Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kettering Heights Post Acute during CMS and state inspections, most recent first.
Failure to Maintain Effective Pest Control Program: The facility did not maintain an effective pest control program after staff reported noises in the ceiling and attic, and records showed wildlife inspections identifying multiple entry points for squirrels, raccoons, and birds. Surveyors observed large holes and gnaw marks in the soffit/fascia area, along with additional openings large enough for squirrels to enter. Facility documentation and interviews confirmed trapped wildlife, including raccoons and a squirrel, while the facility policy stated it maintained an ongoing pest control program to keep the building free of insects and rodents.
Unlabeled food items were found in a resident nourishment refrigerator, including opened frozen foods, ice cream, popsicles, and leftover fast food, with no resident name or use-by date. The DM, MBUM, ADON, DON, and ADM all stated nursing staff were responsible for labeling and discarding family-provided foods, and the facility policy required perishable items to be labeled with the resident's name, item, and use-by date.
Staff failed to follow infection control practices for a resident on contact precautions, as a CNA entered the room without the required gown and gloves and handled the resident’s items. Staff also failed to perform hand hygiene during meal delivery on a resident hall, with a CNA moving between rooms and touching bed controls, linens, and overbed tables without sanitizing hands. In addition, a resident with an indwelling urinary catheter had the drainage bag repeatedly observed in direct contact with the floor, contrary to facility policy and CDC guidance.
Two residents with indwelling urinary catheters had drainage bags left uncovered and visible from hallways or room entrances, despite care plans and staff expectations that privacy covers be used to protect dignity. One resident had moderate cognitive impairment and a suprapubic catheter bag visible with urine exposed, while the other resident reported feeling self-conscious and ashamed when others could see the urine in the bag. Staff, including an LPN, CNA, ADON, DON, and MD, stated catheter bags should be covered and out of sight.
Failure to Assess and Order Self-Administered Inhaler: A resident with COPD and respiratory failure had an inhaler at the bedside and reported self-administering it three times daily after a family member brought it into the facility. The resident had intact cognition, but the IDT had not completed a self-administration assessment, the care plan had no self-administration documentation, and the inhaler was not on the order list when it was observed at the bedside.
Failure to Provide Nail Care: A resident who needed help with ADLs was observed with fingernails extending about one-half inch past the fingertips. The resident said staff had not trimmed or filed the nails and wanted them cut. Records showed shower documentation with inconsistent nail-care entries, while staff interviews and facility policy indicated nail care was expected during showers and included cleaning and regular trimming.
Unlabeled Tube Feeding Bag: A resident with a gastrostomy tube, moderate cognitive impairment, and multiple chronic conditions had an enteral feeding bag observed running through a pump without the resident’s name, room number, date and time hung, formula type, or nurse initials. The same issue was observed again the next day, and an LPN confirmed the bag was not labeled, dated, or initialed as required by facility policy.
A resident with CHF and orthostatic hypotension received midodrine outside the prescriber’s hold parameters on 17 occasions after staff documented administration even when SBP was above 120 mmHg. The pharmacist confirmed the error, and the DON, ARDCS, and MD all acknowledged the medication was given in error and should have been held per the order.
The facility failed to ensure daily staffing postings were accurate for staff directly responsible for resident care. Review showed the postings listed only scheduled nursing hours and did not reflect actual hours worked. An LPN stated the postings only showed scheduled hours, while the DON said she expected the census, nurse hours, and nursing assistant hours to be reflected and updated when staff called off. The Administrator stated he expected only the initial scheduled hours to be posted, despite the facility policy requiring actual time worked to be included.
A resident admitted with multiple medical conditions, including a documented stage II coccyx pressure ulcer present on admission, did not have this pressure ulcer reflected in the baseline care plan. Although a Comprehensive Skin Evaluation identified the ulcer and the resident was assessed as cognitively intact, the baseline care plan omitted the pressure ulcer and contained no related interventions. During interviews, the DON and an MDS coordinator confirmed that the care plan did not address the ulcer, despite facility policy requiring a baseline plan of care to meet immediate health and safety needs within 48 hours of admission.
Two cognitively intact residents with documented pressure ulcers on admission, including an unstageable ulcer that later progressed to stage II and a sacral pressure injury, did not have any corresponding pressure-ulcer care plans or interventions in their records. Review of progress notes and skin evaluations confirmed the presence of these wounds, while care plan review showed no entries addressing them. In an interview, the MDS coordinator and the DON acknowledged that the care plans did not include the residents’ pressure ulcers, despite facility policy requiring comprehensive care plans to be developed following resident assessments.
