Inspection·June 13, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #150) of three reviewed for medication errors. The facility census was 130 residents. Residents Affected - Few Findings include Review of the medical record for Resident #150 revealed an admission date of 04/09/25 with diagnoses including atrial fibrillation, protein calorie malnutrition, dementia, depression, and transient ischemic attacks. Review of the care plan for Resident #150 initiated on 04/09/25 revealed the resident had a potential for cardiac complications related to atrial fibrillation with interventions including to administer medications per orders. Review of the Minimum Data Set (MDS) assessment for Resident #50 dated 04/15/25 revealed the resident had minimal cognitive impairment and required supervision and assistance from staff with activities of daily living (ADLs) Review of the physician's orders for Resident #150 revealed as order dated 04/24/25 per the resident's primary care provider for Diltiazem 180 milligrams (mg) one tablet by mouth every day. Review of physician's orders for Resident #150 transcribed by facility staff on 04/24/25 revealed an order for Dilantin 180 mg one tablet by mouth every day. Review of the Medication Administration Record (MAR) for Resident #150 dated 04/25/25 revealed the resident received Dilantin 180 mg one tablet by mouth on 04/25/25 Review of the Medication Error Form for Resident #150 revealed the resident received Dilantin instead of Diltiazem due to an error in transcription by the facility staff. Interview on 06/13/25 at 1:00 P.M. with the Director of Nursing (DON) confirmed there was a medication error involving Resident #150 which occurred on 04/25/25. Resident #150 was supposed to received Diltiazem 180 mg but instead got Dilantin 180 mg due to a transcription error. The facility provided education to Licensed Practical Nurse (LPN) #840, the nurse involved with the error for Resident #150, regarding the importance of properly transcribing medications following any changes by the physician. Review of the facility policy titled Administering Medications Policy revised 2022 revealed (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 06/13/2025 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)