Health inspection·February 17, 2022

F 0584 Resident #12's over bed table was delaminating on three of the four sides. Level of Harm - Minimal harm or potential for actual harm Resident #23's over bed table was in disrepair delaminating. Resident #33 did not have an over bed table. Residents Affected - Some Resident #45 did not have a bedside table in his room. Resident #76's over bed table was delaminating on the top left corner and damaged in about a six inch area. On 02/16/22 at 12:19 P.M. interview with Maintenance #900 revealed the facility did not have any extra furniture for the resident rooms. On 02/16/22 at 12:25 P.M. observation and interview with the Administrator verified the above residents had damaged over bed tables on the Behavior Unit. The Administrator verified not all residents had bedside and over bed tables. The Administrator revealed she had orders a few over bed tables for no certain residents. The facility presented an invoice dated 02/04/22 where they ordered seven new over bed tables that had not been delivered as of this date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 2 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview and facility policy review the facility failed to ensure Resident #36, who required staff assistance for activities of daily living was provided adequate and timely nail care. This affected one resident (#36) of six residents reviewed for activities of daily living (ADL) care. The facility census was 80. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an initial admission date of 09/25/20 and a readmission date of 01/06/21. Resident #36 had diagnosis including dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21 revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 99 (indicating the resident was unable to complete the interview). Behaviors included inattention, disorganized thinking, hallucinations, delusions, verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. The assessment revealed the resident required extensive assistance of one to two or more staff for all activities of daily living (ADL) care. Review of the care plan, dated 12/14/21 revealed the resident required assistance with ADL's and may be at risk for developing complications associated with decreased ADL self-performance. Interventions included diabetic nail care and grooming (nails/shave/hair) assistance as needed. Observation on 02/14/22 at 11:59 A.M. of Resident #36 revealed he had dirt under his fingernails on his left hand. Observation on 02/14/22 at 2:57 P.M. of Resident #36 revealed his left-hand nails were dirty, uneven, and jagged. Interview on 02/15/22 at 10:56 A.M. with Resident #36 revealed staff did not clean or trim his fingernails. The resident confirmed he would like to have nail care. Observation on 02/15/22 at 10:56 A.M. of Resident #36's nails revealed black debris under his left-hand nails and his right-hand nails were jagged and uneven. Interview on 02/15/22 at 10:58 A.M. with State Tested Nursing Assistant (STNA) #844 confirmed the resident's nails had dirt under them and they were long, uneven and jagged. The STNA revealed nail care was to be completed with every shower/bath. She revealed nail care included cleaning under the fingernails with an orange stick, then cutting and filing the nails. She revealed residents' showers/baths were completed on a resident to resident basis, but most residents were showered at least three times per week. Review of the facility policy titled, Care of Fingernails/Toenails dated 07/2006 revealed nail care included daily cleaning and regular trimming. Further review of the policy revealed fingernails were to be trimmed in an oval shape then smoothed with a nail file or emery board. The policy revealed trimmed and smooth nails prevent the resident from accidentally scratching and injuring his skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 3 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility self-reported incident (SRI) and interview the facility failed to develop and implement a comprehensive and individualized behavioral management plan for Resident #44 to effectively and timely identify and manage resident behaviors to prevent an altercation and assist the resident in maintaining her highest level of total well-being. This affected one resident (#44) of three residents reviewed for abuse. Residents Affected - Few Findings include: Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, muscle weakness and need for assistance with personal care. Review of Resident #44's admission Minimum Data Set (MDS) 3.0 assessment, dated 03/03/21 revealed the resident had memory impairment. Review of the dementia care plan for Resident #44 revealed the resident had altered cognitive function related to dementia, anxiety and a mood disorder. Interventions included to be patient with the resident, ensure resident's physiological needs were met, provide medication as ordered, monitor for signs or symptoms of frustration and take measures to remove these, offer verbal reminders and cues as necessary, provide a calm and relaxing environment, and use a calm and relaxed tone during conversations. Review of a facility self-reported incident (SRI), tracking number 206234, dated 05/15/21 revealed the facility reported an allegation of physical abuse involving Resident #44. A brief description of allegation/suspicion revealed an allegation of staff to resident altercation. The SRI included a narrative summary of the incident indicating during resident care with Resident #44, who was combative, a staff member made contact to posterior head of the resident with her hand. During the shift the resident was noted to have extreme