Inspection·May 24, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility investigation, staff interview, and review of the facility handbook, the facility failed to ensure the resident environment was free of potentially hazardous substances/prescription medications. This affected one (Resident #130) of three residents reviewed for accidents and accident hazards. The facility census was 130. Findings include: Review of the medical record for Resident #130 revealed an admission date of 04/04/23 with diagnoses including frontotemporal neurocognitive disorder, diabetes mellitus type two, rhabdomyolysis, dementia, anxiety, dehydration, falls, hematuria, and polyosteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #130 dated 04/15/24 revealed the resident had severely impaired cognition. Review of the progress note for Resident #130 dated 05/24/24 timed at 10:35 A.M. revealed the resident was sent to the hospital for evaluation and possible treatment for ingestion of medications not prescribed for the resident. Review of facility investigation revealed on 05/02/24 staff found Resident #130 in his room with two medications that belonged to State Tested Nursing Assistant (STNA) #30 in the resident's possession. The resident had found medication bottles containing Wellbutrin (an antidepressant) and Adderall ER (a stimulant medication and a controlled substance) in STNA #30's purse which had been left unattended in the resident dining room. Resident #130 had the bottles of Wellbutrin and Adderall in his possession with one bottle opened and the other remaining closed. Interview with STNA #30 confirmed she could not recall or verify how many individual medications were in either bottle, or how many were taken. STNA #30 further confirmed she had left her purse on the table in the resident dining room while she took her lunch break. A visiting family member had informed staff that Resident #130 was looking through the purse when no staff was around. Two staff members went searching for the resident and found him in his room with both medicine bottles. Review of facility transfer report revealed Resident #130 was sent to the hospital on [DATE] after possible ingestion of two medications that were not prescribed to him. Review of hospital records for Resident #130 dated 05/02/24 revealed the hospital conducted blood tests to determine if the resident had ingested Wellbutrin or Adderall and determined the resident's blood was negative for both substances. The resident returned to the facility with no new orders. (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 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 05/24/2024 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)