Carecore at Mentor

In the surveyor’s words

From the most serious findings on record at Carecore at Mentor, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 10, 2025

  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. […]

• Actual harm, isolatedF686Dec 10, 2025

  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. […]

• Actual harm, isolatedF760May 10, 2024

  Based on record review, review of hospital records, facility policy review and interview the facility failed to ensure Resident #91 was free from a significant medication error when the facility administered Resident #91's diuretic (medication to increase the production of urine) when it should have been on hold. Actual Harm occurred on 03/29/24 when the facility failed to hold Resident #91's diuretic medication resulting in a significant change in the resident's condition resulting in an unplanned hospitalization . […]

• Actual harm, isolatedF684Apr 19, 2024

  Based on record review, facility policy review and interview, the facility failed to provide comprehensive, individualized and sufficient wound care for Resident #28 and Resident #95. This affected two residents (#28 and #95) of three residents reviewed for non-pressure related wound care. The facility census was 90. Actual harm occurred on 03/21/24 when Resident #28, who was incontinent and admitted for wound care, was directly admitted to the hospital with a foul smelling, pus draining, painful wound and diagnosed with cellulitis/infection due to a lack of monitoring and adequate wound care following the resident's admission on 03/12/24. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE]. […]

• Actual harm, isolatedF692Apr 19, 2024

  Based on observation, interview, record review, and policy review, the facility failed to ensure Resident #62 received nutritional supplements as ordered, failed to 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 affected one resident (#62) of three residents reviewed for nutrition. The facility census was 90. Actual harm occurred when Resident #62, who weighed 11.0 pounds on 01/04/24, experienced a severe 6.2% weight loss from 01/04/24 to 02/01/24, continued to lose an additional 8.4% from 02/01/24 to 03/01/24, and the weight loss was not addressed until 02/28/24. Resident #62 did not receive nutritional supplements as ordered. […]