agitation, verbal and physical aggression, delusions and exhibiting response to internal stimuli. The resident had previously been transferring and ambulating independently throughout lounge and dining room area, which was directly across from the nurse's station. During the period of restlessness and agitation staff were noted to be seated at nurse's station providing direct supervision to ensure safety and close monitoring of the resident. During the time period, the resident had pushed a dining room chair close to nurse's station and sat down, which placed the resident out of direct view of staff. Per a staff interview with the alleged wrongdoer, the staff member indicated she had come from behind the nurse's station and placed herself directly behind the resident, who was seated in a chair in front of the nurse's station to provide one on one to the resident. Upon staff attempt to provide one to one monitoring for safety the resident was noted to become increasingly more agitated towards staff and began flailing her arms and attempting to strike out at staff. The alleged wrongdoer attempted to provide verbal cues and reassurance with no effect resulting in staff attempting to calm the resident and gain attention of the resident, with staff reporting at that time that the alleged wrongdoer made contact to the posterior head of Resident #44 with an open hand. The resident was then assisted to a standing position and assisted to ambulate to her room where she was toileted and offered a change in environment to decrease stimuli and attempt to calm the resident. The SRI revealed once toileting and care were provided, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 4 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0744 Resident #44 was assisted to bed with a decrease in physical aggression and combative behaviors noted. Level of Harm - Minimal harm or potential for actual harm The facility investigation included a witness statement from State Tested Nursing Assistant (STNA) #801, dated 05/15/21 that indicated STNA #802 punched Resident #44 in the back of her head with a closed fist. The statement revealed the resident was not hit with a full force but enough to startle the resident. The resident was yelling and saying she is hurting me. Residents Affected - Few A statement from STNA #802, dated 05/15/21 revealed the STNA tried to get the resident's attention by tapping her on her head. On 02/16/22 at 6:10 A.M. interview with STNA #801 regarding the incident that had occurred on 05/15/21 revealed Resident #44 was really confused, combative and verbally calling the staff names while sitting in a chair at the nursing desk. During the interview, STNA #801 reported STNA #802 was behind the resident and used a closed fist to hit the resident in the back of her head. STNA #801 denied the resident sustained any injuries. On 02/16/22 at 6:16 A.M. interview with STNA #802 revealed she tapped the resident on the back of her head using an open palm to get the resident's attention. During the interview, the STNA confirmed she did not preserve the resident's dignity at all times while attempting to manage the resident's behaviors on this date. On 02/16/22 at 6:19 A.M. interview with the Administrator revealed she interviewed both STNA #801 and STNA #802 involved in the incident with Resident #44 and she was aware of the conflicting statements of the two staff members. She stated after completion of the investigation, she felt the incident resulted in Resident #44 not being treated with dignity. As a result of the incident, the Administrator revealed STNA #802 was counseled and educated on managing resident behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 5 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview and facility policy review the facility failed to ensure Resident #36 was provided adequate and timely dental services. This affected one resident (#36) of four residents reviewed for dental care. The facility census was 80. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an initial admission date of 09/25/20 and a readmission date of 01/06/21 with a diagnosis including dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21 revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 99 (indicating the resident was unable to complete the interview). The assessment revealed the resident had behaviors including inattention, disorganized thinking, hallucinations, delusions, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others. The assessment revealed the resident required extensive assistance from one to two or more staff for all activities of daily living (ADL) care. Review of the care plan, dated 12/14/21 revealed Resident #36 had impaired dentition and was at risk for problems related to wearing dentures (uppers and lowers). Interventions included if dentures were ill fitting to contact social services to make arrangements to get dentures adjusted, consult the dentist as needed, dentures to be worn for meals and monitor for ill-fitting dentures. Review of the quarterly oral examination dated 12/20/21 confirmed the resident was edentulous, had no broken teeth and revealed the resident wore dentures (uppers and lowers) most of the time. On 02/14/22 at 2:45 P.M. Resident #36 revealed he had upper and lower dentures that he believed were at his home. The resident denied seeing a dentist recently and stated his lower denture needed an adjustment. On 02/16/22 at 11:25 A.M. interview with State Tested Nursing Assistant (STNA) #844 revealed Resident #36 had a top denture but no bottom denture. The STNA was unable to recall ever seeing the resident with a bottom denture. On 02/16/22 at 2:55 P.M. during an