Inspection visit

Health inspectionApril 13, 2022

MINERVA REHABILITATION AND NURSING CENTERCMS #3661877 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, review of the facility new hire list, review of the facility abuse policy and staff interview the facility failed to ensure all new staff hires were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This affected one Licensed Social Worker (LSW), two housekeeping staff, one dietary staff, one Maintenance Director and one Licensed Practical Nurse (LPN) and had the potential to affect all 20 residents residing in the facility. Residents Affected - Many Findings include: Review of the Bureau of Criminal Identification and Investigation log, dated 2021 to 2022 and review of employee personnel files revealed the following employees had been hired within this time period: Licensed Social Worker/Activity Director #203, Housekeeping Supervisor #220, Housekeeper #222, Maintenance Director #221, Licensed Practical Nurse #225 and [NAME] #223. Licensed Social Worker/Activity Director #203 had a date of hire of 07/05/21 Housekeeping Supervisor #220 had a date of hire of 07/19/21 Housekeeper #222 had a date of hire of 07/14/21 Maintenance Director #221 had a date of hire of 07/21/21 Licensed Practical Nurse #225 had a date of hire of 07/26/21 Cook #223 had a date of hire of 03/31/22 Record review revealed no evidence any of these employees had been checked against the NAR to ensure none of the employees had a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property prior to or at the time of hire. On 04/07/22 at 3:55 P.M. interview with the Administrator verified Licensed Social Worker/Activity Director #203, Housekeeping Supervisor #220, Housekeeper #222, Maintenance Director #221, LPN #225 and [NAME] #223 had not been checked against the NAR prior to hire. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility policy to undertake background checks of all employees and to retain on file prior to hiring a new employee of the Ohio Nurse Assistant Registry and any (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 10 Event ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0606 other nurse assistant registries the facility had reason to believe contain information on an individual prior to using the individual as a nurse assistant. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure a discharge Minimum Data Set (MDS) 3.0 assessment was completed for Resident #1. This affected one resident (#1) of 20 residents whose MDS assessments were reviewed. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 10/04/21 and a discharge date of 10/24/21. Review of the list of Minimum Data Set (MDS) 3.0 assessments completed for Resident #1 revealed no discharge MDS 3.0 assessment was completed. On 04/07/22 at 9:18 A.M. interview with Registered Nurse (RN) #214 verified no discharge MDS 3.0 assessment was completed for Resident #1. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2019 revealed a discharge assessment should have been completed within 14 days of discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for Resident #9 related to oral/teeth status, Resident #12 related to pre-admission screening and resident review (PASARR), Resident #13 related to Hospice, Resident #16 related to medications, Resident #17 related to nutrition and Resident #19 related to pressure ulcers. This affected six residents (#9, #12, #13, #16, #17 and #19) of 20 residents whose MDS 3.0 assessments were reviewed. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 10/31/21 with diagnoses including abnormal posture, repeated falls, hypokalemia, hypertension, osteoarthritis and gastroesophageal reflux disease (GERD). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22 and the comprehensive MDS 3.0 assessment, dated 11/03/22 for Resident #9 revealed the resident did not have his natural teeth. On 04/06/22 at 8:00 A.M. observation and interview with Resident #9 revealed the resident had his own teeth. On 04/06/22 at 4:00 P.M. interview with Registered Nurse (RN) #214 confirmed both MDS 3.0 assessments reviewed above were coded incorrectly as Resident #9 did have his own teeth. 2. Review of the medical record for Resident #16 revealed an admission date of 01/25/22 with diagnoses including anxiety disorder, major depressive disorder, heart failure and muscle weakness. Review of the physician's orders for Resident #16 revealed an order for Hydroxyzine 10 milligrams at bedtime and in the A.M. and as needed every four hours between scheduled and as needed doses. The resident had no orders for any medication(s) in the drug classification of an anti-anxiety. Review of the MDS 3.0 assessment, dated 01/29/22 revealed Resident #16 received an anti-anxiety medication during the assessment reference period. Review of the drug classification for Hydroxyzine according to Medscape revealed it was an antihistamine (relief for allergies) and antiemetic (relief for nausea). On 04/06/22 at 4:00 P.M. interview with RN #214 confirmed the MDS 3.0 assessment, dated 01/29/22 was coded incorrectly as staff had coded the Hydroxyzine as an anti-anxiety medication however, it was an antihistamine and antiemetic and not an antianxiety medication. 3. Review of the medical record for Resident #19 revealed an admission date of 02/05/22 with diagnoses of Alzheimer's Disease, need for assistance with personal care, rheumatoid arthritis, osteoporosis and muscle weakness. Review of the MDS 3.0 assessment, dated 02/09/22 for Resident #19 revealed the resident had a pressure ulcer, scar over a bony protrusion or a non removable dressing or device. