Health inspection·July 25, 2024

F 0679 Level of Harm - Minimal harm or potential for actual harm Once in while she would go outside and sit on the patio. Resident #21 stated she believed the facility was trying to find someone to do activities. Resident #21 stated she would like more activities offered. Resident #21 was observed actively participating in bingo on 07/22/24 at 2:57 P.M. playing bingo with three other residents and on 07/24/24 at 2:15 P.M. Residents Affected - Some Observations on 07/23/24 at 7:55 A.M. and 07/24/24 at 7:36 A.M., 10:46 A.M., and 12:37 P.M. revealed Resident #21 was in her room with the television on but sometimes watching the hallway. No facility initiated activities were observed during those times. On 07/25/24 at 7:43 A.M., Resident #21 was noted sitting in her bed feeding herself. Her face became more animated while talking about playing bingo the previous day. During an interview on 07/24/24 beginning at 9:53 A.M., Activity Director #112 reviewed Resident #21's activity preferences from the MDS, activity calendars and activity participation logs with the surveyor. Activity Director #112 acknowledged Resident #21 had reported it was somewhat important for her to be around animals such as pets. Activity Director #112 stated there had been on animal related activities since April when somebody had taken pet pigs to the facility to visit residents. When discussing that Resident #21 had indicated it was very important to do things with groups of people, Activity Director #112 reviewed the activity calendar and verified multiple activities were either not pertinent because no residents had expressed interest, pertained to only one or two residents, or were available for residents to do as individual activities. Activity Director #112 stated Resident #21's favorite activity was bingo. Activity Director #112 stated although there was only documentation of activity of yard games once in the past three months (July activity participation logs were requested but not provided because they were not filled out) Resident #21 would sit outside on the patio at times. 2. Review of resident council meeting minutes from January 2024 to June 2024 revealed on 02/15/24 residents reported they would like more movie nights and exercise activities. The 04/18/24 meeting notes revealed notes that the facility would be doing movie night around 3 P.M. instead of later in the evening. (The July 2024 activity calendar had Exercise Saturday and walking Wednesday scheduled each week no movie nights.) On 07/22/24 at 9:22 A.M. Resident #77 stated he was not at all interested in participating in activities. He was admitted for short term therapy and administration of intravenous medications. On 07/22/24 at 9:37 A.M., Resident #10 stated the only activities the facility offered was bingo. However, she was not interested in participating in any activities and had no suggestions as to activities she might be interested in if offered. 07/22/24 2:12 P.M. Resident #19's daughter reported Resident #19 had difficulty hearing even with hearing aids and difficulty seeing even with glasses. Attempts to participate in group activities increased anxiety and overwhelmed Resident #19 who preferred not to participate On 07/24/24 starting at 9:53 A.M., the July 2024 activity calendar was reviewed with Activity Director #112. The activity calendar indicated three to four activities were scheduled each day with bingo scheduled at 2:00 P.M. every Monday, Wednesday and Friday. Some of the activities scheduled included one on one visits, leisure time, puzzles and activity packets. Activity Director #112 stated she started her position at the end of February 2024 and followed the activity patterns from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 2 of 13 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 07/25/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some previous calendars. Activity Director #112 stated one person had requested movie nights but she was the only one who participated and one resident had requested an open therapy gym. No other residents had made suggestions. When asked about the puzzles on the activity calendar, Activity Director #112 stated there were two residents with puzzle tables in their rooms and once in a while a few residents would gather and work on the puzzles. Activity Director #112 stated the leisure time on the activity calendar was for residents to obtain papers which she left up front on a bulletin board and do independently. The brain teasers activity was also papers available up front and can be obtained for residents to do individually. The board games activity was also a resident generated activity. There were board games in the activity room which residents could use. Exercise Saturday was supposed to be provided by nursing. Activity Director #112 indicated she did was not aware what the activity consisted of and was not 100% sure it was provided. The Walking Wednesdays activity was provided by a person from psychiatric services who did laps around the facility with residents. The music hour activity consisted of a radio in the dining room which sometimes would be turned on but one of the residents did not care for it so it was not consistent. Group activities that were included in the calendar were bingo, resident council meetings and snacks/treats. During a meeting between a state surveyor and resident council on 07/24/24 at 1:29 P.M., three (Residents #3, #14, and #21) indicated they would like to have more activities offered but did not wish to pursue the matter because it would take away from Activity Director #112's other duties. Resident #17, who also attended, indicated she preferred individual activities. On 07/24/24 at 2:01 P.M., Therapeutic Behavioral Support (TBS) Specialist #200 (identified as the person from the psychiatric services who provided the Walking Wednesday activity) stated she worked with 15 residents at the facility to provide coping skills and mental health services. TBS Specialist #200 stated she only ambulated around the facility