interview with the Director of Nursing (DON), the DON was asked for additional information for the resident related to dental care/services. On 02/16/22 at 3:05 P.M. interview with the Administrator revealed the resident had upper and lower dentures up until approximately two weeks ago according to the completed oral assessment and the last time the dietician observed the resident's dentures. The Administrator revealed the resident was going to be scheduled with the dentist since he reported to her that his bottom dentures were ill fitting. She also revealed the resident told her he put the lower dentures in a shoe box at home, so the administrator assumed the resident had thrown them out. On 02/16/21 at 3:18 P.M. interview with Social Worker (SW) #814 revealed the resident was not seen by the dentist because the VA dictates when he would be seen by the dentist. She stated the resident was not seen by the in-house dentist because it was her belief the resident's family wanted him to only be seen by the VA. SW #814 was unsure when the resident had last been seen by the dentist. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 6 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0790 stated she would contact the VA and obtain dental records. Level of Harm - Minimal harm or potential for actual harm On 02/16/22 at 3:28 P.M. interview with Resident #36's wife revealed the resident had upper and lower dentures and had a history of removing his teeth and laying them wherever. The resident's wife revealed the resident had dentures in the facility although they were not in his mouth when she last visited in November 2021. The resident's wife revealed the resident usually goes to the VA to see the dentist and denied being offered in house dental services since the resident's admission. Residents Affected - Few On 02/17/22 at 10:45 A.M. Resident #36 was observed sitting in a wheelchair in the dining room. The resident did not have any dentures in. Interview with the resident at the time of the interview revealed he had put his upper dentures in yesterday after speaking to the surveyor, but could not find his lower denture. On 02/17/22 at 10:57 A.M. interview with STNA #843 verified the resident only had an upper denture at this time and no lower denture. On 02/17/22 at 11:34 A.M. interview with Social Worker (SW) #814 revealed she was unable to obtain the resident's dental records since the resident was transferred from an out of state VA to a local VA and the entities do not communicate with each other and the records did not flow over. She stated she scheduled the resident for a dentist appointment for his lower denture. She stated she would not have scheduled the dentist appointment prior due to it being the VA's responsibility unless there was a specific reason for a dentist appointment and she stated she did not know there had been any dental need prior to this date. SW #814 confirmed the resident did not have a dental consent on file stating she asked him verbally on admission about it. She also confirmed the resident's dental service needs should have been care planned. Review of the facility policy titled Dental Services, dated 11/14/17 revealed the facility would refer the resident for dental services within three days or as soon as practicable for residents with lost or damaged dentures. Further review of the policy revealed the facility would assist the resident with making dental appointments and arranging transportation to and from the dental service location. The policy continued by revealing the facility would review and update the plan of care for residents or resident representatives who did not wish to be referred for dental services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 7 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review and interview the facility failed to ensure the correct serving size was used during the preparation of the pureed protein (beef) on 02/15/22. This had the potential to affect 17 residents (#9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) of 17 residents who were ordered a pureed diet. The facility census was 80. Findings include: Review of the facility provided menu spreadsheet, dated 11/17/21 revealed for the dinner meal on 02/15/22 residents on a pureed diet were to receive two #10 scoops (six ounces (oz)) of beef. On 02/15/22 beginning at 3:32 P.M. interview with [NAME] #850 revealed there were 17 residents (Resident #9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) who were on a pureed diet and one of those 17 residents received double portions. The cook was observed to remove the beef stir fry to puree and indicated she was using a number six (#6) scoop to measure out 20 servings of beef stir fry to puree. [NAME] #850 indicated the number six scoop was equivalent to six ounces (oz). On 02/15/22 at 4:25 P.M. observation of the dinner meal tray line revealed [NAME] #850 was serving each resident on a pureed diet one scoop of protein (beef) using a number six scoop. On 02/15/22 at 4:26 P.M. interview with [NAME] #850 confirmed she was using a #6 scoop (which was 5.33 oz) to portion out the meal tray for each resident on a pureed diet. Review of a facility provided measurement conversion document revealed a #6 scoop equaled 2/3 of a cup or 5.33 ounces. Further review of the measurement conversion revealed a number ten (#10) scoop was 3/4 of a cup (three ounces) and two scoops were equal to six-ounce servings. On 02/15/22 at approximately 4:30 P.M. interview with [NAME] #850 and Dietary Manager #818 confirmed the residents were receiving 0.67 ounces less than the planned menu when the cook used the #6 scoop instead of two of the #10 scoops. The cook incorrectly identified the #6 scoop as a six ounce serving when it was actually 5.33 oz. On 02/15/22 at 4:51 P.M. during an interview with Dietary Manager (DM) #818, the DM did not dispute the pureed beef was not served with the correct serving scoop, resulting in the residents receiving less protein than the menu called for. