Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Creek Terrace Inc during CMS and state inspections, most recent first.
A resident admitted with impaired cognition, dependence in ADLs, wheelchair use, and multiple medical conditions was identified as a fall risk on admission, yet no fall interventions were documented as in place at that time. The resident experienced several falls before a comprehensive fall care plan was initiated, and the baseline care plan—required within 48 hours per facility policy—was not completed until much later, with limited fall interventions documented. An MDS coordinator confirmed the delay in completing the baseline care plan and the absence of documented fall interventions on admission.
A resident with severe cognitive impairment, dependence in ADLs, and a history of repeated falls had a care plan requiring bilateral fall mats while in bed, but surveyors observed the resident in bed with no fall mats present. An LPN confirmed the mats were ordered in the care plan and had not been in the room that day, and could not recall when they were last seen. The Environmental Director later brought the mats to the room, stating they are only removed when ordered, while the MDS coordinator confirmed the mats were a planned intervention. This failed to follow the facility’s fall management policy requiring interventions based on identified fall risk factors.
Staff did not use appropriate PPE, including N95 respirator and eye protection, or perform proper hand hygiene when providing care to a resident on droplet precautions for COVID-19. A CNA entered the room with only a surgical mask, gown, and gloves, and failed to wash hands before leaving, while both the CNA and DON demonstrated lack of knowledge regarding required infection control measures. This occurred while multiple residents on the dementia care unit were COVID-19 positive, potentially affecting others.
A resident with multiple medical conditions received a pressure ulcer dressing change during which an LPN failed to change gloves or perform hand hygiene between dirty and clean steps, contrary to infection control protocols. Additionally, the facility did not complete required monthly monitoring of water temperatures and chlorine levels as outlined in its Water Management Plan, potentially affecting all residents.
Staff did not follow proper procedures for thawing food, storing utensils, and separating chemicals from food service items. Frozen pot roast was thawed in a prep sink without running water, Styrofoam cups were stored near cleaning chemicals, and wet cups were stacked on the tray line instead of being air dried, affecting nearly all residents.
A resident with multiple medical conditions and severe cognitive impairment did not receive pressure ulcer care according to physician orders. During a dressing change, an LPN failed to cleanse the wound with normal saline as directed, instead using a washcloth to remove old medication before applying Silvadene and barrier cream. The LPN confirmed the deviation from the prescribed wound care protocol.
A resident with severe cognitive impairment and multiple comorbidities, dependent on staff for transfers, experienced an unwitnessed fall resulting in a femur fracture. The facility's investigation was incomplete, lacking required documentation such as witness statements, details of interventions at the time of the fall, and records of the resident's last observed status, contrary to facility policy.
A resident with multiple medical conditions and a G-tube did not receive care according to facility policy when an LPN failed to verify G-tube placement, used an undated syringe, did not dilute crushed medication, and positioned the resident incorrectly during medication administration. The LPN was unaware of the facility's G-tube policy, leading to multiple deviations from required procedures.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall resulting in a femur fracture. Although the incident and injury were noted in an occurrence report and hospital records, there was no documentation in the EMR about the fall or the fracture, as confirmed by the DON.
Failure to Implement Timely Baseline Care Plan and Fall Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan with appropriate fall interventions within 48 hours of admission for a resident identified as being at risk for falls. The resident was admitted with diagnoses including a displaced fracture of the right humerus with routine healing, chronic kidney disease, and anxiety disorder, and had moderately impaired cognition, was dependent for toileting and bathing, and used a wheelchair for mobility. The admission assessment documented the resident as a fall risk, and the medical record showed multiple falls on 03/20/26, 03/27/26 (two falls), and 04/10/26. A comprehensive care plan identifying the resident as at risk for falls, with interventions such as bedside mats, bed in lowest position, call light reminders, non-skid socks, ensuring basic needs were met, PT/OT, following fall protocol after incidents, monitoring for changes in mental status, and proper footwear, was not initiated until 03/24/26. The baseline care plan, which by facility policy was required to be developed within 48 hours of admission and include instructions needed to provide effective, person-centered care, was not completed until 04/05/26, well after admission and after multiple falls had occurred. The baseline care plan’s documented fall risk interventions were limited to encouraging use of the call light for assistance with ADLs and transfers. During interview, the MDS Coordinator confirmed that the baseline care plan with fall interventions was not completed until 04/06/26 and verified that no fall interventions were documented as being in place at the time of admission, despite the resident’s identified fall risk and subsequent fall events.