Two cognitively intact residents with multiple chronic conditions, including COPD, DM, depression, and GERD, reported that a CNA entered their shared room, appeared confused while attempting incontinence care, then opened their closet and urinated on a box inside with the door open, allowing at least one resident to see his side profile and urine on his pants. Both residents began screaming during the incident, and one reported feeling scared, unsafe, and shaken afterward. Facility staff and documentation confirmed that the CNA had urinated in the residents' closet, constituting a failure to treat the residents with dignity and respect.
A resident with multiple comorbidities developed dry gangrene in the left foot, but staff failed to notify the physician promptly, resulting in delayed treatment and an above-knee amputation. Additionally, two residents did not receive accurate or complete skin assessments, with omissions in documentation of wounds and surgical sites. Staff interviews confirmed that facility policies and nursing standards for skin assessment and documentation were not consistently followed.
A resident did not receive appropriate care for existing pressure ulcers, and necessary interventions to prevent new ulcers were not consistently implemented. Surveyors observed lapses in pressure ulcer management protocols, resulting in a deficiency related to pressure ulcer care.
Two residents and their representatives were not provided timely access to their medical records after making valid requests, including one case involving an attorney and another involving a subpoena. Facility staff were unclear about procedures following a change in ownership and did not follow policy requiring records to be provided within two business days, resulting in significant delays.
A facility failed to address a grievance from a resident's representative, leading to a deficiency. The resident, with multiple medical conditions and moderate cognitive impairment, had a daughter who expressed concerns about care and communication. The DON did not return a call from the daughter due to foul language and the resident's discharge, despite the facility's policy requiring responses to grievances.
The facility failed to conduct quarterly care conferences for two residents, despite their medical conditions requiring regular assessments. One resident, with conditions including dementia and CHF, had their last care conference documented months prior to the deficiency finding. Another resident, with COPD and CHF, also lacked recent care conference documentation. The Regional Nurse confirmed the absence of required documentation, indicating non-compliance with facility policy.
A facility failed to implement a speech therapy recommendation to upgrade a resident's diet from dysphagia pureed to advanced dysphagia. Despite the resident tolerating a trial tray well, the diet change was not communicated to the physician, as confirmed by staff interviews. The facility's policy requires therapeutic diets to be prescribed by the attending physician.
A LTC facility failed to administer medications as ordered, resulting in significant errors for three residents. One resident received an extra dose of oxycodone instead of Lyrica due to an LPN's mistake. Another resident missed six days of doxycycline due to a pharmacy issue. A third resident did not receive multiple medications as ordered, and received lisinopril despite low blood pressure. These errors were confirmed through medical record reviews and staff interviews.
The facility failed to perform surgical wound care and PICC line dressing changes as ordered for a resident with chronic conditions, lacking documentation to support care was provided. Another resident with diabetes and osteomyelitis also did not have documented PICC line dressing changes. Staff confirmed the absence of required documentation, despite facility policies emphasizing infection prevention and proper care.
A resident with multiple medical conditions developed an unstageable pressure ulcer that was not timely assessed or reported to a physician. Despite protective skin measures, the ulcer was not documented by an STNA, although the nurse was informed. The wound nurse was notified later and assessed the ulcer, but the resident was hospitalized before new treatment orders were entered.
Two residents experienced medication administration errors. One resident received metoprolol without required blood pressure checks, and another had a lidocaine patch left on beyond the prescribed time. Staff interviews confirmed these discrepancies against physician orders.
The facility failed to follow infection control procedures during wound care and medication administration. An LPN did not wear a gown or change gloves during wound care for a resident under Enhanced Barrier Precautions. In another case, an LPN picked up a dropped medication tablet with bare hands before administering it to a resident, violating the facility's medication administration policy.
A resident with multiple health conditions did not receive prescribed eye medications due to unavailability from the pharmacy. The MAR indicated missed doses, and progress notes confirmed the medications were not available. The DON acknowledged ongoing issues with pharmacy communication to rectify the situation.
A resident did not receive their prescribed eye drops due to the facility's failure to reorder the medication on time. Despite the pharmacy's records showing the medication was ordered and dispensed, it was not available for administration on multiple occasions. Interviews with staff and family confirmed the issue, and the DON acknowledged the need for timely reordering.
