Inspection visit

Health inspectionApril 29, 2022

OAK CREEK TERRACE INCCMS #3658997 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dignified care in relation to a privacy bag for one Resident (#467)'s catheter of one reviewed for dignity. Facility census was 62. Findings include Review of the medical record for the Resident #467 revealed an admission date of 04/11/22. Diagnoses included malignant neoplasm of the bladder, chronic obstructive pulmonary disease, emphysema, heart failure, bladder obstruction, heart failure, chronic embolism, depression, anxiety, and abdominal aortic aneurysm. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #467 was cognitively and required extensive assistance of one to two staff members for transfers and mobility. The MDS revealed resident had an indwelling catheter. Review of the plan of care dated 04/25/22 revealed no mention of resident having a catheter. Review of progress notes dated 04/11/22 revealed resident was admitted with a Foley catheter on this date. Observation on 04/26/22 at 12:14 P.M. revealed Resident #467 had a catheter bag hanging from the side of the bed with no privacy cover. Observation and interview on 04/27/22 at 8:47 A.M. revealed Resident #467's catheter bag hung from the side of the bed with no privacy bag present. Resident revealed he had a catheter since his admission. Resident revealed he would like a catheter privacy cover. Observation and interview on 04/27/22 at 12:40 P.M. revealed Resident #467's catheter was hanging on the side of the bed with no privacy cover. State Tested Nursing Assistant (STNA) #61 confirmed resident's catheter was able to be seen from the hallway and was left with no privacy cover and revealed facility had covers to use for catheters. Interview on 04/27/22 at 12:46 P.M. with Licensed Practical Nurse (LPN) #36 confirmed resident did not have a catheter privacy bag over his catheter and revealed facility has them available. Review of facility policy titled Dignity, dated 01/26/21, revealed the facility failed to implement the policy regarding the area of concern. Resident should be treated with dignity and respect at (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 13 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 04/29/2022 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)

F 0550 all times. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 2 of 13 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 04/29/2022 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, staff interview, and policy review, the facility failed to ensure comprehensive care plans were completed in the areas of activities, activities of daily living, dehydration, and pain . This affected six (#23, #05, #43, #467, #469, and #57) of 18 residents reviewed for comprehensive care plans. The facility census was 62. Findings included: 1. Medical record review for Resident #23 revealed an admission date of 08/19/21. Medical diagnoses included renal insufficiency, heart failure and Non-Alzheimer's Dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was rarely or never understood. His functional status was extensive assistance for bed mobility and toilet use. He was total dependence for transfers and eating. He was always incontinent for bladder and bowel. Review of the comprehensive care plans for Resident #23 revealed he didn't have one for activities or for activities of daily living. Interview with Activity Director (AD) #03 on 04/27/22 at 11:09 A.M. confirmed she made the care plans for the residents and confirmed she didn't have one for Resident #23. Interview with Assisted Director of Nursing (ADON) #49 on 04/27/22 at 1:51 P.M. verified there was no activities of daily living included in the care plan. ADON #49 stated the facility was working on care plans to get them more in depth. 2. Medical record review for Resident #05 revealed an admission date of 10/21/21. Medical diagnoses included a cerebral infarction and viral hepatitis. Review of quarterly MDS dated [DATE] revealed Resident #05 was rarely or never understood. His functional status was extensive assistance for bed mobility, toileting and he was supervision for eating. Transfers did not occur. Review of care plans for Resident #05 revealed there wasn't one for activities. Interview with AD #3 on 04/27/22 at 11:09 A.M. confirmed she made the care plans for the residents and confirmed she didn't have one for Resident #05. 3. Review of the medical record for Resident #43 revealed she admitted to the facility on [DATE]. Diagnoses included noninfective gastroenteritis and colitis, type two diabetes mellitus with diabetic chronic kidney disease, ischemic cardiomyopathy, congestive heart failure, anemia, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, hyperlipidemia, hypertension, major depressive disorder, polyneuropathy, peripheral vascular disease, acute cystitis without hematuria, other chondrocalcinosis of left knee, cardiomyopathy, and end stage renal disease. Review of the quarterly MDS 3.0 assessment, dated 03/16/22, revealed this resident had intact cognition. This resident was assessed to require extensive assistance for bed mobility, limited (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 3 of 13 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 04/29/2022 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)

