Minerva Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interview, the facility failed to ensure pre-employment tuberculosis (TB) testing was completed timely for all new staff and new residents received TB testing on admission. This affected one resident (Resident #7) out of three residents reviewed for TB control with the potential to affect all 15 residents residing in the facility.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure comprehensive care plans were developed timely for Residents #4, #7, #16, #18, and #24. This affected five residents (#4, #7, #16, #18, and #24) of 15 residents reviewed for care plans. The facility census was 16.

Inspectors wroteBased on record reviews, observations, interviews and facility policy review, the facility failed to respect the dignity of residents by failing to empty a urinal in full view of the hallway or cover a urinary catheter drainage bag. This affected two (Resident #16 and Resident #3) of two residents reviewed for dignity and respect. The facility census was 16.

Inspectors wroteBased on record review and interview, the facility failed to provide a complete and accurate baseline care plan for Resident #25. This affect one resident (#25) of 15 residents reviewed for care plans. The facility census was 16.

Inspectors wroteBased on record review, observations, interview and facility policy review, the facility failed to ensure a peripherally inserted central catheter (PICC) line (a long, thin, flexible tube inserted into a vein and threaded into a large vein near the heart) dressing was changed as ordered by the physician for Resident #24. This affected one resident (#24) of five residents reviewed for medication administration. The facility census was 16.

Inspectors wroteBased on record review, observation and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for Resident #25. This affected one (Resident #25) of one resident reviewed for pressure ulcers. The facility census was 16.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure orders were obtained for residents requiring oxygen administration. This affected two (Resident #5 and Resident #25) of three residents reviewed for oxygen use. The facility census was 16.

Inspectors wroteBased on record reviews, observations, interviews and reviews of facility policies, the facility failed to follow proper infection control processes during incontinence care and blood glucose testing for Resident #3 and wound care for Resident #25. This affected two (Residents #25 and #3) of four residents reviewed for infection control. The facility census was 16.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #27's Gabapentin medication was not administered to Resident #21. This finding affected two (Residents #21 and #27) of six residents reviewed for medication administration.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote5. 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. 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. [...]

Inspectors wroteBased on medical record review, policy review, observations, and interviews, the facility failed to ensure activities were provided in accordance with resident preferences. This affected one (Resident #21) of 15 residents interviewed and/or observed for activity participation. This also had the potential to affect 20 of 23 residents who resided at the facility when scheduled activities were known to be of no interests to any of the residents and/or were placed on the activity schedule with the knowledge the activity was an individual and not group based activity. (Residents #10, family of Resident #19 and Resident #77 indicated they were not interested in group activities regardless of what might be offered.

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.