being provided. The facility's policy on urinary incontinence required staff to monitor for complications with long-term indwelling catheters, but this was not followed in the case of Resident #19.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mentor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand River Health & Rehab Center | 3.4 mi | ★★★★★ | 1 | 0 |
| Heritage Healthcare Of Painesville | 4.6 mi | ★★★★★ | 0 | 0 |
| Concord Ridge Health And Rehabilitation | 5 mi | ★★★★★ | 0 | 0 |
| Mentor Ridge Health And Rehabilitation | 5.1 mi | ★★★★★ | 6 | 0 |
| Mentor Hills Post Acute | 5.5 mi | ★★★★★ | 0 | 0 |
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