Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbors At Minerva during CMS and state inspections, most recent first.
A resident with MRSA wound infection and sepsis was not placed on contact isolation as indicated by the care plan, and the chart lacked isolation orders and door signage. In addition, staff did not wear gowns during enhanced barrier catheter care for one resident with a suprapubic catheter, and during another resident’s catheter care a CNA placed supplies directly on the bedside table, used a skin cleanser instead of disinfectant to clean the surface, and left the urinary catheter bag touching the floor.
A resident with multiple health conditions experienced a decline in health, including vomiting and low oxygen saturation, which was not promptly addressed by the facility staff. Despite being medicated for nausea, the resident's condition worsened, leading to cardiac arrest and eventual death. The facility failed to notify the physician in a timely manner and did not reassess the resident promptly, contributing to the adverse outcome.
A resident with complex medical conditions experienced frequent emesis and was unable to retain medications, yet the physician was not notified until the resident's condition significantly deteriorated. Despite abnormal vital signs, the physician was only informed after the resident's rapid decline, leading to a code situation and eventual death. The lack of timely communication and action resulted in a deficiency.
The facility did not complete required performance evaluations for STNAs, as per its policy. Three STNAs, hired at different times, lacked either annual or 90-day evaluations. The facility Administrator confirmed the oversight, which contradicts the policy requiring annual evaluations.
The facility failed to implement Enhanced Barrier Precautions, properly handle indwelling catheters, and conduct required tuberculin testing for staff. A resident's urinary drainage bag was observed dragging on the floor, and another resident with an open wound was not placed under Enhanced Barrier Precautions. Additionally, several staff members did not receive required TB testing, indicating lapses in infection control and employee health protocols.
The facility failed to maintain accurate medical records, affecting several residents. Activities were marked as refused without asking residents, and discrepancies were found in Medicare appeal documentation and meal records. Additionally, enteral nutrition records for a resident did not reflect actual administration, leading to weight loss.
The facility failed to maintain a clean environment, affecting residents and potentially all residents. Observations revealed torn wallpaper, black marks from adhesive tape, and unfinished drywall in various areas, including resident rooms, halls, and common areas. Scraped and damaged drywall from beds was also noted in several resident rooms. These issues were confirmed by the Administrator and Maintenance Director.
The facility failed to maintain privacy for two residents during care. One resident's wound care was conducted with the door and curtain open, exposing the resident to the hallway. Another resident's urinary catheter bag was left uncovered, exposing urine in public areas. These actions were against the facility's policies, as confirmed by staff interviews.
A facility failed to assess the use of a geri chair for a resident with severe cognitive impairment, leading to a deficiency in ensuring the resident was free from unnecessary restraints. The resident's medical record lacked documentation of an assessment to determine if they could independently release the chair from the reclining position. The facility's policy required a comprehensive assessment for assistive devices but did not specify the need for a physician's order.
The facility failed to provide comprehensive, resident-centered activities for two residents, leading to a deficiency in meeting their social and emotional needs. One resident, with multiple diagnoses, was not engaged in activities aligned with his interests, and documentation showed only one activity in the past 30 days. Another resident, with severe impairments, was not provided with planned 1:1 activities, and frequent refusals were marked without consistent engagement. The facility's activities policy was not adequately implemented, contributing to the deficiency.
A resident with a history of limited mobility and at risk for pressure ulcers did not receive appropriate preventative skin care. During a dressing change, LPNs observed open areas and redness on the resident's skin but failed to apply the available barrier cream as per the care plan. This oversight was contrary to the facility's policy on pressure injury prevention.
A resident with severe medical conditions experienced significant weight loss due to inadequate monitoring of enteral nutrition. The facility failed to document the use of a substitute formula and did not notify the physician or RD of the weight loss. The resident's tube feeding was turned off due to emesis, but there was no record of when it was resumed. The facility's policies on feeding tubes and weight monitoring were not followed, leading to the deficiency.
A facility failed to label the contents of a tube feeding bag for a resident with complex medical needs, including a gastrostomy and severe malnutrition. The bag was labeled only with the resident's last name and date, lacking details about the contents or time of preparation. This was confirmed by the DON and Administrator, despite facility policy requiring adherence to practitioner orders.