The facility failed to accurately post staffing information, omitting actual hours worked and not updating for staff absences. Interviews revealed staff were unaware of the requirement to include total hours and update per shift. Discrepancies were found between posted documents and actual coverage.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. Review of the facility’s environmental safety and maintenance documentation noted a concern about possible pests in the attic. During interviews, the Central Supply Clerk/Housekeeper reported that raccoons had been trapped at the facility, squirrels had been heard in the ceiling of the MedBridge B Unit, and droppings had been found in the attic. The same staff member also reported finding a hole in the courtyard area in February 2026 and stated it was not repaired by the Maintenance Director. During observation, surveyors saw a large gaping hole where the soffit and fascia connected above the gutter, with gnaw marks on the fascia. The hole was estimated to be about the size of a basketball. A 2-foot-long piece of vent from the soffit was observed on the ground, and another hole was seen in the opposite corner behind a bush, extending from the ground to the roof and large enough for a squirrel to enter. Another small hole was also observed in the back of the building near room [ROOM NUMBER], which the staff member stated was large enough for a squirrel to get into and could allow animals to travel down the 300 Hall. Facility records showed a wildlife inspection and estimate from one pest control vendor identifying entry points for squirrels, raccoons, and birds, and a later service agreement with another vendor for wildlife trapping in the attic. Service reports documented multiple trapped animals, including raccoons, a gray squirrel, and a cat. The Administrator stated staff had reported noises in the ceiling and that a pest control company was contacted, and he acknowledged a roof hole where squirrels entered. The facility policy stated it maintained an ongoing pest control program to keep the building free of insects and rodents.
Unlabeled Food Stored in Resident Nourishment Refrigerator
Penalty
Summary
The facility failed to ensure food items were stored in a sanitary manner when items in a resident nourishment refrigerator were found without a date or resident name. During an observation with the Dietary Manager, the refrigerator contained an opened package of frozen hot dogs, an opened box of popsicles, two pints of ice cream, a frozen breakfast bowl meal, two opened half-gallons of ice cream, an opened package of ice cream sandwiches, an opened package of ice cream bites, and a bag of leftover fast-food meal, all without a use-by date or resident name. The observation was repeated the next day and the same issue remained with an opened frozen breakfast bowl meal and an opened pint of ice cream still lacking a use-by date or resident name. During interviews, the Dietary Manager stated nursing or housekeeping staff were responsible for maintaining the resident nourishment refrigerator, while the MedBridge Unit Manager, Assistant Director of Nursing, Director of Nursing, and Administrator each stated nursing staff were responsible for ensuring foods brought in from families were labeled with the resident's name and date and were discarded after the appropriate time. The facility policy titled Foods Brought by Family/Visitors required perishable foods stored in the refrigerator to be labeled with the resident's name, the item, and the use-by date, and stated nursing staff would discard perishable foods on or before the use-by date.
Infection Control Failures With PPE, Hand Hygiene, and Catheter Bag Placement
Penalty
Summary
Staff failed to follow contact precautions for a resident with MRSA in a wound. The resident had diagnoses including cognitive communication deficit, an open wound of the right lower leg, a local skin and subcutaneous tissue infection, and sepsis organism. The resident’s orders and care plan indicated contact isolation for MRSA in a wound and directed staff to use PPE as recommended for the type of infection. A CDC contact precautions sign was posted outside the room stating that staff must clean their hands and put on gloves and a gown before room entry. During an observation, a CNA delivered a lunch tray to the resident’s room without putting on PPE before entering. The CNA touched the resident’s beverage cup on the bedside table and adjusted the bedside table after placing the meal tray. During interview, the CNA stated she thought gloves were needed if she was going to have contact with the resident and did not think any other PPE was needed for delivering a meal tray and touching the resident’s items. The ADON, who was also the Infection Preventionist, stated staff needed to have the required PPE on before entering a contact precaution room and that the required PPE was a gown and gloves. The DON and Administrator stated staff were expected to follow the signage for PPE. Staff also failed to perform hand hygiene during meal delivery on one resident hall. During observation of meal service on the 100 Hall, a CNA delivered multiple meal trays to residents in several rooms and repeatedly exited rooms without performing hand hygiene between room entries. The CNA touched overbed tables, bed controls, bed linens, and a door frame while delivering trays, and at one point spilled liquids onto bed linens and handled the linens before leaving the room without hand hygiene. When asked, the CNA stated she had not sanitized her hands and apologized. An LPN stated CNAs should sanitize their hands during meal delivery to decrease the risk of infections. The facility’s hand hygiene policy stated hand hygiene is the primary means to prevent the spread of infections and included hand hygiene after contact with objects in the resident’s immediate vicinity and before and after assisting a resident with meals. The facility also failed to keep a urinary catheter drainage bag under clean and sanitary conditions for a resident with neurogenic bladder and an indwelling urinary catheter. The resident’s catheter drainage bag was observed attached to the bed rail with approximately 1700 mL of fluid and in direct contact with the floor. On later observations, the drainage bag remained in direct contact with the floor, including when contained within a privacy bag hanging from the bed rail. Staff interviews stated the bag should remain below bladder level, be secured appropriately, and stay off the floor. The ADON, PA, Medical Director, and DON all stated the drainage bag should be secured off the floor. The facility’s catheter care policy stated the catheter tubing and drainage bag should be kept off the floor, and the CDC guideline stated the collecting bag should be kept below the level of the bladder and not rest on the floor.