Failure to Implement Care-Planned Fall Mats for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions as outlined in the care plan for a resident with a history of repeated falls. The resident, admitted with diagnoses including cerebral atherosclerosis, pulmonary fibrosis, chronic kidney disease, and repeated falls, had a recent MDS assessment showing severe cognitive impairment and dependence with bathing and toileting. The resident’s care plan, dated 03/13/26, identified the resident as at risk for falls and specified the use of bilateral fall mats while the resident was in bed. The medical record documented multiple falls on 03/09/26, 03/13/26 (twice), 03/14/26 (twice), 03/22/26 (twice), 03/24/26, 03/26/26, and 03/27/26. On 04/24/26 at 10:34 A.M., surveyor observation found the resident lying in bed with no fall mats on either side of the bed or anywhere in the room, despite the care plan requirement. At 10:35 A.M., an LPN confirmed that the resident’s care plan included bilateral fall mats while in bed and acknowledged that there were no fall mats present, further stating that the mats had not been in the room all day and could not recall the last time they were seen there. At 10:54 A.M., the Environmental Director was observed placing fall mats in the resident’s room and stated that fall mats are only removed when ordered. At 12:06 P.M., the MDS coordinator confirmed that fall mats were part of the resident’s care plan. Review of the facility’s Fall Management policy dated 01/2021 indicated that interventions should address unique risk factors identified by the risk assessment tool, which was not followed in this case.
Failure to Follow COVID-19 PPE and Hand Hygiene Protocols
Penalty
Summary
Staff failed to adhere to proper infection control protocols when caring for a resident who tested positive for COVID-19 and was placed on droplet precautions. A Certified Nursing Aide (CNA) entered the resident's room wearing only a surgical mask, gown, and gloves, but did not use required eye protection or an N-95 respirator as recommended by CDC guidance for confirmed COVID-19 cases. After attempting to feed the resident, the CNA removed her gown and gloves, handled the resident's tray, and performed additional tasks in other rooms before removing her mask and washing her hands in a bathroom down the hall, rather than performing hand hygiene immediately upon exiting the resident's room. The CNA confirmed she did not wash her hands before leaving the room and was unaware of the need for eye protection or an N-95 mask. Interviews with the CNA and the Director of Nursing (DON) revealed gaps in knowledge regarding appropriate PPE use and hand hygiene protocols for droplet precautions, particularly for residents with COVID-19. Facility policy required the use of masks and eye protection for droplet precautions and specified hand hygiene before leaving resident rooms. CDC guidance further specified the need for a NIOSH-approved N95 respirator, gown, gloves, and eye protection for staff entering rooms of residents with confirmed COVID-19. The facility had five residents positive for COVID-19 on the dementia care unit at the time of the survey, with the potential to affect other residents on the unit.
Infection Control and Water Management Deficiencies Identified
Penalty
Summary
During a dressing change for a pressure ulcer, a Licensed Practical Nurse (LPN) failed to follow proper infection control practices. The LPN removed an incontinent brief and wiped off old medication from a resident's sacral pressure ulcer using gloved hands, then applied new medication with the same gloves, without changing gloves or performing hand hygiene between the dirty and clean steps. The LPN later acknowledged not leaving the bedside to wash hands and change gloves as required. The resident involved was severely cognitively impaired, dependent on staff for transfers and toileting, and had multiple medical diagnoses including heart failure, renal insufficiency, and malnutrition. Additionally, the facility did not adhere to its Water Management Plan (WMP) as required. Maintenance staff confirmed that monthly monitoring of cold water temperatures and free chlorine levels, as outlined in the facility's policy for Legionnaires Disease prevention, had not been completed. This lapse had the potential to affect all residents in the facility.
Improper Food and Utensil Storage and Handling
Penalty
Summary
Staff failed to store food and utensils in a safe and sanitary manner, as observed during multiple kitchen inspections. Frozen bags of pot roast were found thawing in water in the preparation sink without running cold water, contrary to facility policy which requires food to be submerged under running cold water during thawing. Additionally, a stack of Styrofoam cups was stored on a cart in the dining room next to a bucket of sanitizer solution and a spray bottle of heavy-duty cleaner, instead of being stored separately as required by policy. The Dietary Manager confirmed these practices did not align with facility procedures. Further observations revealed a stack of wet cups stored on the tray line, rather than being air dried on a rack near the three-compartment sink as specified by facility policy. The Dietary Manager acknowledged that cups should be air dried before being stacked or used for service. These deficiencies had the potential to affect 61 out of 62 residents, as only one resident was identified as NPO and did not receive food from the kitchen.