The facility failed to change oxygen tubing weekly for two residents as ordered, leading to discrepancies between treatment records and actual practice. Observations showed outdated and soiled equipment, and interviews confirmed that treatments were inaccurately signed off as completed.
The facility did not ensure timely physician review of pharmacy recommendations for three residents, affecting medication management. A resident's recommendations for Mirtazapine, Rivaroxaban, Diltiazem, and Vitamin D were delayed, while another resident's Lipitor use was not evaluated despite hospice care. A third resident's Miralax and Depakote orders were not updated promptly. The DON confirmed the lack of timely physician responses.
A facility failed to maintain a medication error rate below 5%, with an error rate of 7.69%. A resident received an incorrect dose of Amlodipine Besylate due to outdated medication cards, and a nurse did not assist the resident in rinsing her mouth after using a Trelegy Ellipta inhaler, contrary to recommended practice.
A resident with mild cognitive impairment and a history of verbal aggression inappropriately touched another resident with severe cognitive impairment in a common area. The incident was witnessed by an STNA, who intervened immediately. Despite the facility's policy to prevent abuse, the incident was substantiated, indicating a failure in policy implementation.
A facility failed to report a resident-to-resident sexual abuse incident within the required timeframe. An STNA witnessed inappropriate touching in the dining area and intervened, but the report to the administrator and state agency was delayed. The involved residents had cognitive impairments, and the facility's policy requires immediate reporting of such incidents.
Failure to Follow Isolation and Catheter Care Precautions
Penalty
Summary
Transmission-based precautions were not followed for a resident with a right hip MRSA wound infection and sepsis. The resident was admitted with diagnoses including sepsis and had a discharge summary from the hospital documenting acute on chronic right hip periprosthetic MRSA wound infection status post revision of total hip arthroplasty and debridement. The care plan included contact isolation precautions with gown and gloves, and the resident was receiving prolonged IV antibiotics through 02/17/26 for the MRSA infection. However, physician orders reviewed for January and February 2026 did not include contact isolation orders, and on 02/09/26 at 7:35 P.M. the resident did not have contact isolation signage on the door. An LPN confirmed the resident should have been on contact isolation because she was positive for MRSA, and the DON verified there were no contact isolation orders from 01/16/26 through 02/09/26. Infection control practices were not followed during suprapubic catheter care for a resident with end stage renal disease, obstructive and reflux uropathy, and chronic gout. The resident’s care plan directed staff to use gown and gloves when providing direct care, and physician orders included enhanced barriers while performing high-contact activity related to the catheter and dialysis, as well as routine suprapubic catheter changes every four weeks. During observation, two CNAs moved the resident with a Hoyer lift and cleansed the suprapubic catheter with a washcloth and soapy water, then rinsed and dried it. Both CNAs wore latex gloves but did not wear isolation gowns while providing the catheter care, despite the resident’s door signage indicating enhanced barrier precautions. The CNAs confirmed they did not implement isolation gowns during the care. In a separate observation, catheter care for another resident with an indwelling urinary catheter was performed with multiple items placed directly on the bedside table without a barrier, including a cup, remote, basin of water, towel, barrier cream, skin cleanser, and visible food residue. The CNA performed catheter and perineal care, repeatedly set the skin cleanser and barrier cream back on the bedside table, and used the towel from the table to dry the resident. After care was completed, the urinary catheter bag was noted to be touching the floor. When interviewed, the CNA stated a barrier was not used because the bedside table had been cleaned, but identified the product used as a perineal skin cleanser rather than a disinfectant. The CNA confirmed the catheter bag was on the floor.
