Inspection·January 18, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations and staff interview the facility failed to ensure residents were administered as ordered resulting in two medication errors out of 25 opportunities or an eight percent (%) medication error rate. This affected two (#18 and #19) out of of four residents observed for medication administration. The facility census was 88. Residents Affected - Few Findings include: 1. Review of medical record for Resident #18 revealed admission date of 04/18/23. Diagnoses include alcoholic hepatic failure without coma, traumatic subdural hemorrhage, bipolar disorder, chronic obstructive pulmonary disorder, depression and chronic respiratory failure. The resident remained in the facility. Observation of medication pass on 01/18/24 at 8:15 A.M. with Licensed Practical Nurse (LPN) #118 for Resident #18 revealed she was given Amlodipine (blood pressure) 10 milligrams (mg), Keppra (seizures) 750 mg, Lisinopril (blood pressure) 20 mg, Metformin (diabetes) 500 mg, Senna (laxative) 8.6 mg and Zyprexa (antipsychotic) 2.5 mg. Further review of Resident #18's physician orders revealed an order for each of the medication administered except Zyprexa. Review revealed an order for Zyprexa 2.5 mg daily with a start date of 06/21/23 and an end date of 08/21/23. Interview and observation on 01/18/24 at 12:58 P.M. with LPN #18 verified Resident #19's Zyprexa was not a current order. Observation of the pharmacy supplied medication revealed Zyprexa was listed on and present in the provided medication bag. 2. Review of medical record for Resident #19 revealed admission date of 01/05/24. Diagnoses include right femur fracture, and chronic obstructive pulmonary disease. Observation of medication pass on 01/18/24 at 8:19 A.M. with LPN #118 for Resident #19 revealed she was administered Breo Ellipta (fluticasone furoate and vilanterol) (corticosteroid) 100 micrograms (mcg)/ 25 mcg. Further review of Resident #19's physician orders revealed no order for Breo. There was an order for Trelegy Ellipta (flucosone- Umecliidinium-Vilanterol) (COPD) 200-62.5-25 mcg. Interview on 01/18/24 at 1:00 P.M. with LPN #118 verified Breo was administered to Resident #19 and (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: 365821 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 365821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439 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)