Inspection·January 26, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of self-reported incidents, review of pharmacy documents, review of written statements, and policy review, the facility failed to report an allegation of misappropriation to the State Survey Agency. This affected one (#100) of two residents reviewed for misappropriation. The facility census was 95. Findings include: Record review of Resident #100 revealed the resident was admitted to the facility on [DATE] and expired at the facility on [DATE]. The resident was receiving hospice services. Diagnoses for Resident #100 include diabetes, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and required extensive assistant of two staff for activities of daily living. Review of physician orders revealed Resident #100 was ordered the antianxiety medication Ativan every four hours as needed starting on [DATE]. Review of Resident #100's nursing progress note dated [DATE] at 12:30 A.M. revealed a verbal emergency order from the physician for Ativan intensol 0.25 milligrams by mouth every four hours as needed for anxiety. Review of the pharmacy delivery document dated [DATE] revealed Ativan and the narcotic pain medication morphine for Resident #100 was delivered on [DATE] at 3:41 A.M and Licensed Practical Nurse (LPN) #60 signed the receipt of the delivery document. Review of Resident #100's [DATE] medication administration record (MAR) revealed the resident did not receive doses of Ativan until [DATE] and subsequently received doses on [DATE], [DATE] and [DATE]. Review of LPN's #60 written statement, provided to the Director of Nursing (DON), revealed LPN #60 received a delivery package from the pharmacy on [DATE]. The delivery package had a black bag and a silver bag. LPN #60 stated she verified the morphine was in the black bag and LPN #60 disposed of the silver bag assuming it to be freezer packing. Review of facility self-reported incidents (SRIs) revealed no incident of Resident #100's missing (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 4 Event ID: 365081 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 365081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248 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)