Failure to Monitor and Provide Timely Care Leads to Resident's Death
Penalty
Summary
The facility failed to adequately monitor and provide timely care for a resident following a change in condition, resulting in actual harm. The resident, who had a history of paraplegia, morbid obesity, obstructive hydrocephalus, and other conditions, experienced nausea and vomiting over several days. Despite being medicated for these symptoms, the resident's condition worsened, with vital signs indicating a decline. The resident vomited brown-colored emesis and had a significant drop in oxygen saturation, yet the physician was not notified as documented, and the resident was only reassessed hours later. On the night of the incident, the resident's condition continued to deteriorate. The LPN administered Tylenol for pain but did not reassess the resident until nearly three hours later, at which point the resident was in severe distress with low oxygen saturation and was unable to have her blood pressure read. The physician was then notified, and an order was given to send the resident to the emergency room. However, before EMS could arrive, the resident went into cardiac arrest, and CPR was initiated by the nursing staff. EMS arrived but was not initially aware of the emergency nature of the situation, leading to further delays. Despite efforts to resuscitate the resident, including intubation and continued CPR, the resident was pronounced dead shortly after. The death certificate listed sepsis syndrome, pyelonephritis, and gastroenteritis as causes of death. Interviews with staff revealed lapses in communication and timely reassessment, contributing to the resident's decline and eventual death.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely physician notification following a significant change in a resident's condition, which led to a deficiency. The resident, who had a complex medical history including paraplegia, morbid obesity, and obstructive hydrocephalus, experienced frequent episodes of emesis over three days and was unable to retain medications, fluids, and food. Despite these symptoms, the physician was not notified until the resident's condition had deteriorated significantly. The nursing progress notes indicated that the resident's vital signs were abnormal, with low oxygen saturation and rapid pulse, yet the physician was not informed of these critical changes until much later. The situation escalated when the resident's condition worsened, leading to a rapid decline. The resident was found with short, rapid respirations, cold and moist skin, and an inability to obtain a blood pressure reading. Oxygen was administered, and the physician was finally notified, resulting in an order to send the resident to the ER. However, the resident coded shortly before EMS arrival, and CPR was initiated by the nursing staff. The physician later confirmed that he had not been notified of the resident's concerning symptoms earlier, which he deemed significant enough to warrant immediate action beyond administering Tylenol. This lack of timely communication and action contributed to the resident's rapid decline and subsequent death.
Failure to Complete STNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) had their performance evaluations completed as required by the facility's policy. The employee files for three STNAs were reviewed, revealing that STNA #274, hired on June 14, 2023, and STNA #219, hired on August 17, 2022, did not have annual performance evaluations on file. Additionally, STNA #501, with a hire date in February 2024, did not have a 90-day performance evaluation completed. During an interview, the facility Administrator confirmed that the evaluations for these STNAs were not completed. The facility's policy, dated January 1, 2022, mandates that employee performance evaluations be conducted at least annually.
Infection Control and Staff Testing Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions and ensure proper handling of indwelling catheters, handwashing, and tuberculin testing of staff. Resident #51, who had multiple medical conditions including type 2 diabetes, cognitive communication disorder, and severe sepsis, was observed with a urinary drainage bag that was not covered and was dragging on the floor. This was confirmed by the facility administrator, indicating a lack of adherence to infection control protocols. Resident #35, diagnosed with dysphagia, Parkinson's disease, and vascular dementia, was not placed under Enhanced Barrier Precautions despite having an open wound. During a dressing change, LPNs did not use additional personal protective equipment beyond gloves. The Director of Nursing confirmed that the resident should have been on Enhanced Barrier Precautions due to the open wound, highlighting a lapse in following the facility's revised infection control policy. The facility also failed to conduct required tuberculin testing for several staff members, including STNAs and LPNs, as per their policy. The facility administrator confirmed the absence of initial and annual TB tests and screenings for these employees, indicating a systemic issue in maintaining employee health records and compliance with TB risk assessment protocols.
Inaccurate Medical Records and Documentation Issues
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to discrepancies in documentation and care. For Resident #35, the activities aide marked refusals for activities without asking the resident if they wanted to participate, as the aide assumed the resident would not attend due to staying in bed. This practice was confirmed by the Activities Director, who acknowledged that marking refusals without asking the resident was misleading. Resident #42's medical record showed similar issues, with refusals marked for activities without the resident being asked. The resident was observed in bed or in a wheelchair in their room, contrary to a sign indicating they should be up and engaged in activities. The activities aide admitted to not asking the resident about attending activities, and the Activities Director confirmed that refusals should not be marked if the resident was not asked. For Resident #37, there was a discrepancy in the Medicare Part A skilled services documentation. The resident signed a cut letter indicating a desire to appeal, but the Business Office Manager did not file an appeal, assuming the resident marked the option by mistake. Additionally, Resident #49's records inaccurately documented that the resident was up for meals when they were actually refusing to get out of bed. The Director of Nursing confirmed this incorrect documentation. Lastly, Resident #42's enteral nutrition records did not reflect the actual administration, with no documentation of when the tube feed was held or when Jevity 1.5 was used as a substitute, leading to a significant weight loss for the resident.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean environment, which affected residents and had the potential to affect all residents residing in the facility. Observations made on August 22, 2024, from 9:00 A.M. to 9:20 A.M. revealed several issues. Torn wallpaper borders were noted between resident rooms and in various halls, including above the medical and storage room on the 100 hall, 300 hall resident rooms, and above the 300 hall shower room and nurses' station, as well as 400 hall resident rooms. Black marks from adhesive tape were observed on the ceiling near a resident's room and above the medical and storage rooms on the 100/200 halls. Repaired drywall with unfinished/untextured drywall compound was seen outside the women's bathroom in the front lobby, inside and outside the private dining room, at the 300/400 nurses' station and fire doors, and the 100/200 hall nurses' station and fire doors. Additionally, scraped and damaged drywall from resident beds was noted in several resident rooms. These observations were verified through an interview with the Administrator and Maintenance Director.
