Health inspection·January 18, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately reflect residents' status on Minimum Data Set (MDS) assessments related to mental health status and oxygen use. This affected three (Residents #11, #21, and #33) of 24 residents whose assessments were reviewed. The facility census was 53. Residents Affected - Few Findings include: 1. Review of Resident #11's medical record review revealed diagnoses including schizoaffective disorder (bipolar type), psychosis, pseudobulbar affect, depression, bipolar disorder and anxiety disorder. A Preadmission Screen and Resident Review dated 07/05/22 indicated Resident #11 had no indications of serious mental illness. Resident #11 was hospitalized between 11/14/22 and 12/07/22. Review of a Preadmission Screen and Resident Review Determination (PASRR) determination revealed Resident #11 was approved for nursing facility services. The attached summary report dated 12/01/22 indicated Resident #11 was first medically hospitalized ( for increased ammonia level in the blood and diagnosed with pneumonia and metabolic encephalopathy) and when stable was transferred to the inpatient psychiatric unit. The summary indicated Resident #11 had mental health diagnoses of psychotic disorder, language disorder - cognitive communication deficit, major depressive disorder, bipolar disorder, and dependence on psychotropic medications with induced mood disorder and anxiety disorder. The summary indicated Resident #11 was hospitalized for having unreal thoughts and seeing and hearing things that were not there. Resident #11 also exhibited physical aggression. The summary indicated Resident #11 had one inpatient psychiatric hospitalization in the past two years and was receiving psychotropic medication. There were no recommendations for disability specific services. However, the summary indicated services and supports which would be needed to be provided included an Occupational Therapy evaluation, a safety plan, ongoing evaluation of the effectiveness of psychotropic medications on target symptoms, ongoing medication review by a psychiatrist or similarly-credentialed professionals, medication evaluation and monitoring by a designated physician, family involvement in care, and socialization and recreation activities to decrease isolation, improve mood and increase social interaction. Review of Resident #11's annual MDS dated [DATE] indicated Resident #11 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related conditions. During an interview on 01/18/24 at 9:48 A.M., Registered Nurse (RN) #355 verified the annual MDS dated [DATE] was marked incorrectly regarding serious mental illness. (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 6 Event ID: 366306 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 366306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Oaks Care Center 500 Selfridge Street East Liverpool, OH 43920 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)