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. 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: 365899 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 365899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Creek Terrace Inc 2316 Springmill Road Kettering, OH 45440 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)