F0692

D

Failure to Maintain a Conducive Dining Environment Due to Unaddressed Resident Yelling

Kettering, Ohio Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The facility failed to ensure the common dining environment was conducive for residents eating in the main dining room. Resident #84, who had severe cognitive impairment, a history of behavioral symptoms directed toward others, type 2 diabetes with chronic kidney disease, major depressive disorder, anxiety, and early-onset Alzheimer's disease, was observed yelling out non-stop during lunch on two separate days while seated in the dining room. During both observations, Resident #84 did not appear to be in distress, yet continued to yell continuously throughout the meal period while other residents were dining nearby.

Residents #24 and #63, both on mechanically altered diets and requiring set-up assistance with meals, were seated near Resident #84 during these meals and reported ongoing disturbance from the yelling. Resident #63, who had moderate cognitive impairment and a history of traumatic brain injury and severe protein-calorie malnutrition, stated he was tired of coming to the dining room and having to listen to the yelling every day, and reported having voiced these concerns to staff and management multiple times. Resident #24 similarly reported that the yelling occurred at every meal and that her concerns to dining staff had not resulted in any change. A CNA and an LPN confirmed that Resident #84 yelled continuously at every meal and that multiple residents complained, but stated that management would not remove Resident #84 from the dining room because there were not enough staff to feed her in her room, with only one CNA available on the hall during meals. This situation affected two of six residents reviewed for dining and had the potential to affect all 16 residents who ate in the main dining room.