Oak Pointe Nursing & Rehabilitation

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of nursing schedules, employee time punch review and interviews, the facility failed to ensure a registered nurse was scheduled for eight consecutive hours every day. This had the potential to affect all 81 residents. Findings include: Review of nursing schedules and time punches for the days dated 04/08/23, 04/09/23, 04/22/23, 05/06/23, 05/07/23, 05/20/23 and 06/17/23 revealed there was no registered nurse (RN) coverage for eight consecutive hours. During an interview on 01/30/24 at 1:43 P.M. with the Administrator verified the facility had no RN coverage for eight consecutive hours on the following dates 04/08/23, 04/09/23, 04/22/23, 05/06/23, 05/07/23, 05/20/23, and 06/17/23. The deficient practice was corrected on 10/15/23 when the facility implemented the following corrective actions: - Actively recruited RN hires for both day and night shift positions. - Audited third quarter nurse schedules to ensure minimum qualifications were met. -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview the facility failed to ensure all residents had clean linen and furniture in good repair. This affected five residents (#12, #23, #33, #45 and #76) of 80 residents residing in the facility. Findings include: The following environmental concerns were identified during the annual recertification survey: a. On 02/14/22 at 1:43 P.M. interview with Resident #76 revealed concerns her bedspread and bed sheets were dirty. She said her sheets had only been changed three times since she arrived to the facility. The resident said she had spilled pop on her bedspread. On 02/14/22 at 1:45 P.M. observation of the resident's bed revealed there were approximately seven brown areas on the bedspread covering an approximate three foot by three foot area of the white bedspread. There were also brown areas on the fitted mattress sheet and pillow case. On 02/16/22 at 11:16 A.M. observation of the resident's bed revealed her pillow case had red/brown marks on it as well as the fitted sheet. The bedspread had six to seven brown areas as observed 02/14/22.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.