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of progress notes, assessments and orders from 02/09/22 revealed no evidence of any skin related issues for Resident #19. On 04/06/22 at 4:00 P.M. interview with RN #214 confirmed the MDS 3.0 assessment, dated 02/09/22 was coded incorrectly as Resident #19 did not have any skin related issues at the time of assessment. Residents Affected - Some 6. Review of the medical record for Resident #13 revealed an admission date of 09/29/21. Resident #13 had diagnoses including hypertension, need for assistance with personal care, osteoarthritis, major depressive disorder and personal history of malignant neoplasm of the breast. Review of the physician's orders for April 2022 revealed the resident had an order for Hospice services. Review of the quarterly MDS 3.0 assessment, dated 03/20/22 for Resident #13 revealed no evidence the resident was receiving Hospice services. On 04/06/22 at 12:11 P.M. interview with RN #214 verified the quarterly MDS 3.0 assessment dated [DATE] was inaccurate as it should have coded Resident #13 received Hospice services. 4. Review of Resident #12's medical record revealed diagnoses including profound intellectual disabilities and cognitive communication deficit. A Preadmission Screening/Resident Review (PASARR) Identification Screen, signed 02/20/18 indicated Resident #12 had a diagnosis of developmental disability and was receiving services from a County Board of Developmental Disabilities. Review results indicated Resident #12 had indications of a developmental disability and referral to the local Developmental Board evaluation for Level II evaluation had been received. An in-person assessment was performed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/16/22 indicated Resident #12 was not considered by the State Level II PASARR process to have serious mental illness and/or intellectual disability. On 04/07/22 at 10:55 A.M. interview with RN #214 verified the MDS 3.0 assessment, dated 01/16/22 was inaccurate regarding PASARR information and intellectual disabilities. 5. Review of Resident #17's medical record revealed diagnoses including dysphagia, type 2 diabetes mellitus and morbid obesity. Review of the December 2021 Medication Administration Record (MAR) revealed Resident #17 was provided the enteral feeding, Jevity 1.2 continuously between 12/07/21 and 12/11/21. An admission MDS 3.0 assessment, assessment dated [DATE] indicated Resident #17 ate once or twice. Review of the January 2022 MAR revealed nutrition was provided to Resident #17 through a feeding tube every day since his readmission to the facility 01/14/22. On 01/16/22 a weight of 312 pounds was recorded. On 01/25/22 a weight of 295 pounds was recorded. Review of the quarterly MDS 3.0 assessment, dated 01/25/22 revealed Resident #17 only ate once or twice and had no significant weight change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0641 Level of Harm - Minimal harm or potential for actual harm On 04/07/22 at 10:55 A.M. interview with RN #214 verified the MDS assessments dated 12/11/21 and 01/25/22 were coded incorrectly for eating as Resident #17 had received enteral (tube) feeding only during those time frames. RN #214 also verified the MDS 3.0 assessment, dated 01/25/22 should have reflected Resident #17 had a significant loss. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop an individualized and comprehensive care plan related to Resident #16's diagnosis of anxiety. This affected one resident (#16) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, major depressive disorder, heart failure and muscle weakness. Review of the physician's orders for Resident #16 revealed an order for Hydroxyzine 10 milligrams at bedtime (HS) and A.M. and as needed (PRN) every four hours between scheduled and as needed doses for anxiety. Hydroxyzine is classified as an antiemetic and antihistamine medication and not an anti-anxiety medication. The resident was not ordered any medications that were in the anti-anxiety drug classification. Review of the resident's care plans revealed a plan of care related to monitoring side effects of anti-anxiety medication. However, there was no individualized or comprehensive plan of care to address the resident's diagnosis of anxiety or to identify the source/cause of the anxiety. There was no goal developed specific to anxiety and no interventions to resolve/address situations of anxiety including the use of any appropriate non-pharmacological interventions or situations when PRN Hydroxyzine should be administered. On 04/06/22 at 4:00 P.M. interview with Registered Nurse (RN) #214 verified the facility had not developed an individualized and comprehensive plan of care related to the resident's diagnosis of anxiety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure care conference meetings included Resident #21 and/or the resident's family. This affected one resident (#21) of one resident reviewed for care conferences. Findings include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including respiratory failure, low back pain, osteoporosis, anemia, wedge compression fracture lumbar vertebra, atrial fibrillation, anxiety disorder, pulmonary embolism, dysphagia, major depressive disorder, hypertension and chronic obstructive pulmonary disease. Review of the face sheet reveled Family Member #200 was the responsible party for Resident #21. On 04/04/22 at 8:49 P.M. interview with Resident #21 revealed she had never been to or invited to a care conference meeting to discuss her plan of care. On 04/06/22 at 9:45 A.M. interview with Licensed Social Worker/Activity Director #203 revealed resident care conferences were done within the first 72 hours of admission and then every three months. She indicated she would send out an invitation to the residents families and they would be able to attend in person or by phone. On 04/06/22 at 10:22 A.M. a follow up interview with Licensed Social Worker/Activity Director #203 revealed she could not find any evidence of a care conference for Resident #21 since the resident's admission. On 04/07/22 at 10:19 A.M. interview Family Member #200 revealed he was Resident #21's responsible party and had never been invited to a care conference meeting or had never received a letter in the mail inviting him to