Carecore at Minster

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Sep 26, 2022

  Based on observations, resident record reviews, review of the emergency squad run report, review of hospital records, review of policy, review of the website Medscape, staff interviews, resident representative interview, physician interview, and interview with pharmacy staff, the facility failed to ensure one newly admitted resident (Resident #02) was free from significant medication errors, when Resident #02 who had a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death, when Resident #02 began having [CONDITION(S)] activity at the facility which required the resident be sent to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Jul 21, 2025

  Based on medical record review, staff interview, review of a Facility Reported Incident, review of police report, review of hospital records, and review of policy, the facility failed to ensure a cognitively impaired resident was free from physical abuse by a facility staff member. This resulted in physical harm when Resident #01 was forcefully pushed down on to a bed by Certified Nursing Assistant (CNA) #200 causing physical injuries of bruising, skin impairments and pain. During the incident, Licensed Practical Nurse (LPN) #202 observed and failed to intervene to protect Resident #01 from abuse. This affected one (#01) of three residents reviewed for abuse. The facility census was 55. Findings include:Review of the medical record of Resident #01 revealed an admission date of 11/26/24. […]

• Actual harm, isolatedF684Dec 4, 2023

  Based on medical record review, review of hospital records, and staff and Physician #850 interviews, the facility failed to ensure a newly admitted resident received appropriate diabetes care when the facility staff failed to clarify a resident's diabetes diagnosis and the need for blood sugar monitoring and insulin administration. This resulted in Actual Harm when staff failed to monitor Resident #04's blood sugars and the resident subsequently had a change in condition resulting in hospitalization and a diagnosis of hyperglycemia requiring intravenous (IV) and subcutaneous (SQ) insulin administration and (IV) fluids. Additionally, the facility failed to have blood glucose monitoring and insulin in place for Resident #38, which placed the resident at risk for more than minimal harm. […]

• No harm, potential for more than minimal, widespreadF812Sep 18, 2025

  Based on observation, staff interview, review of manufacturer instructions, and policy review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner. This had the potential to affect all residents who receive food from the kitchen. The facility identified one (#10) resident that did not receive food from the kitchen. The facility census was 56.Findings include:1. Observation of the kitchen on 09/15/25 at 7:49 A.M. revealed one of the two hand washing sinks did not have paper towels to dry hands, the two storage shelves under the preparation tables were covered in a greasy debris. Additional observation revealed greasy debris in the cabinet shelf above the preparation table. […]

• No harm, potential for more than minimal, widespreadF727Sep 26, 2022

  Based on review of a staffing tool, review of staff schedule and staff interview; the facility failed to ensure a registered nurse (RN) was on duty for eight consecutive hours a day, seven days a week. This had the potential to affect all 35 residents. The census was 35. Findings include: Review of a staffing tool and staff schedules dated 08/15/22 through 08/21/22, revealed on 08/20/21 and 08/21/22 there was no RN coverage. Interview on 09/21/22 at 2:12 P.M. with the Administrator revealed the facility had no RN coverage for weekends. The Administrator revealed the Director of Nursing (DON) provided RN coverage eight hours a day Monday through Friday but on Saturday and Sunday there was no RN employed by the facility to cover the shift. […]