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 (continued on next page) 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: 366254 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 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)