Privacy Violations During Resident Care
Penalty
Summary
The facility failed to maintain privacy during wound care for Resident 7, who was admitted with diagnoses including spina bifida, paraplegia, and stage three pressure ulcers. During an observation, an LPN and an STNA entered Resident 7's room to perform wound care but left the door open and the curtain drawn, exposing the resident's buttocks, abdomen, perineal area, and pressure wounds to the hallway. This lack of privacy was confirmed by the LPN during an interview, and it was noted that the facility's policy required screening for privacy as the first step in the procedure. Additionally, the facility did not provide a covering for Resident 51's urinary catheter drainage bag, which was visible and exposed yellow urine. Resident 51, who was admitted with conditions including type II diabetes and cognitive communication disorder, was observed multiple times with the uncovered catheter bag while in public areas such as the dining room and outside smoking area. The Director of Nursing and Administrator verified the lack of coverage for the catheter bag, despite the facility's policy requiring privacy bags for catheter drainage bags.
Failure to Assess Geri Chair Use as a Restraint
Penalty
Summary
The facility failed to ensure that the use of a geri chair for a resident was appropriate and not considered a restraint. During the annual survey, a resident was observed seated in a reclined geri chair, but there was no evidence in the medical record of any assessment to determine if the resident could independently release the chair from the reclining position. The resident had a history of cerebrovascular accident with hemiplegia, prostate cancer, and vascular dementia, with a severely impaired cognition level. The Minimum Data Set (MDS) assessment indicated no restraint use, and there was no documentation of any assessment for the geri chair. Additionally, the resident's medical record showed previous physician's orders for a broda chair, which was assessed for use as a comfort measure for end-of-life care. However, there was no order or assessment for the use of the geri chair, as confirmed by the Director of Nursing. The facility's policy on the use of assistive devices required a comprehensive assessment but did not specify the need for a physician's order. This lack of assessment and documentation led to the deficiency in ensuring the resident was free from unnecessary restraints.
Deficiency in Resident-Centered Activities
Penalty
Summary
The facility failed to provide comprehensive, resident-centered activities for two residents, leading to a deficiency in meeting their social and emotional needs. Resident #35, who has multiple diagnoses including Parkinson's disease and vascular dementia, was observed to remain in bed without engagement in activities that align with his interests, such as religious activities, music, and pet visits. Despite having a care plan that included 1:1 visits and in-room activities, documentation showed only one activity in the past 30 days, and numerous refusals were marked without the resident being asked. Interviews with staff revealed a lack of adherence to the care plan and improper documentation of activity refusals. Resident #42, with severe cognitive and physical impairments, was also not provided with the planned 1:1 activities, such as aromatherapy and being read to, as outlined in his care plan. Observations showed the resident was mostly in bed or in a wheelchair in his room, with minimal engagement from activity staff. The activity logs indicated frequent refusals, but interviews revealed that the resident was not consistently asked to participate in activities. A sign in the resident's room instructed staff to take him to all activities, but this was outdated and not followed. The facility's activities policy emphasizes enhancing residents' well-being and promoting engagement, but the implementation for these two residents was inadequate. The Activities Director acknowledged staffing shortages and missed documentation, contributing to the failure to meet the residents' activity needs. The deficiency highlights a gap between the facility's policy and the actual delivery of resident-centered activities.
