Health inspection·May 29, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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] 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] 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 Page 1 of 4 366254 366254 05/29/2025 Oak Pointe Nursing & Rehabilitation 130 Buena Vista Street Baltic, OH 43804

F 0644 letter dated 02/03/25. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few On 05/28/25 at 3:03 P.M., interview with Clinical Coordinator/Licensed Practical Nurse #271 verified there was no evidence the required PASARR services had been implemented after Resident #50 was approved for Specialized Services on 02/03/25. On 05/29/25 at 8:07 A.M., interview with Social Service Designee (SSD) #273 verified Resident #50's PASARR was approved with specialized services and these had not been addressed to date. On 05/29/25 at 9:40 A.M., interview with SSD #273 stated when he receives the PASARR Level II outcomes, he reviews the determination and then he was to update the care plan. SSD #273 notifies the clinical coordinator and physician to see if they want to order any of those services on the determination letter. SSD #273 stated he did not realize the behavioral health services and Specialized Services were required to be provided per the determination letter by the admitting nursing facility. 366254 Page 2 of 4 366254 05/29/2025 Oak Pointe Nursing & Rehabilitation 130 Buena Vista Street Baltic, OH 43804

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, review of manufacturer guidelines and Medscape guidance, and staff interview, the facility failed to ensure their medication error rate did not exceed five percent (%). Nine errors occurred within 26 opportunities for an error rate of 34.6%. This affected three (#17, #62, and #72) of five residents observed for medication administration. The facility census was 82. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including schizophrenia, paraplegia, congestive heart failure, and anxiety disorder. Review of Resident #17's physician orders dated May 2025 revealed to administer medications upon rising which included Aripiprazole (antipsychotic) 7.5 milligrams (mg). Review of the pharmacy pre-packaged pouch labeled At Rise for Resident #17 dated 05/27/25 revealed the pouch included Aripiprazole 7.5 mg with instructions 'Do Not Crush'. On 05/27/25 between 9:26 A.M. and 9:35 A.M., observation revealed Licensed Practical Nurse (LPN) #255 prepared Resident #17's medications including Aripiprazole and eight other medications. LPN #22 placed the nine medications into a plastic sleeve including the Aripiprazole and crushed the medications. LPN #255 put the crushed tablets in pudding and administered the medications to Resident #17. On 05/27/25 at 9:57 A.M., interview with LPN #255 verified she crushed Resident #17's Aripiprazole and the pharmacy instructions on the pre-packaged pouch indicated do not crush Aripiprazole. Review of Medscape guidance found at https://reference.medscape.com/drug/Abilify-maintena-aristada-aripiprazole-342983#11 revealed to swallow tablet whole; do not divide, crush, or chew. 2. Medical record review revealed Resident #72 was admitted on [DATE] with diagnoses including anxiety, Alzheimer's disease, hypertension and psychosis. Review of the physician orders dated May 2025 revealed to administer medications including tramadol (opioid), ativan (anxiety), benazepril (blood pressure), Colace (stool softener), famotidine (gastroesophageal reflex disease), Meloxicam (nonsteroidal anti-inflammatory), Miralax (stool softener), and lactulose liquid (stool softener). On 05/27/25 between 9:38 A.M. and 9:55 A.M., observation revealed Licensed Practical Nurse (LPN) #255 prepared Resident #72's At Rise medications including tramadol, ativan, benazepril, colace, famotidine and Meloxicam into a plastic sleeve, crushed the medications and put the crushed tablets in pudding. LPN #255 prepared Resident #72's Miralax in six ounces of water, lactulose liquid dose was poured into a glass of nutritional supplement and the above medications were taken to the lounge area where Resident #72 was seated in a specialty wheelchair. LPN #255 was observed scooping the crushed medications from the medication cup with a plastic spoon into Resident #72's mouth. The resident was observed to take the crushed medications in pudding that was heaping above the rim of the spoon; however, the bowl of the plastic spoon remained full of crushed medications and pudding. LPN #255 poured the liquid lactulose into the nutritional supplement and Resident #72 drank approximately five 366254 Page 3 of 4 366254 05/29/2025 Oak Pointe Nursing & Rehabilitation 130 Buena Vista Street Baltic, OH 43804

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ounces of the nutritional supplement. The remaining doses of the crushed medications and liquid medications were all discarded in the trash. On 05/27/25 at 9:57 A.M., interview with LPN #255 verified the entire dose of crushed medications and liquid medication were not administered to Resident #72 and had been discarded in the trash. LPN #255 was unable to state which medications and how much of the medication was left in the pudding or nutritional supplement due to the medications were mixed together. 3. Medical record review revealed Resident #62 was admitted on [DATE] with diagnoses including congestive heart failure. Review of the physician orders dated May 2025 revealed to administer medications including Eliquis (anticoagulant), Lasix (diuretic), and Sacubitril-Valsartan (treats heart failure; also known as Entresto). On 05/28/25 at 3:30 P.M., observation of Resident #62's medication administration revealed Registered Nurse (RN) #281 placed Eliquis, Lasix and Sacubitril-Valsartan into a plastic sleeve, crushed the medication, put the crushed tablets in chocolate pudding and administered the medications to Resident #62. On 05/28/25 at 3:57 P.M., interview with RN #281 verified the above observation and stated the medications including Sacubitril-Valsartan were crushed because Resident #62 would chew the medications if not crushed. Review of the Novartis: Entresto manufacturer guidelines dated April 2024 does not recommend the splitting or crushing of Entresto. If you cannot swallow tablets, or if tablets are not available in the prescribed strength, you may take Entresto tablets prepared as a liquid (oral) suspension or may take Entresto sprinkle. Review of the policy titled Medication Administration dated 06/21/17 revealed medications were to be administered by legally-authorized and trained persons in accordance to applicable state, local and federal lows and consistent with accepted standards of practice. 366254 Page 4 of 4