F 0656 assistance for transfer, dressing, toileting, and personal hygiene as well as supervision for eating. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 06/08/21 revealed no care plan related to activities of daily living. Residents Affected - Some Interview on 04/27/22 at 5:54 P.M. with Registered Nurse (RN)/MDS Coordinator #51 confirmed Resident #43 did not have a care plan for activities of daily living. 4. Review of the medical record for the Resident #467 revealed an admission date of 04/11/22. Diagnoses included malignant neoplasm of the bladder, chronic obstructive pulmonary disease, emphysema, heart failure, bladder obstruction, heart failure, chronic embolism, depression, anxiety, and abdominal aortic aneurysm. Review of progress notes dated 04/11/22 revealed resident was admitted with a Foley catheter. Review of the admission MDS assessment dated [DATE] revealed Resident #467 was cognitively intact and required extensive assistance of one to two staff members for transfers and mobility. The MDS revealed resident had an indwelling catheter. Review of the comprehensive care plan dated 04/25/22 revealed no mention of resident having a catheter. Observation on 04/26/22 at 12:14 P.M. revealed Resident #467 had a catheter bag hanging from the side able to be viewed from the hallway. Observation and interview on 04/27/22 at 8:47 A.M. revealed Resident #467's catheter bag hung from the side of the bed in view of the hallway. Resident revealed he had a catheter since his admission. Observation and interview on 04/27/22 at 12:40 P.M. revealed Resident #467's catheter was hanging on the side of the bed in view from the hallway. Interview on 04/27/22 at 12:46 P.M. with Licensed Practical Nurse (LPN) #36 confirmed resident had a catheter since admission. Interview on 04/27/22 at 1:35 P.M. with RN #49 revealed the care plan provided during the survey was dated 04/27/22 and included catheter care, but confirmed catheter was put on the care plan on 04/27/22. RN #49 confirmed facility policy was not followed in updating the care plan in a timely manner once the MDS assessment was completed. 5. Review of the medical record for the Resident #469 revealed an admission date of 04/04/22. Diagnoses included heart failure, chronic obstructive pulmonary disease, dementia with behaviors, protein malnutrition, respiratory failure, fracture of nasal bones, hearing loss Alzheimer's disease, depression and hypertension. Review of the admission MDS assessment dated [DATE] revealed Resident #469 had moderate cognitive impairment and required extensive assistance of one to two staff members for ambulation and mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 4 of 13 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 04/29/2022 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 04/25/22 revealed Resident #469 was receiving a mechanically altered diet (pureed) with nectar thick liquids. Resident was at risk for weight loss and malnutrition and an electrolyte imbalance due to thickened liquids and diuretic use with interventions to coordinate care with hospice team, honor preferences, monitor for signs and symptoms of aspiration, and monitor labs. The care plan did not specifically address fluid intake requires and risk of dehydration. Residents Affected - Some Review of nutrition assessment dated [DATE] revealed resident was receiving a pureed diet with nectar thick liquids due to dysphasia. The assessment states resident should have an intake of 1648 (cc's) or milliliters (ml) of fluid daily. Review of intake logs revealed resident's fluid intake ranged from 240 to 1160 ml of fluid daily with an average of 545.7 ml per day over the 21 days accounted. Review of resident's hospice preference paperwork dated 04/05/22 revealed before leaving my room, check the call light and water pitcher. Facility was unable to provide laboratory results for review. Interview on 04/27/22 at 1:35 P.M. with RN #49 confirmed the care plan did not include specifics regarding hydration status and monitoring for dehydration. Interview on 04/27/22 at 3:36 P.M. with Diet Tech #21 revealed she completed a nutrition assessment shortly after admission which includes resident fluid intake requirements based on her medical needs and weight. She confirmed Resident #469 requires 1648 ml of fluid intakes daily. Diet tech revealed she was concerned after printing and reviewing the fluid intake logs for resident due to the low amounts of fluid intakes since admission. 