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 8 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure milk served during the dinner meal on 02/15/22 to residents on the secured unit was served at a proper and palatable temperature. This had the potential to affect 11 residents (#18, #72, #31, #5, #69, #5, #45, #23, #71, #60 and #3) of 41 residing on the secured unit who received milk with their evening meal. The facility census was 80. Residents Affected - Some Findings include: On 02/15/22 at 4:40 P.M. a half gallon of milk was observed sitting on a paper towel on the counter of the small dining room on the secured unit. On 02/15/22 at 4:41 P.M. interview with State Tested Nursing Assistant (STNA) #826 revealed the half gallon of milk had been removed from the hot beverage cart, before it was removed from the dining room by kitchen staff, to provide the residents with milk when their meals were served. The STNA revealed it was the procedure to remove the milk from the beverage cart prior to the cart being taken back to the kitchen. She confirmed the milk remained on the counter while waiting for the residents meals and then indicated a glass was poured for the residents who wanted milk once their meal tray arrived. STNA #826 confirmed the milk sat out on the counter until all the meal trays were passed and the last resident was served. The milk was then returned to the kitchen. On 02/15/22 at 4:41 P.M. a glass of milk from the half gallon sitting out on the counter was poured and the temperature was taken by Dietary Manager (DM) #818. The milk temperature was 46 degrees Fahrenheit. The findings were confirmed with Dietary Manager #818 who indicated the milk should have been stored in the provided bucket of ice. DM #818 then obtained a new half gallon of milk to provide the residents. On 02/15/22 at 4:49 P.M. the last resident meal was provided and a glass of milk was poured from the half gallon of milk that remained sitting on the counter. The temperature of the milk was taken and it was 47.6 degrees. The findings were confirmed with Dietary Manager #818 at the time of the observation. On 02/15/22 at 5:20 P.M. interview with STNA #826 revealed 11 residents, Resident #18, #72, #31, #5, #69, #5, #45, #23, #71, #60 and #3 would have received the milk from this container (which was not the proper temperature) with their evening meal. On 02/16/22 at 12:51 P.M. interview with Dietician #829 revealed the facility did not have a cold food storage policy and indicated they follow the federal guidelines. Review of the Ohio Department of Health website (https://odh.ohio.gov/know-our-programs/food-safety-program/fact-sheets-for-consumers) titled Food Safety Fact Sheets for Consumer revealed cold foods needed to be kept below 41° F. A cooler with ice or gel packs should be used to keep the foods cold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 9 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, facility policy and procedure review and interview the facility failed to ensure pureed protein (beef) was prepared at the correct consistency and prepared in a form to meet each residents needs. This had the potential to affect 17 residents (#9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) of 17 residents who were ordered a pureed diet. The facility census was 80. Findings include: Review of the facility provided menu spreadsheet, dated 11/17/21 revealed for the dinner meal on 02/15/22 residents on a pureed diet were to receive two #10 scoops (six ounces (oz)) of beef. On 02/15/22 beginning at 3:32 P.M. interview with [NAME] #850 revealed there were 17 residents (Resident #9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) who were on a pureed diet and one of those 17 residents received double portions. Observation of the pureed process with [NAME] #850 revealed the cook used a number six (#6) scoop, (5.33 ounce (oz)) to remove servings of the beef stir fry to puree. The cook placed ten #6 scoops of beef in the food processor and turned it on, allowing it to puree. The beef was removed from the food processor and the process repeated for 10 additional servings. During the observation, there was no evidence the cook was following a recipe or that she had referred to a recipe to detail the steps involved in the process to puree the beef stir fry. Upon completion of the pureed process, the surveyor requested to taste the food. Observation and tasting of the beef stir fry, with [NAME] #805 and Dietary Manager (DM) #818 present revealed the food contained a piece of broccoli that was still intact and that had not been properly pureed. On 02/15/22 at 3:38 P.M. [NAME] #850 (after seeing of the broccoli that was not pureed) placed the food into a second smaller food processor and continued to process the stir fry. At 3:41 P.M. [NAME] #850 was observed filling the food processor with the partially pureed beef covering the entire blade shaft. On 02/15/22 at 3:45 P.M. [NAME] #850 and Dietary Manager #818 tasted the beef for the second time and stated the consistency was now correct for pureed food item. On 02/15/22 at 3:46 P.M. the pureed stir fry was tasted by three surveyors. The stir fry had fibers that made the texture stringy and a chunk of food had to be chewed by one of the surveyors. On 02/15/22 at 3:47 P.M. interview with [NAME] #850 revealed beef was difficult to puree and