Health 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 Page 1 of 2 365376 365376 06/13/2025 Ohio Valley Manor Nursing and Rehabilitation 5280 State Routes 62 68 Ripley, OH 45167

F 0760 medications were to be administered in a safe and timely manner and as prescribed. Level of Harm - Minimal harm or potential for actual harm This deficiency represents noncompliance investigated under Complaint Number OH00165207. Residents Affected - Few 365376 Page 2 of 2