F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident and staff interview, the facility failed to notify the a resident of a change in
medications. This affected one resident (#85) of one reviewed for care planning. The facility census was
135.
Findings include:
Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses
including displaced fracture of right femur, type 2 diabetes, cirrhosis of liver, and major depressive disorder.
Record review of the Minimum Data Set (MDS) assessment completed on 10/10/19 revealed Resident #85
was cognitively intact.
Review of physician orders dated 11/06/19 for Resident #85 revealed the resident had a change from
Ensure nutritional supplement to Glucerna nutritional supplement, before meals and at bedtime. The
resident also had a change in Calcium Citrate 950 milligrams (mg) every morning, from Calcium Citrate 975
mg every morning. There was no documentation the resident was notified of the change.
Interview with Resident #85 on 12/03/19 at 10:16 A.M. revealed he was not notified of the medication
changes. care.
Interview with the Director of Nursing (DON) on 12/05/19 at 1:44 P.M. verified there was no notification to
Resident #85 of the changes in medication and the supplement.
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 2
Event ID:
365376
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
365376
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ohio Valley Manor Nursing and Rehabilitation
5280 State Routes 62 68
Ripley, OH 45167
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.
Based on observation, staff interview, facility policy review, and review of manufacture's guidelines, the
facility failed to date open vials of medications. This had potential to affect one Resident (#231) identified by
facility as a new admission. The facility further failed to remove expired medications out of active medication
use, this had the potential to affect one Resident (#67) for who it was prescribed for. The facility census
135.
Findings include:
1. Observation on 12/03/19 at 4:43 P.M. with Licensed Practical Nurse (LPN) #100 of the medication room
on Unit One revealed there was an opened vial of Tuberculin Protein Derivative Diluted Aplisol (TB) with no
date when it was opened.
Interview on 12/03/19 at 4:45 P.M. with LPN #100 verified the vial of Tuberculin Protein Derivative Diluted
Aplisol was opened and not dated.
Review of the manufacturers recommendations for storage for Tuberculin Protein Derivative Diluted Aplisol,
revealed vials in use for more than 30 days should be discarded due to possible oxidation and degradation
which may affect potency.
2. Observation on 12/03/19 at 5:24 P.M. with the Director of Nursing (DON) of the Maple Unit medication
room revealed a bottle of Lorazepam (anti-anxiety) Oral Concentrate two milligrams (mg) per milliliter (ml)
was opened with the only dose given date 07/26/19. The medication had a 90-day shelf life after opened.
Review of the Controlled Drug Record for Resident #67 revealed the only dose of Lorazepam Oral
Concentrate 2 mg/ml was given on 07/26/19.
Interview on 12/03/19 at 5:26 P.M. with the DON verified the Lorazepam Oral Concentrate 2 mg/ml was
opened with the only dose given on 07/26/19.
Review of the Lorazepam Oral Concentrate 2 mg/ml manufacturing guidelines revealed to discard opened
bottle after 90 days.
Review of the facility policy titled, Storage of Medications, dated 11/27/19 revealed the facility shall not use
discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the
dispensing pharmacy or destroyed, some drugs have a shelf life that is different than the expiration date
after opening. These drugs shall be labeled with the date opened to ensure that no outdated or deteriorated
drugs are stored.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365376
If continuation sheet
Page 2 of 2