Failure to Follow Physician Orders During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency was identified when staff failed to follow physician orders during a pressure ulcer dressing change for a resident with multiple medical conditions, including a left femur fracture, heart failure, hypertension, renal insufficiency, neurogenic bladder, malnutrition, and respiratory failure. The resident was severely cognitively impaired and dependent on staff for transfers and toileting. Physician orders specified that the sacral pressure ulcer should be cleansed with normal saline, Silvadene applied, followed by a barrier cream, and then covered with an ABD pad twice daily. During an observed dressing change, the LPN did not cleanse the wound with normal saline as ordered. Instead, the LPN wiped off the old medication with a washcloth, applied Silvadene with the same gloved hands, then washed hands, donned new gloves, applied barrier cream, and covered the wound with an ABD pad. The LPN confirmed during interview that the wound was not cleansed with normal saline per physician orders, verifying that the prescribed protocol was not followed.
Failure to Thoroughly Investigate Resident Fall with Major Injury
Penalty
Summary
The facility failed to thoroughly investigate a fall with major injury involving a resident who was at medium risk for falls and had significant medical conditions, including a prior femur fracture, heart failure, and severe cognitive impairment. The resident, who was dependent on staff for transfers and required a Hoyer lift, experienced an unwitnessed fall during the night and was found on the floor with abrasions. The resident reported confusion at the time of the fall and was subsequently diagnosed at the hospital with a closed fracture of the distal end of the left femur. The facility's investigation into the incident was incomplete, lacking written witness statements, documentation of interventions in place at the time of the fall, records of the last time the resident was seen or toileted, and other required details. The facility's fall management policy required a thorough post-fall assessment, documentation of all actions, and collection of witness statements in the case of injury, but these steps were not fully carried out in this case.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, dysphagia, diabetes mellitus, cellulitis, peripheral vascular disease, renal insufficiency, and benign prostatic hyperplasia, who was moderately cognitively impaired and dependent on a G-tube for nutrition, did not receive care in accordance with facility policy and physician orders. During a medication administration, an LPN failed to verify the placement of the G-tube before administering water, medication, and a bolus feeding. The resident was positioned at a 90-degree angle in a chair, rather than the required 30-45 degree angle. Additionally, the LPN used an undated syringe to administer medications and did not dilute the crushed aspirin with water prior to administration through the G-tube. The facility's policy required verification of G-tube placement, proper dilution of medications, use of dated syringes, and correct resident positioning during G-tube medication administration. The LPN involved was unaware of the facility's G-tube policy and confirmed the deviations from protocol, including not checking tube placement, not diluting the medication, using an undated syringe, and incorrect resident positioning. These actions were observed and confirmed through staff interview and policy review.
Incomplete Medical Record Documentation After Resident Fall with Major Injury
Penalty
Summary
The facility failed to ensure that a resident's medical records were complete and accurately documented following a significant incident. A resident with multiple medical diagnoses, including a history of femur fracture, heart failure, and severe cognitive impairment, experienced an unwitnessed fall resulting in a major injury. The fall was documented in an occurrence note, which described the resident being found on the floor with abrasions and subsequently being sent to the hospital. Hospital records confirmed the resident sustained a closed fracture of the left femur as a result of the fall. Despite the occurrence and the resulting injury, there were no documented notes in the electronic medical record (EMR) regarding the fall or the fracture for the period following the incident. This lack of documentation was confirmed by the Director of Nursing during an interview. The deficiency was identified during a review of records for residents at risk for accidents, affecting one of five residents reviewed in this area.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 526 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kettering
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Village | 1.9 mi | ★★★★★ | 0 | 0 |
| Bellbrook Health And Rehab | 2.2 mi | ★★★★★ | 21 | 0 |
| Kettering Heights Post Acute | 2.4 mi | ★★★★★ | 6 | 0 |
| Village At The Greene | 2.6 mi | ★★★★★ | 4 | 0 |
| St Leonard Hcc | 2.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oak Creek Terrace Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.