Health 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. Page 1 of 7 365376 365376 09/09/2022 Ohio Valley Manor Nursing and Rehabilitation 5280 State Routes 62 68 Ripley, OH 45167

F 0644 Level of Harm - Minimal harm or potential for actual harm An interview on 09/01/22 at 10:08 A.M. with Social Services #204 and #216 confirmed the PASRR for Resident #96 was not updated with new diagnoses of major depressive disorder and psychotic disorder with delusions added in 2020. Residents Affected - Few 365376 Page 2 of 7 365376 09/09/2022 Ohio Valley Manor Nursing and Rehabilitation 5280 State Routes 62 68 Ripley, OH 45167

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #96 received appropriate nail care. This affected one of four residents reviewed for activities of daily living. The facility census was 134. Residents Affected - Few Findings include: Review of the medical record for Resident #96 revealed an admission date of 10/11/19 with diagnoses including unspecified dementia with behaviors, psychotic disorder with delusions, depression, anxiety and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #96 had severe cognitive impairment with delusions, physical and verbal behaviors directed towards others. Resident #96 required extensive assistance of two persons for personal hygiene and was totally dependent on two persons for bathing. Review of the plan of care revealed Resident #96 needed staff assistance to complete activities of daily living. Review of the shower sheets for Resident #96 from 07/04/22 through 08/29/22 revealed the nurses signature ensured the resident had been provided nail care with the shower. Observations on 08/30/22 at 9:33 A.M. and at 3:22 P.M. and on 08/31/22 at 9:55 A.M. revealed Resident #96 to have long, jagged fingernails with a brown and black substance underneath the fingernails. An interview on 08/31/22 at 10:05 A.M. with State Tested Nursing Assistant (STNA) #8 confirmed Resident #96 fingernails were long and jagged with a brown and black substance underneath the fingernails. STNA #8 stated nail care would be provided with showers and as needed. 365376 Page 3 of 7 365376 09/09/2022 Ohio Valley Manor Nursing and Rehabilitation 5280 State Routes 62 68 Ripley, OH 45167

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observation and interview, the facility failed to prepare and serve the puree diet as planned by a Registered Dietitian for Residents #40, #28, # 22, #75, #68, #23, #2, and #20. The facility census was 134. Findings Include: Record review for Resident # 40 revealed admission date of 06/01/22, medical diagnosis of Alzheimer's disease and No Added Salt puree diet order. Record review for Resident #28 revealed admission date of 12/05/17, medical diagnosis of dementia with behavioral disturbance and Regular puree diet order. Record review for Resident # 22 revealed admission date of 10/03/19, medical diagnosis of Alzheimer's Disease and Regular, puree, nectar consistency diet order. Record review for Resident # 75 revealed admission date of 04/01/22, medical diagnosis of Atrial Fibrillation and No Added Salt, No Concentrated Carbohydrate and puree consistency diet order. Record review for Resident #68 revealed admission date of 03/08/22, medical diagnosis of unspecified convulsions and No Added Salt puree diet order. Record review for Resident #23 revealed admission date of 10/24/19, medical diagnosis of Alzheimer's Disease and Regular, nectar consistency, puree diet order. Record review for Resident #2 revealed admission date of 11/03/21, medical diagnosis of dementia with behavioral disturbance and No Concentrated Sweets, honey consistency and puree diet order. Record review for Resident #20 revealed admission date of 11/23/20, medical diagnosis of chronic congestive heart failure and No Added Salt, No Concentrated Sugar, nectar consistency and puree diet order. Review of lunch menu spreadsheet dated 08/31/22 revealed the puree diet was to consist of six ounces of puree lasagna with two ounces sauce, a number eight scoop serving size of puree green beans and a number 12 serving size of puree roll. Observation on 8/31/22 at 9:35 A.M. revealed [NAME] #260 pureed the roll/bread with the green beans in the blender. There was no separate serving of roll/bread. Interview on 08/31/22 at 9:40 A.M., [NAME] #260 verified she had pureed the green beans with the bread. She stated she purees the vegetable with the bread because it dries out on the steam table during serving time. Interview on 08/31/22 at 11:35 the Registered Dietitian, (RD) #90 verified the puree roll/bread should have been pureed separately and served separately from the green beans. Review of the Puree Recipe Guidelines, undated, revealed directions to follow the spreadsheet when 365376 Page 4 of 7 365376 09/09/2022 Ohio Valley Manor Nursing and Rehabilitation 5280 State Routes 62 68 Ripley, OH 45167

F 0803 preparing puree foods. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365376 Page 5 of 7 365376 09/09/2022 Ohio Valley Manor Nursing and Rehabilitation 5280 State Routes 62 68 Ripley, OH 45167

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to store foods, discard expired foods and monitor refrigerator temperatures. This had the potential to affect 133 residents who received food from the kitchen. The facility census was 134. Findings include: Observation on 08/29/22 at 10:05 A.M. revealed following sanitation violations in the main kitchen: 1. Open container of syrup dated 08/13/21 with no open or use by date in the dry storage area. 2. In the reach in refrigerator, six containers of liquid, identified as juice, with no label or date 3. Three reach-in refrigerators temperature monitoring logs not completed of random dates totaling 85 missing temperature entries. Observation on 08/29/22 at 10:30 A.M. revealed following sanitation violations in Parkview satellite kitchen: 1. In the reach in refrigerator, three containers of liquid, identified as juice, with no label or date. 2. One reach in refrigerator temperature monitoring log not completed of random dates totaling 54 missing temperature entries. Observation on 08/29/22 at 10:40 A.M. revealed following sanitation violations in the Birch satellite kitchen: 1. One reach in refrigerator temperature monitoring log not completed of random dates totaling 48 missing temperature entries. 2. In the dry storage area, an open loaf of bread with no open or use by date. 3. In the reach in refrigerator, six containers of liquid, identified as juice, with no label or date. 4. Opened, unlabeled bag of darkened, browned green vegetable, identified as lettuce, with no open or use by date. Interview on 08/29/22 at 10:40 Diet Manager Assistant, #98 verified the foods should have been labeled and dated, including the containers of juices, the lettuce and bread loaf. The refrigerator temperature monitoring logs should have been completed. She verified the skilled facility residents receive foods from the main kitchen, Parkview satellite and Birch satellite kitchens. 365376 Page 6 of 7 365376 09/09/2022 Ohio Valley Manor Nursing and Rehabilitation 5280 State Routes 62 68 Ripley, OH 45167

F 0812 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Food Storage, dated 01/20/22, revealed dry food will be labeled and dated. All foods stored in the refrigerator will be covered, labeled, and dated. Refrigerated food will indicate the date the food shall be consumed or discarded for a maximum of seven days. Functioning of the refrigeration will be monitored at designated intervals throughout the day. Residents Affected - Some 365376 Page 7 of 7