with Resident #14 because walking was one of her coping skills and helped promote body self image for her. TBS Specialist #200 stated while she visited she would try to engage residents in activities to help with coping skills. TBS Specialist #200 stated Activity Director #112 did not always have time to do both social service responsibilities and activities and the facility's budget did not really allow for more activities or staff. TBS Specialist #200 stated she did believe residents could benefit from more activities. Review of the facility's Activity Programs policy (revised August 2006) indicated the activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. The activity programs consisted of individual and small and large group activities that were designed to meet the needs and interests of each resident and include, at a minimum: 1. activities that stimulated the cardiovascular system and assisted with range of motion offered five to seven times a week 2. intellectual activities that were mentally stimulating five to seven times a week 3. weather permitting, at least one activity a month is head away from the facility 4. weather permitting, outdoor activities were held on a regular basis 5. At least one evening activity was offered per week depending on population needs 6. spiritual programming was scheduled to meet the religious needs of the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 3 of 13 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 07/25/2024 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 0679 7. at least two group activities per day were to be offered on Saturday, Sunday and holidays Level of Harm - Minimal harm or potential for actual harm 8. At least four group activities were offered per day Monday through Friday Residents Affected - Some 9. Creative and expressive activities, such as arts and crafts, ceramics, painting, drama, creative writing, poetry and music were available on a regular basis to meet the needs of residents 10. Social activities were scheduled to increase self esteem, to stimulate interest and friendships and to provide fun and enjoyment. Activities, included, but were not limited to, daily coffee social, birthday and holiday parties, entertainment, candlelight dinner, country breakfast, cultural and theme events) 11. Participation in community groups and religious organizations were encouraged based on the needs of the resident population. The activity programs policy further explained activities were not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents and family members could also provide the activities. Activity schedules were posted on the resident bulletin board and provided individually to residents who could not access the bulletin board. Individual and group activities were provided that reflected the schedules, choices and rights of the residents, were offered at hours convenient to the residents (including evenings, holidays and weekends), reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents and appeal to men and women as well as those of various age groups residing in the facility. On 07/25/24 at 11:22 A.M., Activity Director #112 stated she had never read and was not sure she had access to the activity program policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 4 of 13 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 07/25/2024 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files and staff interview, the facility failed to ensure Activities Director #112 was qualified to direct the facility activities program. This had the potential to affect all 23 residents in the facility. Residents Affected - Many Findings include: Review of the personnel file for Activities Director #112, who also served as the facility's Social Services Designee, revealed a hire date of 10/29/22. There was no evidence of completion of a certification or training program for leading activities programs in long term care centers. On 07/23/24 at 1:20 P.M., an interview with the Administrator stated Activities Director #112 was the only activities staff for the facility. On 07/23/24 at 2:17 P.M., an interview with Human Resources Director #114 stated Activities Director #112 began her role as the facility's Activities Director on 02/15/24 and she was unsure what training was provided. The Administrator, who was standing nearby, stated Activities Director #112 was trained by the former staff member who previously filled that role. On 07/23/24 at 2:37 P.M., an interview with the Administrator stated the only training Activities Director #112 had prior to taking over the role of Activities Director was a one week training led by the former staff member who previously filled that role. On 07/23/24 at 3:08 P.M., an interview with the Administrator stated Activities Director #112 had not yet been enrolled in a activities professional training program because the facility was looking for the cheapest option for completing the training. On 07/23/24 at 3:34 P.M., an interview with the Administrator stated she was unaware that Activities Director #112 was hired with the contingency that oversight would be provided by a qualified activities professional until Activities Director #112 had completed the required trainings. She verified Activities Director #112 had not received the required oversight for the activities programs at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 5 of 13 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 07/25/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of physician orders/medication administration records, policy review, and interview, the facility failed to ensure a medication rate of less than 5 percent (%). Two errors were identified out of 25 opportunities for error resulting in a 8% medication error rate. This affected one resident (Resident #7) of six residents observed for medication administration Residents Affected - Few Findings include: On 07/24/24 at 7:43 A.M., Licensed Practical Nurse (LPN) #131 was observed administering medication to Resident #7. Among medications administered were two tablets of Senna (laxative-stimulant) 8.6 milligrams (mg). No Glycolax (laxative) was administered. However, it was signed off as administered. Review of physician orders and the Medication Administration Record (MAR) revealed among medications ordered for administration at 8:00 A.M. were two tablets of Senna docusate (used to treat constipation) 8.6/50 mg and Glycolax powder 17 grams. On 07/24/24 at 8:33 A.M., LPN #131 verified she administered Senna instead of Senna docusate and she had not administered Glycolax. Review of the facility's Administering Medications policy (revised December 2012) revealed medications must be administered in accordance with the orders. