Health inspection·January 23, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to submit an accurate Preadmission Screening and Resident Review (PASRR) Level I for one (Resident #7) of three sampled residents reviewed for PASRR requirements. Specifically, Resident #7's PASRR Level I did not reflect the presence of diagnosed mental illness or the use of psychotropic medications. Residents Affected - Few Findings included: Review of the facility policy titled, Ohio Non-Licensed PASRR Designation Process, revised 01/12/2022, indicated, 3. He/She [individual responsible for completing PASRRs] will complete the PASRR screenings in accordance with OAC [Ohio Administrative Code] 5160-3-15.1 and 15.2. Review of the Resident Face Sheet indicated the facility admitted Resident #7 on 07/30/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Parkinson's disease; bipolar disorder (BPD), unspecified; major depressive disorder (MDD) single episode, unspecified; and alcohol abuse, uncomplicated. Review of Resident #7's Preadmission Screening and Resident Review (PASRR) Identification Screen, signed by the Social Services Designee (SSD) on 07/31/2024, revealed the screening type was a Resident Review due to Expiring Hospital Exemption. Section E: Indications of Serious Mental Illness indicated the resident did not have mental illness diagnoses of schizophrenia, mood disorders, delusional disorders, panic or severe anxiety disorders, somatic symptom disorders, personality disorders, other psychotic disorders, or another mental disorder that may lead to a chronic disability. The resident's diagnoses of BPD, MDD, and alcohol abuse were not reflected. The PASRR Identification Screen also indicated Resident #7 had not received psychotropic medications, including antidepressant and anti-psychotic medications, in the past six months and had no indicators of serious mental illness. Review of the Preadmission Screening and Resident Review Result Notice, dated 07/31/2024, indicated there were no indicators of serious mental illness and/or developmental disability for Resident #7, so a Level II evaluation was not required. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #7 had active diagnoses including depression and BPD. The MDS indicated Resident #7 received antipsychotic and antidepressant medications during the seven-day assessment look-back period. During an interview on 01/23/2025 at 1:22 P.M., the social service designee (SSD) stated she had been with the facility since 2022 as a state trained nurse aide and had accepted the social services Page 1 of 2 366237 366237 01/23/2025 Wadsworth Pointe 540 Great Oaks Trail Wadsworth, OH 44281

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few position six months prior. The SSD stated she completed PASSRs in the facility if they were not completed at the hospital. The SSD stated that when she was completing a PASRR she reviewed diagnoses, medications, and would contact the family. The SSD stated the mental health section of the PASRR form asked about mental illness history, the illness's effect on the resident's life and personal care, psychiatric medications, and addiction history. The SSD reviewed Resident #7's PASRR, dated 07/31/2024, confirmed she completed it, and stated she saw no indication of serious mental illness reflected on the PASRR. The SSD stated Resident #7 received psychotropic medications, including antidepressant and antipsychotic medications, and had diagnoses of BPD, MDD, and alcohol abuse that were present upon admission and should have been reflected on the resident's PASRR. The SSD stated she must have overlooked those diagnoses while completing Resident #7's initial PASRR. During an interview on 01/23/2025 at 3:27 P.M., the Interim Administrator reviewed Resident #7's diagnoses list and their PASRR Level I. The Interim Administrator stated the resident's diagnoses of BPD and MDD should have been reflected. 366237 Page 2 of 2