Health inspection·April 11, 2019

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 record review and staff interview; the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected two (Resident #17 and #30) of 24 residents reviewed for accuracy of the MDS assessment. The facility census was 64. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depressive disorder. Review of the medication administration record (MAR), dated 01/2019, revealed Resident #17 was administered Buproprion (antidepressant medication) 75 milligram (mg.) two tablets on 01/25/19. Continued review of the MAR revealed Resident #17 was administered Buproprion 150 mg. one tablet on 01/26/19, 01/27/19, 01/28/19, 01/29/19, 01/30/19, and 01/31/19. Review of the MAR dated 01/2019, revealed the resident was administered antidepressant medication on seven days of the seven day reference period. Review of the admission MDS assessment, dated 01/31/19, revealed Resident #17 was administered antidepressant medication on six days of the seven day reference period. Interview on 04/11/19 at 12:13 P.M. with MDS Coordinator #200 verified the admission MDS assessment dated [DATE] for Resident #17 was not accurate. The MDS Coordinator revealed antidepressant medication was administered on seven days of the seven day reference period. 2. Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage cerebral atherosclerosis and congestive heart failure. Review of the document titled, Physician's Initial Certification of Terminal Illness certification date 11/23/18 to 02/20/19, revealed Resident #30 was terminally ill and had a limited life expectancy/prognosis of six months or less if the terminal illness runs its normal course for the terminal diagnosis of cerebral atherosclerosis. Review of the admission MDS assessment, dated 02/18/19, section J1400, revealed no assessment of Resident #30's chronic condition/disease that may result in life expectancy of less than six months. Interview on 04/11/19 at 8:56 A.M. with the MDS Coordinator #200 verified the admission MDS assessment, dated 02/18/19, section J1400, for Resident #30 was not accurate. Page 1 of 6 365899 365899 04/11/2019 Oak Creek Terrace Inc 2316 Springmill Road Kettering, OH 45440

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to develop and implement a person-centered comprehensive care plan for antipsychotic medication use. This affected one (Resident #17) of sixteen resident reviewed for the development of person-centered comprehensive care plans. The census was 64. Findings include: Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, vascular dementia and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/31/19, revealed Resident #17 was administered antipsychotic medication on seven days during the seven day reference period. Review of the medication administration record (MAR) dated 01/2019 and 02/2019, revealed Residents #17 was administered the antipsychotic medication Seroquel 25 milligram (mg.) tablet one time a day at bedtime from 01/24/19 to 02/28/19. Review of the medication administration record, dated 03/2019, revealed Resident #17 was administered Seroquel 25 mg. on 03/01/19. Continued review of the MAR dated 03/2019 revealed the Seroquel was increased to 50 mg. tablet one time a day at bedtime on 03/02/19. Resident #17 was administered Seroquel 50 mg from 03/02/19 to 04/10/19. Review of Resident #17's comprehensive care plan, revision date 04/09/19, revealed there was no care plan to address the potential for drug related complications associated with the use of antipsychotic medication. Interview on 04/11/19 at 12:13 P.M. with the MDS Coordinator #200 verified there was no comprehensive care plan to address antipsychotic medication use for Resident #17. 365899 Page 2 of 6 365899 04/11/2019 Oak Creek Terrace Inc 2316 Springmill Road Kettering, OH 45440

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview; the facility failed to review and revise a comprehensive care plan to include a change in a residents dialysis access site. This affected one (Resident #7) of 16 residents reviewed for care plans. The facility census was 64. Findings include: Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease. Review of physician orders, dated 02/10/17, revealed Resident #7's right chest port was to be flushed at dialysis per protocol. The medical record failed to identify the hemodialysis access site located in the resident left arm and the care/services to provide for the access site. Review of the comprehensive care plan, revision date 04/10/19, revealed Resident #7 required dialysis related to renal disease. Continued review of the care plan revealed the plan did not identify the AV fistula located in the resident left arm or the care and services required for an AV fistula. Observation on 04/11/19 at 10:00 A.M. of Resident #7 revealed the resident had an arteriovenous (AV) fistula, located in the resident left arm, for hemodialysis access. Further observation of Resident #7 revealed no hemodialysis access site located on the resident's right chest. Interview on 04/11/19 at 10:01 A.M. with the Assistant Director of Nursing (ADON) verified Resident #7 no longer had a right chest port. The ADON revealed the resident's dialysis access site was located in the resident's left arm. The ADON verified Resident #7's care plan was not updated to include the change of the residents hemodialysis access site. 365899 Page 3 of 6 365899 04/11/2019 Oak Creek Terrace Inc 2316 Springmill Road Kettering, OH 45440