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right route of administration before giving the medication. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 6 of 13 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 07/25/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, staff interview, and review of the job description and performance standards for the Administrator, the facility's Administrator failed to provide adequate oversight of hiring and promotion of facility staff to ensure minimum qualifications were met for their assigned duties in providing activities to meet resident needs/preferences This had the potential to affect all 23 residents in the facility. Residents Affected - Many Findings include: Review of resident council meeting minutes from January 2024 to June 2024 revealed on 02/15/24 residents reported they would like more movie nights and exercise activities. The 04/18/24 meeting notes revealed notes that the facility would be doing movie night around 3 P.M. instead of later in the evening. (The July 2024 activity calendar had Exercise Saturday and walking Wednesday scheduled each week no movie nights.) Review of the personnel file for Activities Director #112, who also served as the facility's Social Services Designee, revealed a hire date of 10/29/22. There was no evidence of completion of a certification or training program for leading activities programs in long term care centers. On 07/22/24 at 9:22 A.M. Resident #77 stated he was not at all interested in participating in activities. He was admitted for short term therapy and administration of intravenous medications. On 07/22/24 at 9:37 A.M., Resident #10 stated the only activities the facility offered was bingo. However, she was not interested in participating in any activities and had no suggestions as to activities she might be interested in if offered. 07/22/24 2:12 P.M. Resident #19's daughter reported Resident #19 had difficulty hearing even with hearing aids and difficulty seeing even with glasses. Attempts to participate in group activities increased anxiety and overwhelmed Resident #19 who preferred not to participate On 07/23/24 at 2:17 P.M., an interview with Human Resources Director #114 stated Activities Director #112 began her role as the facility's Activities Director on 02/15/24 and she was unsure what training was provided. The Administrator, who was standing nearby, stated Activities Director #112 was trained by the staff member who previously filled that role. On 07/23/24 at 3:08 P.M., an interview with the Administrator stated Activities Director #112 had not yet been enrolled in a activities professional training program because the facility was looking for the cheapest option for completing the training. On 07/23/24 at 3:34 P.M., an interview with the Administrator stated she was unaware that Activities Director #112 was hired with the contingency that oversight would be provided by a qualified activities professional until Activities Director #112 had completed the required trainings. The Administrator further stated the reason she was unaware of this contingency was because she only worked part-time as the Administrator for this facility. She verified Activities Director #112 had not received the required oversight for the activities programs at the facility. On 07/24/24 starting at 9:53 A.M., the July 2024 activity calendar was reviewed with Activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 7 of 13 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 07/25/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Director #112. The activity calendar indicated three to four activities were scheduled each day with bingo scheduled at 2:00 P.M. every Monday, Wednesday and Friday. Some of the activities scheduled included one on one visits, leisure time, puzzles and activity packets. Activity Director #112 stated she started her position at the end of February 2024 and followed the activity patterns from the previous calendars. Activity Director #112 stated one person had requested movie nights but she was the only one who participated and one resident had requested an open therapy gym. No other residents had made suggestions. When asked about the puzzles on the activity calendar, Activity Director #112 stated there were two residents with puzzle tables in their rooms and once in a while a few residents would gather and work on the puzzles. Activity Director #112 stated the leisure time on the activity calendar was for residents to obtain papers which she left up front on a bulletin board and do independently. The brain teasers activity was also papers available up front and can be obtained for residents to do individually. The board games activity was also a resident generated activity. There were board games in the activity room which residents could use. Exercise Saturday was supposed to be provided by nursing. Activity Director #112 indicated she did was not aware what the activity consisted of and was not 100% sure it was provided. The Walking Wednesdays activity was provided by a person from psychiatric services who did laps around the facility with residents. The music hour activity consisted of a radio in the dining room which sometimes would be turned on but one of the residents did not care for it so it was not consistent. Group activities that were included in the calendar were bingo, resident