6. Review of Medical Record for Resident #57 admission date of 02/03/21 and readmission date of 10/19/21 with diagnoses including but not limited to vascular dementia with behavioral disturbance, osteoporosis, osteoarthritis, depression, anxiety, chronic pain, and intervertebral disc degeneration lumbar region. Medications include but not limited to buspirone 5 mg (anxiety), Depakote sprinkles 125 mg (dementia), Gabapentin 400 mg (pain), and routine Tylenol 325 mg (pain). Resident #57 also has an order may apply warm compress to lower back. Review of MDS revealed Resident #57 is a limited assist of one for transfers, ambulation, dressing, bathing, and hygiene. Review of Care Plan for Resident #57 revealed no care plan regarding pain. Interview with ADON #49 on 04/27/22 at 1:51 P.M. verified there was no pain included in the care plan. ADON #49 stated that the facility was working on care plans to get them more in depth. Review of Policy titled Comprehensive Care Plans not dated revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 5 of 13 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 04/29/2022 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)

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 medical record review, staff interview, and policy review, the facility failed to ensure care conferences were conducted as required. This affected three (Resident #05, #49, and #61) out of three residents reviewed for care conferences. The facility census was 62. Findings include: 1. Review of the medical record for Resident #61 revealed he admitted to the facility on [DATE]. Diagnoses included Parkinson's Disease, type two diabetes mellitus without complications, spondylosis without myelopathy or radiculopathy, morbid obesity, hypertension, major depressive disorder, anxiety disorder, hypotension, insomnia, tinea cruris, intervertebral disc degeneration of lumbar region, and low back pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/12/22, revealed this resident had intact cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene as well as supervision for eating. Review of the nursing progress notes revealed Resident #61 last had a care conference on 09/16/20. Interview on 04/26/22 at 10:45 A.M. with Resident #61 revealed he had not attended a care conference for some time. Interview on 04/26/22 at 5:09 P.M. with Social Services Director #52 confirmed she was unable to find documentation regarding care conferences for Resident #61 since 09/16/20. 2. Medical record review for Resident #49 revealed an admission date of 02/05/19. Medical diagnoses included diabetes, and Non-Alzheimer's Disease. Review of quarterly MDS dated [DATE] revealed Resident #49 was rarely/never understood. She was extensive assistance for bed mobility, transfers only occurred once or twice, eating was supervision and toilet use was total dependence. Review of the care conferences revealed there was one conducted on 04/27/21 and 04/26/22 which only had the Licensed Social Worker (LSW) in attendance. Interview with LSW #52 on 04/27/22 at 12:15 P.M. confirmed she was supposed to have care conferences quarterly and confirmed there was supposed to be other disciplinary team members in attendance for the care conferences. 3. Medical record review for Resident #05 revealed an admission date of 10/21/21. Medical diagnoses included a cerebral infarction and viral hepatitis. Review of quarterly MDS dated [DATE] revealed Resident #05 was rarely or never understood. His functional status was extensive assistance for bed mobility, toileting and he was supervision for eating. Transfers did not occur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 6 of 13 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 04/29/2022 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of care conferences for Resident #05 revealed the last one was 11/11/21 and the only team members present was the LSW. Interview with Resident #05 on 04/26/22 at 10:02 A.M. revealed even though he was coded as rarely or never understood he could shake his head to yes and no answers. At the time of the interview he shook his head no he wasn't receiving care conferences. Interview with LSW #52 on 04/27/22 at 12:15 P.M. confirmed she was supposed to have care conferences quarterly and confirmed there was supposed to be other disciplinary team members in attendance for the care conferences. Review of the undated facility policy titled Care Planning and Care Conferences revealed