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and staff interview, the facility failed to provide adequate care and treatment with the application of a physician ordered compression stockings. This affected one (Resident #216) of sixteen residents reviewed for quality of care. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record of Resident #216 revealed an admission date of 04/04/19 with diagnoses including hypo-osmolality and hyponatremia, weakness, dehydration, hypothyroidism, essential hypertension, age related osteoporosis. Review of the admission assessment, dated 04/04/19, revealed the resident was alert and oriented to person, place, time and situation, and required supervision with all Activities of Daily Living. Further review of the resident's medical record revealed a physician order dated 04/04/19 for compression stockings (to prevent the formation deep vein thrombosis and pulmonary embolism) to apply in the morning (6:00 A.M.) and remove in the evening (10:59 P.M.) as tolerated, one time a day and remove as scheduled. Observations on 04/09/19 at 10:31 A.M. and on 04/10/19 at 9:32 A.M., were made of resident during interviews and revealed the resident was not wearing the ordered compression stockings. The compression stockings were observed hanging on the towel rod in the resident's bathroom during both observations. Interview on 04/09/19 at 10:31 A.M. with Resident #216 stated he needs staff assistance to apply the stockings and wants to wear the stockings to keep the swelling down in his feet and lower legs. The resident stated he hasn't worn the stockings the past two days. Interview on 04/10/19 at 1:31 P.M. with State Tested Nursing Assistant (STNA) #3 revealed she started the shift at 7:00 A.M. and provided care to Resident #216 when she arrived on the unit and stated the resident did not have on his compression stockings. Interview on 04/10/19 at 3:34 P.M. with the Director of Nursing (DON) revealed she spoke with the nurse and the STNA assigned to the resident the night of 04/09/19 and the nurse informed her he did not check to verify if the STNA applied the resident's compression stockings. The STNA informed her she did not apply the resident's compression stockings during her shift. 365899 Page 4 of 6 365899 04/11/2019 Oak Creek Terrace Inc 2316 Springmill Road Kettering, OH 45440

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview; the facility failed to ensure fall interventions were in place as ordered by the physician. This affected one (Resident #17) of three resident reviewed for falls. The facility census was 64. Findings include: Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, vascular dementia, injury of nerves and spinal cord, neuropathic bladder, hypothyroidism, insomnia, spinal stenosis, major depressive disorder, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 01/31/19, revealed Resident #17 had impaired cognition. The resident required extensive assistance of two people for bed mobility and was totally dependent of two people for transfers. Review of physician orders, dated 01/29/19, revealed an order for bilateral bolsters applied to Resident #17's bed to define the parameter. Review of the care plan, initiated on 01/30/19 with a revision date of 04/09/19, revealed Resident #17 was at risk for falls related to gait/balance problems. Interventions included bolsters to both sides of the bed to define the parameter. Review of a fall risk assessment dated [DATE], revealed Resident #17 was at high risk for falls. Review of a progress note, dated 04/06/19 at 12:11 A.M., revealed on 04/05/19, Resident #17 was found by an state tested nurse aid (STNA) laying on the floor, face down, next to the residents bed. There was no injury noted. There was no documentation of fall interventions in place prior to the resident fall. Multiple observations made on 04/09/19 between 9:00 A.M. and 3:00 P.M., revealed no observation of bilateral bolsters pads applied on Resident #17's bed. Interview on 04/09/19 at 11:56 A.M. with the resident's representative revealed Resident #17 fell from the bed on 04/05/19. The resident representative reported the bolster pads were placed in the resident room in 01/2019. The resident representative revealed the bolster pads were put in the resident's closet and were never placed on the resident bed. Interview on 04/09/19 at 3:05 P.M. with the Assistant Director of Nursing (ADON) #205 confirmed Resident #17 had a physician order dated 01/29/19, for bilateral bolsters to be applied to the resident's bed. The ADON further confirmed the bolster pads were also a care planned intervention for fall prevention. The ADON verified the bolster pads were not in place prior to the resident's fall and continued to not be in place to this date and time. Interview on 04/09/19 at 3:55 P.M. with STNA #13 revealed Resident #17 was found on the floor, in the resident's room, next to the bed on 04/05/19. STNA #17 revealed the resident's bed was in the 365899 Page 5 of 6 365899 04/11/2019 Oak Creek Terrace Inc 2316 Springmill Road Kettering, OH 45440

F 0689 Level of Harm - Minimal harm or potential for actual harm lowest position prior to finding the resident on the floor. The STNA verified there were no bolsters on the resident's bed. STNA #17 revealed the resident had never had bolsters applied to the bed while a resident at the facility. Residents Affected - Few 365899 Page 6 of 6