a care conference meeting to discuss his mother's plan of care. Review of the facility policy titled Resident Participation-Assessment/Care Plans, dated 12/2016 revealed the resident and representative were encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The Social Service Director or designee was responsible for notifying the resident/representative and for maintaining records of such notices. The notices should include the date, time, location of conference, the name of each person contacted and the dated they were contacted, the method of contact, input from the resident or representative if they were not able to attend, refusal of participation and the date and signature of the individual making the contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure medications were not left unattended at the bedside for Resident #9 without being administered to the resident by a licensed nurse. This affected one resident (#9) randomly observed during the initial tour of the facility of 20 residents residing in the facility. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, repeated falls, abnormal posture, dysphagia, chronic embolism, hypertension, osteoarthritis, major depressive disorder and spinal stenosis. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22 revealed Resident #9 had intact cognition. On 04/04/22 at 7:35 P.M. Resident #9 was observed to have a medication cup on his bedside stand with two 500 milligrams (mg) Acetaminophen tablets in the medication cup. At the time of the observation, interview with the Director of Nursing verified Resident #9 was not assessed to be capable of self administration of medications and indicated the nurse should not have left the medications at the resident's bedside. Review of a progress note, dated 04/04/22 at 8:14 P.M. revealed Resident #9 refused to take his scheduled 2:00 P.M. 1000 mg Acetaminophen The nurse asked Resident #9 why he had not taken the medication and he stated he was not ready to take them. Review of the facility policy titled, Storage of Medication, dated 04/2007 revealed the facility should store all drugs and biologicals in a safe, secure and orderly manner. Review of the facility policy titled, Administrating Medications, dated 12/2012 revealed residents may self administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined the resident had the decision-making capacity to do so safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 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 366187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Minerva Rehabilitation and Nursing Center 1035 East Lincolnway Minerva, OH 44657 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of the facility assessment and interview the facility failed to ensure the development of an accurate assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. This had the potential to affect all 20 residents. Findings include: Review of the facility assessment, dated 2022 revealed the following: a. A minimum of five times the assessment referred to a facility by another name when determining its capabilities and needs. On 04/06/22 at 4:25 P.M. interview with the Director of Nursing (DON) verified the facility assessment did refer to the names of other facilities which were used as a template for this facility's assessment. b. The facility assessment indicated the number of residents licensed for the facility by another name was 91. On 04/06/22 at 4:25 P.M. interview with the DON verified the capacity was not 91. This facility's capacity was 34. c. One area of the assessment indicated employment of a full time Administrator and another area indicated a part time Administrator was required. d. The facility assessment indicated a separate social service worker, activity director and two activity assistants were employed. On 04/06/22 at 4:25 P.M. interview with the DON verified the facility employed one person to work as the social worker/activity director and had no activity assistants which differed from information in the facility assessment. e. The facility assessment indicated the Minimum Data Set (MDS) nurse ran a census and condition report each morning and provided it to the DON so she could assess staffing needs. On 04/06/22 at 4:25 P.M. interview with the DON revealed the MDS nurse did not run a census and condition report each morning and provide it to her. f. The assessment indicated the Dietary Manager's licensure/certification requirements was a high school diploma or equivalent and was silent to requirements for the Activity Director. On 04/06/22 at 4:25 P.M. interview with the DON verified the facility assessment was silent as to the qualifications of the Activity Director and that the Dietary Manager was required to have training in food safety and management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 10 of 10

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Citations

7 citations 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.

0606GeneralS&S Fpotential for harm
F606 - The facility must—
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
0640GeneralS&S Dpotential for harm
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
0641GeneralS&S Epotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0838GeneralS&S Fpotential for harm
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

FAQ · About this visit

Common questions about this visit

What happened during the April 13, 2022 survey of MINERVA REHABILITATION AND NURSING CENTER?

This was a inspection survey of MINERVA REHABILITATION AND NURSING CENTER on April 13, 2022. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MINERVA REHABILITATION AND NURSING CENTER on April 13, 2022?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Not hire anyone with a finding of abuse, neglect, exploitation, or theft."

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

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·April 13, 2022