care conferences will be scheduled at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 7 of 13 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 04/29/2022 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)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff and resident interview the facility failed to ensure communication devices were implemented for one (#49) of one resident reviewed for communication during the annual survey. The facility identified there was only one resident who spoke a foreign language. The facility census was 62. Residents Affected - Few Findings included: Medical record review for Resident #49 revealed an admission date of 02/05/19. Medical diagnoses included diabetes, and Non-Alzheimer's Disease. Review of care plan dated 02/14/22 revealed Resident #49 has a communication problem related to language barrier. Her primary language was Spanish. Interventions were to anticipate and meet needs, ensure availability and functioning of adaptive communication board. The resident was able to communicate by using translation such as communication board. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was rarely/never understood. She was extensive assistance for bed mobility, transfer only occurred once or twice, eating was supervision and toilet use was total dependence. Interview and observation of Resident #49 on 04/26/22 at 11:06 A.M. revealed she did not speak English and she continued to speak Spanish. Observation of medication administration on 04/27/22 at 8:22 A.M. revealed Licensed Practical Nurse (LPN) #36 took blood pressure of Resident #49 and spoke hello in Spanish. The resident continued to speak in Spanish and the LPN stated I wish I could speak Spanish. The resident continued to speak to the nurse in Spanish and the nurse held her hand and spoke in English to the resident. There was a white communication board in the room with phrases written in English and Spanish on it, that was behind a pot of flowers, sitting on the chest of drawers in the room. Interview with LPN #36 on 04/27/22 at 8:30 A.M. confirmed she didn't know what the resident was saying and didn't know how to speak Spanish. She confirmed there were devices to be used to communicate with the resident, but confirmed she didn't use them. She said it was something urgent to understand from the resident the resident would be guarding and pointing to the problem. She said she didn't know if there were any Spanish speaking nurse who worked at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 8 of 13 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 04/29/2022 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)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interviews, and medical record review, the facility failed to ensure activities were provided for two (#49 and #23) of three dependent residents reviewed for activities. The facility census was 62. Residents Affected - Few Findings included: 1. Medical record review for Resident #49 revealed an admission date of 02/05/19. Medical diagnoses included diabetes, and Non-Alzheimer's Disease. Review of care plan dated 02/14/22 for Resident #49 revealed she had some cognitive loss and primary language was Spanish. The resident needed encouragement to attend out of room events. Interventions were to assist to and from activities, encourage out of room activities and invite to crafts. Review of activities from 03/29/22 through 04/24/22 revealed she was active on 04/05/22 and 04/13/22 and passive on 04/17/22. She observed on 03/29/22 and 04/16/22. Resident was not available on 04/02, 04/03, 04/10, 04/11, 04/12, 04/14, 04/19, 04/23, and 04/24. She refused on 04/08/22. No family visits or room visits were documented. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was rarely/never understood. She was extensive assistance for bed mobility, transfer only occurred once or twice, eating was supervision and toilet use was total dependence. Review of the activity calendar dated 04/26/22 revealed at 10:15 A.M. revealed chair exercise, at 10:30 A.M. ladder ball and at 1:30 P.M. revealed theater popcorn. On 04/27/22 the calendar revealed at 10:15 A.M. coffee and donuts and at 10:30 A.M. news talk. Observations of activities on 04/26/22 at 10:15 A.M., 10:30 A.M. and 1:30 P.M. revealed Resident #49 was not in the activity and was in her room in bed. Further observation on 04/27/22 at 10:15 A.M. and 10:30 A.M. the resident was not in those activities either and was in bed in her room. Interview with Activity Director (AD) #03 on 04/27/22 at 11:05 A.M. confirmed Resident #49 was not invited to activities on 04/26/22 and 04/27/22. She said only if the residents are up and out of bed would they be invited to attend the activities. She said at times the activity staff encourage the aides to get the residents up so they can attend the activities. 