Failure to Apply Barrier Cream for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide preventative skin care to a resident with pressure ulcers, specifically Resident #35, who was identified as being at risk for pressure ulcer development. The resident's medical history included palliative care, Parkinson's disease, vascular dementia, and other conditions that contributed to their vulnerability. A Braden Scale assessment indicated the resident had very limited mobility and was at risk for pressure ulcers. The care plan included applying a protective barrier cream after each incontinence episode to maintain skin integrity. However, during an observation of a dressing change, it was noted that the resident had several open areas on the sacrum, and the skin was deep red between the gluteal folds. Despite the availability of barrier cream in the resident's room, it was not applied to the red periwound or gluteal fold areas as per the care plan. The facility's Pressure Injury Prevention Guidelines policy, revised earlier in the year, emphasized the implementation of evidence-based interventions for residents at risk or with existing pressure injuries. During an interview, the LPNs involved in the dressing change confirmed that the resident's skin was deep red and acknowledged that the barrier cream should have been applied according to the care plan. This oversight in following the care plan and facility policy contributed to the deficiency in providing adequate pressure ulcer care and prevention.
Failure to Monitor Enteral Nutrition Leads to Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor the enteral nutrition administration for a resident, resulting in significant weight loss. The resident, who had a traumatic brain injury and other severe medical conditions, was prescribed Nutren 2.0 at a specific rate, with Jevity 1.5 as a substitute if Nutren was unavailable. However, the order did not specify the administration rate for Jevity 1.5. The Medication Administration Record (MAR) indicated that the resident received the full ordered amount of Nutren 2.0 daily, but there was no documentation of any variances or the use of Jevity 1.5. The resident experienced a significant weight loss of 10.5 pounds over a month, and there was no documentation of the physician or Registered Dietitian (RD) being notified of this weight loss. Progress notes revealed that the resident had episodes of emesis, leading to the tube feeding being turned off, but there was no documentation of when it was turned back on or if Jevity 1.5 was used. The RD noted the weight loss and recommended continuing the tube feeding as ordered, but did not specify a timeframe for the intolerance or the use of Jevity 1.5. Interviews with the Director of Nursing (DON) and RD confirmed the lack of documentation and communication regarding the resident's nutrition and weight loss. The DON acknowledged that the weight loss was the facility's fault and that the RD should have specified an administration rate for Jevity 1.5. The RD stated that the facility was short on Nutren 2.0 and Jevity 1.5 was used, which could have contributed to the weight loss. The facility's policies on feeding tubes and weight monitoring were not followed, as there was no notification of the physician or RD about the significant weight loss.
Failure to Properly Label Tube Feeding Bag
Penalty
Summary
The facility failed to properly label the contents of a tube feeding/enteral nutrition bag for a resident, which was identified during an observation. The resident, who was affected by this deficiency, had a complex medical history including traumatic subarachnoid hemorrhage, severe protein calorie malnutrition, gastrostomy, tracheostomy, seizures, dysphagia, cognitive communication disorder, and was in a persistent vegetative state. The physician's orders specified Nutren 2.0 calorie at 50 ml per hour. During an observation, it was noted that the tube feeding bag was labeled only with the resident's last name and the date, lacking information about the contents or the time it was poured. This was confirmed during an interview with the Director of Nursing and the Administrator, who acknowledged that the type of tube feeding in the bag was undetermined. The facility's policy required that enteral nutrition administration be consistent with practitioner orders, which was not adhered to in this instance.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents by not adhering to the physician's orders for changing oxygen tubing weekly. For Resident #35, the medical record indicated a requirement for weekly changes of oxygen tubing and filters, with an order to run oxygen at 4.0 liters per minute continuously. However, observations revealed that the nasal cannula was on the floor, the oxygen condenser was set incorrectly at 3.5 LPM, and the nasal cannula equipment was not dated. Additionally, a nebulizer mask was found soiled and not replaced as per policy. The treatment sheet inaccurately documented that the oxygen tubing was changed on specific dates, although the tubing was dated much earlier, indicating it had not been changed as required. Similarly, for Resident #32, the medical record showed a plan of care for COPD with orders to change oxygen tubing weekly. Despite this, the nasal cannula tubing was observed to be dated over a month prior, and the treatment sheets falsely indicated that the tubing had been changed weekly. Interviews with the DON confirmed that the treatments were signed off as completed when they had not been performed, leading to a failure in providing safe and appropriate respiratory care for the residents.