council meetings and snacks/treats. During a meeting between a state surveyor and resident council on 07/24/24 at 1:29 P.M., three (Residents #3, #14, and #21) indicated they would like to have more activities offered but did not wish to pursue the matter because it would take away from Activity Director #112's other duties. Resident #17, who also attended, indicated she preferred individual activities. On 07/24/24 at 2:01 P.M., Therapeutic Behavioral Support (TBS) Specialist #200 (identified as the person from the psychiatric services who provided the Walking Wednesday activity) stated she worked with 15 residents at the facility to provide coping skills and mental health services. TBS Specialist #200 stated she only ambulated around the facility with Resident #14 because walking was one of her coping skills and helped promote body self image for her. TBS Specialist #200 stated while she visited she would try to engage residents in activities to help with coping skills. TBS Specialist #200 stated Activity Director #112 did not always have time to do both social service responsibilities and activities and the facility's budget did not really allow for more activities or staff. TBS Specialist #200 stated she did believe residents could benefit from more activities. Review of the facility's Activity Programs policy (revised August 2006) indicated the activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. The activity programs consisted of individual and small and large group activities that were designed to meet the needs and interests of each resident and include, at a minimum: 1. activities that stimulated the cardiovascular system and assisted with range of motion offered five to seven times a week 2. intellectual activities that were mentally stimulating five to seven times a week 3. weather permitting, at least one activity a month is head away from the facility 4. weather permitting, outdoor activities were held on a regular basis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 8 of 13 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 07/25/2024 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 0835 5. At least one evening activity was offered per week depending on population needs Level of Harm - Minimal harm or potential for actual harm 6. spiritual programming was scheduled to meet the religious needs of the residents 7. at least two group activities per day were to be offered on Saturday, Sunday and holidays Residents Affected - Many 8. At least four group activities were offered per day Monday through Friday 9. Creative and expressive activities, such as arts and crafts, ceramics, painting, drama, creative writing, poetry and music were available on a regular basis to meet the needs of residents 10. Social activities were scheduled to increase self esteem, to stimulate interest and friendships and to provide fun and enjoyment. Activities, included, but were not limited to, daily coffee social, birthday and holiday parties, entertainment, candlelight dinner, country breakfast, cultural and theme events) 11. Participation in community groups and religious organizations were encouraged based on the needs of the resident population. The activity programs policy further explained activities were not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents and family members could also provide the activities. Activity schedules were posted on the resident bulletin board and provided individually to residents who could not access the bulletin board. Individual and group activities were provided that reflected the schedules, choices and rights of the residents, were offered at hours convenient to the residents (including evenings, holidays and weekends), reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents and appeal to men and women as well as those of various age groups residing in the facility. On 07/25/24 at 11:22 A.M., Activity Director #112 stated she had never read and was not sure she had access to the activity program policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 9 of 13 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 07/25/2024 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 record review and interview, the facility failed to conduct an annual review of the facility assessment between January 2023 and July 2024. This had the potential to affect all 23 residents in the facility. Findings include: Review of the facility assessment revealed it was last reviewed on 01/26/23, indicating it had not been reviewed in 18 months. In addition, the facility assessment indicated the facility's social worker would be licensed by the State of Ohio. On 07/24/24 at 9:45 A.M., an interview with the Administrator verified the facility assessment had not been reviewed since 01/26/23 and stated she was working on the new format for the 2024 facility assessment. She also verified that the list of people responsible for reviewing the assessment annually was inaccurate because the listed Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, and resident representative were no longer at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 10 of 13 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 07/25/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 5. On 07/24/24 at 7:43 A.M., LPN #131 was observed administering medication to Resident #7. During the medication administration, LPN #131 was observed touching items in the environment such as the over bed table. LPN #131 returned to the medication cart and obtained a medication cup to prepare medication for Resident #10 without performing hand hygiene. LPN #131 verified she had not performed hand hygiene but continued to prepare and administer medication to Resident #10 including an inhaler and medications by mouth prior to washing her hands. Residents Affected - Many Review of the facility's Administering Medications policy (revised December 2012) revealed staff were required to follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc) for the administration of medications. Review of the facility's