Inspection·September 9, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a resident's mental health diagnoses were accurately coded on the Pre-admission Screening and Resident Review (PASARR). This affected two (#44, #96) of four residents reviewed for PASARR. The facility census was 134. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] diagnoses included depression, lung disease, anxiety, unspecified dementia with behaviors, and heart failure. Review of Resident #44 quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfer, dressing and toileting. Review of Resident # 44's PASARR dated 08/31/20 revealed Resident #44 did not have any mental health diagnoses. Review of Resident #44's face sheet dated 09/02/20 revealed Resident #44 admitted to the facility with diagnoses of depressive disorder and anxiety. Interview with the Social Worker (SW) # 204 on 09/01/22 at 10:11 A.M. verified Resident #44's mental health diagnoses including mood disorder, anxiety, and unspecified dementia with behavioral disturbance were not listed on Resident #44's 08/31/20 PASARR. SW #204 noted another PASSAR was not completed to reflect these changes. 2. Review of the medical record for Resident #96 revealed an admission date of 10/11/19 with diagnoses including unspecified dementia with behaviors (11/22/19), major depressive disorder (03/23/20), anxiety (11/22/19), and psychotic disorder with delusions (04/16/20). Review of the annual MDS dated [DATE] revealed Resident #96 had severe cognitive impairment with delusions, and physical and verbal behaviors directed towards others. The MDS indicated Resident #96 was not considered by state level II PASRR process to have a serious mental illness or related condition. Review of the PASRR dated 10/11/19 indicated Resident #96 had no indications of serious mental illness. (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 7 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 09/09/2022 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)