2. Medical record review for Resident #23 revealed an admission date of 08/19/21. Medical diagnoses included renal insufficiency, heart failure and Non-Alzheimer's Dementia. Review of quarterly MDS dated [DATE] revealed Resident #23 was rarely or never understood. His functional status was extensive assistance for bed mobility and toilet use. He was total dependence for transfers and eating. He was always incontinent for bladder and bowel. Review of activity participation from 03/29/22 through 04/27/22 revealed he observed on 03/29/22, 04/02/22, 04/16/22 and 04/17/22 and was active on 04/03/22. There were 16 out of 30 days the family visited. There were seven room visits out of 30 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 9 of 13 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 04/29/2022 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)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the activity calendar dated 04/26/22 revealed at 10:15 A.M. revealed chair exercise, at 10:30 A.M. ladder ball and at 1:30 P.M. revealed theater popcorn. On 04/27/22 the calendar revealed at 10:15 A.M. coffee and donuts and at 10:30 A.M. news talk. Observations of activities on 04/26/22 at 10:15 A.M., 10:30 A.M. and 1:30 P.M. revealed Resident #23 was not in the activity and was in his room in bed. Further observation on 04/27/22 at 10:15 A.M. and 10:30 A.M. the resident was not in those activities either and was in bed in his room. Interview with the family on 04/26/22 at 12:03 P.M. revealed Resident #23 does not get invited to activities and doesn't have one on ones either. Review of care plan dated 04/27/22 for Resident #23 revealed he was dependent on staff for socialization and stimulation. He needed encouragement from staff to attend events. Interventions were to assist to and from activities. Interview with AD #03 on 04/27/22 at 11:05 A.M. confirmed Resident #23 was not invited to activities on 04/26/22 and 04/27/22. She said only if the residents are up and out of bed would they be invited to attend the activities. She said at times the activity staff encourage the aides to get the residents up so they can attend the activities. Interview with Director of Nursing (DON) on 04/28/22 at 1:49 P.M. denied they had an activity policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 10 of 13 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 04/29/2022 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to provide adequate fluids to one Resident (#469) reviewed for hydration. The facility census was 62. Residents Affected - Few Findings include Review of the medical record for the Resident #469 revealed an admission date of 04/04/22. Diagnoses included heart failure, chronic obstructive pulmonary disease, dementia with behaviors, protein malnutrition, respiratory failure, fracture of nasal bones, hearing loss Alzheimer's disease, depression and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #469 had moderate cognitive impairment and required extensive assistance of one to two staff members for ambulation and mobility. Review of the plan of care dated 04/25/22 revealed Resident #469 was receiving a mechanically altered diet (pureed) with nectar thick liquids. Resident was at risk for weight loss and malnutrition and an electrolyte imbalance due to thickened liquids and diuretic use with interventions to coordinate care with hospice team, honor preferences, monitor for signs and symptoms of aspiration, and monitor labs. Review of nutrition assessment dated [DATE] revealed resident was receiving a pureed diet with nectar thick liquids due to dysphasia. The assessment states resident should have an intake of 1648 (cc's) or milliliters (ml) of fluid daily. Review of intake logs revealed resident's fluid intake ranged from 240 to 1160 ml of fluid daily with an average of 545.7 ml per day over the 21 days accounted. Review of resident's hospice preference paperwork dated 04/05/22 revealed before leaving my room, check the call light and water pitcher. Facility was unable to provide laboratory results for review. Observation and interview on 04/26/22 at 10:28 A.M. and again at 4:10 P.M. with Resident #469 revealed she asked for surveyor to hand her a cup of water. Resident did not have anything to drink visible in her room. Resident was observed to be given two small drinks with the dinner meal. Observation on 04/27/22 at 8:37 A.M. revealed she was given two drinks with her breakfast meal. No other drinks were provided. Interview on 04/27/22 at 12:40 P.M. with State Tested Nursing Assistant (STNA) #61 revealed facility has thickened liquid behind the nurses' station that can be provided to residents upon