Delayed Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and addressed by a physician in a timely manner, affecting three residents. For Resident #10, multiple pharmacy recommendations were made, including discontinuing Mirtazapine, re-evaluating the use of Rivaroxaban, changing the administration frequency of Diltiazem, and altering the Vitamin D dosage schedule. However, these recommendations were not addressed promptly, with some remaining unacknowledged for over 86 days. The Director of Nursing confirmed the lack of provider responses on the recommendation forms and the absence of evidence in the medical records that these recommendations were addressed. Resident #58, who was receiving end-of-life hospice services, had a pharmacy recommendation to evaluate the continued use of Lipitor. Despite the recommendation being made, there was no evidence that the physician was notified or had reviewed the recommendation over a month later. The Director of Nursing verified that the recommendation had not been reviewed or addressed by the physician. For Resident #51, several pharmacy recommendations were not addressed in a timely manner. These included updating the administration instructions for Miralax and changing the formulation of Depakote from delayed release to extended release. Additionally, a recommendation to evaluate the doses of Zoloft and Depakote was not addressed. The Director of Nursing confirmed that the physician had not addressed these recommendations promptly, and several recommendations were for the same medication where the order was not clarified upon readmission.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, with the error rate calculated at 7.69%. This deficiency was identified during an observation of medication administration involving a resident diagnosed with chronic obstructive pulmonary disease (COPD), myocardial infarction, coronary artery disease (CAD), and acute respiratory failure with hypoxia. The resident was prescribed Amlodipine Besylate 5 mg for CAD and Trelegy Ellipta inhaler for COPD. However, a registered nurse administered an incorrect dose of Amlodipine Besylate, giving 10 mg instead of the prescribed 5 mg. The error occurred because the facility nurses had not updated the medication card to reflect the new dosage, despite the order change being made earlier in the month. Additionally, the nurse failed to advise or assist the resident in rinsing her mouth after using the Trelegy Ellipta inhaler, as recommended to reduce the risk of Candida albicans infection. The facility's policy on medication administration requires nurses to verify medication details against the medication administration record, which was not adhered to in this instance. The oversight in medication administration and failure to follow post-inhalation instructions contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident sexual abuse, affecting one resident out of four reviewed for abuse. The incident occurred in the common dining area when a resident with mild cognitive impairment and a history of verbally aggressive behavior touched another resident's breast over clothing. This inappropriate touching was witnessed by a State Tested Nurse Aide (STNA), who immediately intervened by instructing the resident to keep his hands to himself and separating the two residents. The incident lasted less than 30 seconds, and local law enforcement was contacted to complete a report. The resident who was touched had severe cognitive impairment and was unable to recall the incident during an interview. The resident who committed the act had a history of nervous system degeneration, major depressive disorder, and mild cognitive impairment, with no prior documented sexually inappropriate behaviors. The facility's policy on abuse, neglect, and exploitation, dated earlier in the year, was reviewed, indicating a commitment to preventing such incidents. However, the deficiency was substantiated, highlighting a failure in the facility's implementation of its policies to prevent sexual abuse.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident sexual abuse to the administrator and state survey agency, affecting one resident out of four reviewed for abuse. The incident involved inappropriate touching by one resident towards another in the common dining area, which was witnessed by a State Tested Nurse's Aide (STNA). The STNA immediately intervened and separated the residents, then completed a witness statement and placed it under the administrator's office door. However, the incident was not reported to the administrator and state survey agency within the required two-hour timeframe. The medical records of the involved residents revealed that the resident who was touched had severely impaired cognition, while the resident who committed the act had mild cognitive impairment. The facility's policy mandates immediate investigation and reporting of abuse allegations to the administrator and relevant agencies within two hours. The administrator confirmed the delay in reporting, as they were only made aware of the incident the following day upon finding the witness statement. This deficiency was investigated under a specific complaint number.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Minerva
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Minerva Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 10 | 0 |
| Louisville Gardens Care Center | 8.9 mi | ★★★★★ | 17 | 0 |
| Carroll Healthcare Center Inc | 9.4 mi | ★★★★★ | 2 | 0 |
| Canterbury Villa Of Alliance | 13 mi | ★★★★★ | 3 | 0 |
| Saint Joseph Care Center | 13.1 mi | ★★★★★ | 17 | 0 |
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