Handwashing/Hand Hygiene policy (revised August 2015) revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Staff were instructed to use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap and water for situations such as before and after direct contact with resident and after contact with objects in the immediate vicinity of the resident. Based on record review, observations, interviews, and review of facility policies, the facility failed to record tuberculin skin test results for all new employees upon hire, ensure staff perform hand hygiene during medication administration, and to have signage indicating Resident #23 required reverse isolation protocol. This had the potential to affect all 23 residents residing in the facility. Findings include: 1. Review of the personnel file for State Tested Nurse Aide (STNA) #101 revealed a hire date of 07/02/24. Review of the Tuberculin Skin Test Record Form, dated 07/02/24, indicated a skin test was administered to STNA #101 on 07/02/24 at 6:50 A.M. and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/09/24, indicated a skin test was administered to STNA #101 on 07/09/24 at 8:00 A.M. and there were no results documented on the form. On 07/25/24 at 10:30 A.M., an interview with Licensed Practical Nurse (LPN) #115 verified the tuberculin skin tests were administered to STNA #101 on 07/02/24 and 07/09/24 and the results of the skin tests were not recorded. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 2. Review of the personnel file for State Tested Nurse Aide (STNA) #118 revealed a hire date of 06/24/24. Review of the Tuberculin Skin Test Record Form, dated 06/25/24, indicated a skin test was administered to STNA #118 on 06/25/24 at an unspecified time and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/02/24, indicated a skin test was administered to STNA #118 on 07/02/24 at 8:00 A.M. and there were no results documented on the form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 11 of 13 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 07/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 07/25/24 at 10:30 A.M., an interview with LPN #115 verified the tuberculin skin tests were administered to STNA #118 on 06/25/24 and 07/02/24 and the results of the skin tests were not recorded. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 3. Review of the personnel file for State Tested Nurse Aide (STNA) #126 revealed a hire date of 07/08/24. Review of the Tuberculin Skin Test Record Form, dated 07/09/24, indicated a skin test was administered to STNA #126 on 07/09/24 at an unspecified time and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/16/24, indicated a skin test was administered to STNA #126 on 07/16/24 at 8:10 A.M. and there were no results documented on the form. On 07/25/24 at 10:30 A.M., an interview with LPN #115 verified the tuberculin skin tests were administered to STNA #126 on 07/09/24 and 07/16/24 and the results of the skin tests were not recorded. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 4. Review of the personnel file for STNA #128 revealed a hire date of 07/09/24. Review of the Tuberculin Skin Test Record Form, dated 07/09/24, indicated a skin test was administered to STNA #128 on 07/09/24 at 2:25 P.M. and there were no results documented on the form. Review of the Tuberculin Skin Test Record Form, dated 07/16/24, indicated a skin test was administered to STNA #128 on 07/16/24 at 8:00 A.M. and there were no results documented on the form. On 07/25/24 at 8:39 A.M., an interview with the Director of Nursing (DON) verified the tuberculin skin tests were administered to STNA #128 on 07/09/24 and 07/16/24 and the results of the skin tests were not recorded. On 07/25/24 at 8:45 A.M., an interview with LPN #115 stated she administered the skin tests for STNA #128 and she read the results two days later. She stated she forgot to document the results of the skin tests on the forms. Review of the facility policy titled Guidelines for Skin Testing for Potential New Employees, not dated, revealed all new employees would be screened for tuberculosis, new employees who did not have results of a two-step tuberculin skin test completed within the past one year would undergo the first step skin test before beginning employment and a second step seven to 10 days after the first step was administered, and a written report of test results would be maintained in the employee file. 6. Review of Resident #23's active physician orders revealed the resident was on protective isolation starting 02/09/24 related to chronic lymphocytic leukemia of B-cell type not having achieved remission. Observation on 07/22/24 at 9:41 A.M. revealed there was a three-drawer plastic bin of personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366187 If continuation sheet Page 12 of 13 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 07/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete protective equipment (PPE) inside Resident #23's room upon entering however there was no signage indicating Resident #23 was on enhance barrier precautions (EBP). Interview on 07/22/24 at 9:58 A.M. with LPN #110 revealed that residents only have the three-drawer plastic bins of PPE in their room when they are on EBP or isolation precautions. LPN #110 explained that Resident #23 was on protective isolation, also known as reverse isolation, because he was immunocompromised due to receiving chemotherapy. Anyone entering Resident #23's room was required to wear a mask, gloves, and a gown to protect him. LPN #110 stated Resident #23 should have a sign on his door that instructed visitors and staff what his precautions were. Upon notification that Resident #23 did not have any door signage LPN revealed she was unaware the resident didn't have signage on the door. She provided the surveyor a copy of the sign that should have been hanging on his door that said please stop at the nurse's station before entering. Thank you and then was observed hanging the sign on the door. Event ID: Facility ID: 366187 If continuation sheet Page 13 of 13