Health inspection·February 24, 2025

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 record reviews, interviews, review of facility Self Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure a SRI was filed with the State Agency following an allegation of sexual abuse. This affected one resident (#83) out of the three residents reviewed for abuse. The facility census was 136. Findings include: Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included bipolar disorder, anxiety disorder, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/29/15, revealed the resident was assessed by staff to have a long term memory problem. Review of the physicians order, dated 12/30/24, revealed the resident was to be referred to a gynecologist related to vaginal bleeding. Review of the gynecologist visit note, dated 01/28/25, revealed resident in with acute bleeding for one month duration status post complete hysterectomy and Computed Tomography (CT) scan showed no uterus. emergency room (ER) reported on 01/16/25 speculum was full of blood and cleaned once, filled up with blood again. Patient has dementia and reported being sexually active with husband and bleeding started after sex. Physical exam revealed no blood in vagina, intact cuff, urethral meatus normal, external genitalia normal. Assessment/plan- no active vaginal bleeding, concern for prior vaginal laceration based on ER report from 01/16/25. Laceration likely has healed, vaginal cuff intact. The potential of an acute vaginal laceration raises concern for potential sexual assault. Unable to fully assess patient due to mobility issues. Visualization was poor but confident no longer actively bleeding from the vagina. Unable to visualize if possible prior laceration. Review of the SRI's filed by the facility revealed no SRI was filed with the State Agency related to the potential sexual assault alleged by the physician at the gynecologist office. Interview with the Administrator on 02/24/25 at 2:45 P.M. confirmed there had not been an SRI filed with the State Agency following the documented allegation of sexual assault from the gynecologist office. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, implemented on 09/15/21, revealed if the event that caused the allegation involves abuse (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 02/24/2025 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)