took some time. She also indicated the food processor was overfilled, stating she was trying to make the process quick. The cook then removed several scoops of the beef and pureed the beef for the third time. There was no evidence the cook obtained or followed a recipe to puree the beef. On 02/15/22 at 4:51 P.M. during an interview with Dietary Manager (DM) #818, the DM did not dispute the pureed beef would have been served after the first pureed attempt even though the consistency was not smooth, chunks were present and the texture was stringy. Review of the facility policy titled Pureed Casserole (Protein), dated 03/24/16 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 10 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm protein (beef) should have been pureed with a little stock/cooking liquid to reach a smooth consistency. Further review of the policy revealed the puree consistency should have been smooth and similar to pudding or mashed potato consistency. There was no evidence the policy detailed the amount of stock/cooking liquid that should be used or the included the type of stock/cooking liquid to use to puree beef stir fry. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 11 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the accurate documentation for thromboembolic deterrent (TED) hose and an ankle-foot orthosis (AFO) device for Resident #20. This affected one resident (#20) of one resident reviewed for edema. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, morbid obesity, chronic obstructive pulmonary disease, diabetes mellitus, thrombocytopenia, and acute embolism and thrombosis of deep vein of left lower extremity. Review of the 11/19/21 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, hallucinated and had delusions. The resident had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) one to three days of the assessment period and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) four to six days of the review review period. The assessment revealed the resident did not reject care, required extensive assistance from one staff for bed mobility and extensive assist from two staff for transfers. The resident did not receive scheduled pain medication but received as needed pain medication. The resident's pain was assessed to be almost constant and made it hard to sleep at night but did not limit activities. She said her pain was rated a ten on a scale of 0-10 with ten being the worst. Review of the resident's current physician's orders revealed an order (initiated 06/01/20) for an AFO to the left lower leg. The order indicated the AFO may be taken off for personal care and hygiene and remove at bedtime (HS). Check skin integrity daily to bilateral lower extremities (BLE) two times a day for brace (AFO) on in A.M. and off at HS and an order (initiated 08/17/20) for bilateral compression hose on in A.M. and off at bedtime (HS) two times a day for edema. On 02/14/22 at 11:56 A.M. and 1:27 P.M. and on 02/15/22 at 10:08 A.M. observation of Resident #20 revealed the resident had bilateral lower leg edema, had slipper socks on with swelling bulging over the top of the socks. The resident did not have on TED hose or an AFO. On 02/15/22 at 10:08 A.M. interview with Resident #20 revealed she had them but doesn't wear the TED hose because they leave lines on her legs. She said she doesn't like the AFO device. On 02/15/22 at 10:32 A.M. interview with State Tested Nursing Assistant (STNA) #815 revealed Resident #20 did not wear TED hose. The STNA revealed the resident's legs were usually still swollen in the morning even after being in bed at night. On 02/15/22 at 10:38 A.M. interview with Licensed Practical Nurse (LPN) #829 revealed Resident #20 refused to wear TED hose. On 02/16/22 at 11:13 A.M. Resident #20 was observed in the dining room getting ready for lunch. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 12 of 13 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 366254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was observed to have bilateral lower leg edema with slipper socks half off. She did not have on TED hose or an AFO in place. Review of the Treatment Administration Record (TAR) revealed Resident #20 had TED hose and the AFO documented as being in place every day from 02/01/22 through 02/14/22. However, based on the above observations and interview, neither device was in place on 02/14/22 even though staff documented they were. Review of the January 2022 TAR reflected the application of the AFO and TED hose everyday with the exception of 01/31/22. The December 2021 TAR revealed the application of the AFO was documented as ordered with the exception of 12/16/21 and 12/29/21 which noted the resident had refused on those dates. The application of the TED hose was documented as being applied as ordered with the exception of 12/15/21, 12/16/21 and 12/29/21 when the resident refused. The November 2021 TAR revealed the AFO and TED hose were applied as ordered except for on 11/05/21 when the resident refused. On 02/16/22 at 2:22 P.M. interview with Licensed Practical Nurse (LPN) #80 revealed the resident cycled. There were times she would wear the TED hose and AFO as ordered. LPN #80 revealed the last time she saw the resident with TED hose on was one day last week. LPN #80 revealed after medications were administered she completed resident documentation. The LPN revealed she documented yes, the TED hose and AFO device were in place out of habit and without actually verifying the application of the devices which resulted in the resident's medical record being inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366254 If continuation sheet Page 13 of 13