request. STNA revealed being unsure why resident was only getting fluids with her meals. Interview on 04/27/22 at 12:46 P.M. with Licensed Practical Nurse (LPN) #36 revealed Resident #469 was not on a fluid restriction and had no medical orders for having fluid restricted. LPN revealed staff pass ice to residents each day but when resident have thickened liquids ordered, they do not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 11 of 13 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 04/29/2022 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pass ice or water in large pitchers as the thickener would separate in large amounts by the time it was drank. Interview on 04/27/22 at 3:36 P.M. with Diet Tech #21 revealed she completed a nutrition assessment shortly after admission which includes resident fluid intake requirements based on her medical needs and weight. She confirmed Resident #469 requires 1648 ml of fluid intakes daily. Diet tech revealed she was concerned after printing and reviewing the fluid intake logs for resident due to the low amounts of fluid intakes since admission. Diet tech revealed she would speak with staff about fluid intake increases for resident. Interview on 04/27/22 at 3:50 P.M. with Diet tech #21 revealed she spoke with staff and requested for nursing staff to provide increased fluids during each meal pass and also requested for staff to increase the amount of fluids resident was given at meal-times. Diet tech did not provide update on how staff will maintain resident hydration status during other times of day or when she requests fluids outside of meal-times and medication pass times. Several observations on 04/26/22 and 04/27/22 throughout the days revealed staff did not provide any fluid except at meals on her tray. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 12 of 13 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 04/29/2022 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and interview, the facility failed to use a recipe to accurately make pureed texture food. This affected all six Residents (#07, #18, #23, #29, #42, #469) with orders for pureed diets. The facility census was 62. Findings include Interview and observation on 04/27/22 at 10:35 A.M. with Dietary Staff #13 revealed residents were having pot roast with the menu giving guidance of 3-ounce (oz) servings. She revealed six residents have orders for pureed meals and she placed six - 3 oz servings of meat along with six - 3 oz servings of broth in the blender. Dietary #13 also revealed she adds bread to each item in the meal (meats and vegetables) and added three slices of bread to the blender. She turned on the blender to begin mixing. She revealed facility does not use specific menus or recipes to make the pureed food and revealed she just know what the texture looks like. Interview on 04/27/22 at 10:50 A.M. with Dietary Manager #16 revealed facility does not use menus or recipes to ensure staff know how much fluid to use and what to use for liquids when making pureed meals. She revealed they do not use water and will start off with a little bit and continue adding small amounts of liquid at a time to get the correct consistency. She revealed dietary staff just know what pureed looks like so they do not use guides. Interview and Observation on 04/27/22 at 10:56 A.M. with Dietary Staff #13 revealed she scooped the pureed pork roast mixture into the bowls. The mixture appeared as a very thin and watery consistency similar to pancake mix and was dripping off the serving spoon. When asked if this was the correct consistency Dietary #13 revealed it was thinner than she would like. She revealed pureed food should be more similar to mash potato consistency and it mix was thinner than that. She placed the mixture back in the blender and added a fourth piece of bread and blended the mixture. Then she added three packets of thickener (each was for a 4 oz serving), then added two more packets and eventually three additional packets for a total of 8 packets of thickener. Dietary #13 revealed you would probably want it a little thicker. Dietary #13 then used the scooper to fill bowls for each of the six residents. It appeared similar to a thick applesauce but did not hold its shape in the bowl. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365899 If continuation sheet Page 13 of 13

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

FAQ · About this visit

Common questions about this visit

What happened during the April 29, 2022 survey of OAK CREEK TERRACE INC?

This was a inspection survey of OAK CREEK TERRACE INC on April 29, 2022. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OAK CREEK TERRACE INC on April 29, 2022?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·April 29, 2022