Oak Pointe Nursing & Rehabilitation

F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28704

Residents Affected - Few Based on observation, medical record review, review of the pre-admission screening and resident review (PASARR) assessment, and staff interview, the facility failed to implement specialized services as indicated

in the PASARR level II outcome determination letter. This affected one (#50) of three residents reviewed for PASARR. The facility census was 82.

Findings include:

Medical record review revealed Resident #50 was admitted on [DATE REDACTED] with diagnoses including schizoaffective bipolar type disorder, delusional disorder, panic disorder, auditory hallucinations, psychosis, suicidal ideations, depression, generalized anxiety, and insomnia.

Review of the care plan: PASARR recommendations due to significant change dated 01/11/24 revealed interventions for interdisciplinary team to review the PASARR recommendations and follow recommendations as able or applicable. There was no evidence the other recommended services were added to the care plan after the PASARR determination letter was received approving Specialized Services

on 02/03/25.

Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed Resident #50's PASARR level II conditions indicated there resident had a serious mental illness and had been discharged to an inpatient psychiatric facility.

Review of the PASARR level II outcome report dated 02/03/25 revealed it was determined Resident #50 was appropriate for nursing facility services with approved Specialized Services. The following behavioral health services were required to be provided by the nursing facility including: a crisis intervention plan, a behavior management safety plan to decrease inappropriate behaviors and ensure safety, ongoing evaluation of the effectiveness of current psychotropic medication on target symptoms, ongoing medication review by a psychiatrist or similarly credentialed professional, mental health counseling, and a behaviorally based treatment plan. The reason for those services was to reduce mental health symptoms and provide supports. Other recommended services the resident would need to be provided by the certified nursing facility included but were not limited to : self-health care management training, activities of daily living (ADL) training, therapy evaluations, skills training, adaptive equipment evaluation, and structured therapeutic activities. The reason for the above supports was to promote health, wellness and independence.

There was no evidence in Resident #50's medical record of a crisis intervention plan or behavior management safety plan as required or other recommendations as indicated in the PASARR determination letter dated 02/03/25.

On 05/27/25 at 12:17 P.M., observation and interview revealed Resident #50 was laying in bed and refused to acknowledge Registered Nurse (RN) #215 or speak to the surveyor. RN #215 stated Resident #50 has not been receptive to staff and stated Resident #50 might need her medications adjusted. RN #215 stated Resident #50 was seen by the psychiatrist but did not know if the resident had a crisis plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 366254 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 366254 B. Wing 05/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Pointe Nursing & Rehabilitation 130 Buena Vista Street Baltic, OH 43804

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)