F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, medical record review, and interview the facility failed to monitor circulatory status of
a resident who had an edematous (swollen) left foot and studies indicating a thrombus (blood clot). This
affected one (Resident #97) of 17 residents observed for evidence of edema.
Residents Affected - Few
Findings include:
Observations on 02/01/22 at 8:38 A.M. and 11:06 A.M. and on 02/02/22 at 7:50 A.M. and 12:20 P.M.
revealed Resident #97 sitting on the side of his bed with his legs dangling off the side of the bed and his
feet on the floor.
Review of Resident #97's medical record revealed a diagnosis of a fracture of the left femur. On 12/30/21
an order was written for a venous ultrasound of the left lower extremity due to increased edema. Venous
doppler results dated 12/31/21 indicated there appeared to be a thrombus (a blood clot formed in situ within
the vascular system of the body and impeding blood flow) in the left gastrocnemius vein (The
gastrocnemius vein is considered a deep muscular vein of the calf.) There was no evidence of circulatory
assessments related to the thrombus.
On 02/03/22 at 10:55 A.M., the Director of Nursing (DON) verified she was unable to locate any evidence of
circulatory checks and stated she understood the concern of circulatory checks not being completed for a
resident with a blood clot.
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:
366306
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
366306
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Valley Oaks Care Center
500 Selfridge Street
East Liverpool, OH 43920
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, medical record review and staff interview the facility failed to ensure range of motion
services were provided for residents identified with a limitation in joint mobility. This affected one (Resident
#26) of two residents reviewed for range of motion services. The facility census was 46.
Findings include:
Review of Resident #26's medical record revealed an admission date of 10/18/15 and a readmission date
of 09/18/19 with diagnoses that included Alzheimer's disease with dementia and congestive heart failure.
Review of the Minimum Data Set (MDS) 3.0 assessment with a reference date of 12/31/21 indicated
Resident #26 had limitation in range of motion to both upper and lower extremities. Further review of the
medical record including a hospice recertification completed on 12/31/21 indicated Resident #26 had
contractures to the bilateral legs and hands. Further review of the medical record found no evidence of any
splint device use or any restorative services for joint mobility. No documentation was found to indicate a
reason for joint mobility services not provided.
Interview with the Director of Nursing on 02/03/22 at 8:55 A.M. verified Resident #26 had limitation in joint
mobility to bilateral hands and legs, does not receive any joint mobility services and there was no
documentation to indicate a reason for not providing joint mobility services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366306
If continuation sheet
Page 2 of 4
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
366306
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Valley Oaks Care Center
500 Selfridge Street
East Liverpool, OH 43920
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)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based on medical record review and staff interview the facility failed to ensure monthly pharmacy reviews
identified physician orders were not being followed regarding acetaminophen administration. This affected
one (Resident #12) of five residents reviewed for monthly pharmacy reviews. The facility census was 46.
Findings include:
Review of Resident #12's medical record revealed an admission date of 07/13/16 with diagnoses that
included Alzheimer's disease with dementia, osteoarthritis and epilepsy.
Review of the physician's orders revealed current orders for acetaminophen (analgesic) 650 milligram (mg)
three times daily and Norco (hydrocodone and acetaminophen analgesic) 5 mg - 325 mg four times daily. A
total of 3250 mg of acetaminophen was administered daily.
Review of the Medication Administration Record (MAR) revealed acetaminophen and Norco administered
daily as ordered for a total of 3.25 gm of acetaminophen administered each day.
An additional physician's order indicated to not exceed 3 grams (gm) of acetaminophen daily.
Review of monthly pharmacy recommendations revealed no indication the acetaminophen dosage
exceeding physician orders was identified by the reviewing pharmacist.
Interview with the Director of Nursing on 02/02/22 at 1140 A.M. verified Resident #12 received 3.25 gm of
acetaminophen on a daily basis and monthly pharmacy recommendations did not address the
acetaminophen dosage exceeding physician orders.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366306
If continuation sheet
Page 3 of 4
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
366306
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Valley Oaks Care Center
500 Selfridge Street
East Liverpool, OH 43920
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)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review and staff interview the facility failed to ensure physician orders were
followed regarding acetaminophen dosage. This affected one (Resident #12) of five residents reviewed for
medication use. The facility census was 46.
Residents Affected - Few
Findings include:
Review of Resident #12's medical record revealed an admission date of 07/13/16 with diagnoses that
included Alzheimer's disease with dementia, osteoarthritis and epilepsy.
Review of the physician's orders revealed current orders for acetaminophen (analgesic) 650 milligram (mg)
three times daily and Norco (hydrocodone and acetaminophen analgesic) 5 mg - 325 mg four times daily. A
total of 3250 mg of acetaminophen was administered daily.
Review of the Medication Administration Record (MAR) revealed acetaminophen and Norco administered
daily as ordered with 3.25 gm of acetaminophen administered each day.
An additional physician's order indicated to not exceed 3 grams (gm) of acetaminophen daily.
Interview with the Director of Nursing on 02/02/22 at 8:40 A.M. verified Resident #12 received 3.25 gm of
acetaminophen on a daily basis despite the physician's order to not exceed 3 gm per day.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366306
If continuation sheet
Page 4 of 4
