Inspection·September 15, 2022

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record Review of Resident #20 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: abnormal posture, atherosclerosis, atrial fibrillation, dementia, GERD, mesothelioma, muscle weakness, post-traumatic stress disorder, protein-calorie malnutrition, adult failure to thrive, hypertension, ileus, mood disorder, myocardial infarction, seizures, COVID-19, lack of coordination, and anemia. Residents Affected - Few Review of the Minimum Data Set(MDS) assessment completed on 02/09/22 revealed this resident had severe cognitive impairments. Resident #20 was admitted with an active diagnosis of PTSD and mood disorder on review of admitting diagnoses on 09/28/21. Review of the Preadmission Screening and Resident Review(PASARR) revealed this was completed by sending facility on 09/28/21. On Section E(Indications of Serious Mental Illness) the information provided this resident did not have any of the mental disorders listed. This included Mood Disorder, which was one of the resident's medical diagnoses on admission. On 09/14/22 at 9:33 AM Interview with Social Service Director #265 verified Mood Disorder was an active diagnosis on the medical record and was not accurately captured on the PASARR screening result notice. She also verified this diagnosis should have been indicated on this screen. Based on record review and interview the facility failed to complete the Pre-admission Screening and Resident Review (PASARR) Identification Screen correctly for two residents (Resident #20 and #58) out of six residents reviewed during the annual survey. The facility census was 64. Findings include. 1. Medical record review for Resident #58 revealed an admission date of 08/12/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, idiopathic aseptic necrosis of right femur, right femur fracture, ventricular tachycardia, major depressive disorder, generalized anxiety disorder, unspecified mood disorder, bipolar disorder, and history of alcohol dependence. Review of Resident #58's physician orders revealed an order for Clonazepam one milligram by mouth twice daily, start date of 08/13/22, Aripiprazole 10 milligrams by mouth once daily for depression, start date of 08/12/22, and Sertraline 50 milligrams by mouth once daily for depression, start date of 08/12/22. (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 4 Event ID: 365791 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 365791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Ohio Valley 2932 South 5th Street Ironton, OH 45638 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)