Uncovered catheter bags visible to others
Penalty
Summary
The facility failed to ensure residents’ right to a dignified existence when staff did not keep urinary catheter drainage bags covered for two residents with indwelling catheters. Resident #28 was admitted with diagnoses including obstructive and reflux uropathy, hydronephrosis, neuromuscular dysfunction of the bladder, and urinary retention. The resident’s MDS showed moderate cognitive impairment and an indwelling catheter, and the care plan identified risk related to the suprapubic catheter with interventions for catheter care every shift. During multiple observations, the resident’s catheter bag was visible from the hallway and had no privacy cover, with approximately 200 mL of pale-yellow urine visible. Resident #34 was admitted with neuromuscular dysfunction of the bladder and had an indwelling urinary catheter for neurogenic bladder. The resident’s care plan included use of a privacy cover for the catheter bag to promote dignity. During observation, the catheter drainage bag was visible from the room entrance and hallway, and at one point was in contact with the floor. The resident stated feeling self-conscious when others entered the room and observed the urine, and later stated feeling ashamed and unaware that a privacy cover existed. When the bag was later observed with a protective cover, the resident stated the cover reduced those concerns. Staff interviews confirmed that catheter bags should be covered and out of sight for dignity. An LPN stated there should have been a cover on Resident #28’s bag for dignity. CNA and nursing leadership staff stated catheter drainage bags should be positioned appropriately, covered, and not visible from the hallway. The facility’s Resident Rights policy stated employees shall treat residents with kindness, respect, and dignity and that residents have the right to privacy and confidentiality.
Failure to Assess and Order Self-Administered Inhaler
Penalty
Summary
The facility failed to ensure that a resident who had an inhaler at the bedside and was self-administering it was assessed by the interdisciplinary team for safe self-administration and had an order for the medication. Resident #12 was admitted with COPD and respiratory failure and had a BIMS score of 14, indicating intact cognition. During observation, a budesonide-glycopyrrolate-formoterol fumarate inhaler was seen on the resident’s bedside table, and the resident stated that a family member brought it into the facility and that the inhaler was self-administered three times daily for personal use. The resident later stated they did not recall being asked if they wanted to self-administer. The resident’s care plan addressed respiratory risk and directed staff to administer medications as ordered, but it contained no documentation regarding self-administration of medications. The order summary did not include an order for the inhaler at the time it was observed at the bedside; the medication order was dated after the observation. Staff interviews confirmed the resident had not been assessed for self-administration, and the ADON stated that medications eligible for self-administration required a physician’s order and completion of a self-administration assessment. The DON and ARDCS stated medications should not be kept at the bedside, and the ARDCS stated the facility was not aware the resident intended to self-administer.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to ensure staff provided nail care for one resident who required assistance with ADLs. Resident #37 was admitted with diagnoses including cognitive communication deficit and a need for assistance with personal care. The resident’s MDS indicated substantial to maximum assistance was needed for showering and bathing and supervision or touching assistance was needed for personal hygiene. The care plan identified that the resident required assistance with ADLs and was dependent on staff for hygiene. During an observation and interview, Resident #37 was found lying in bed with fingernails on both hands extending approximately one-half inch past the fingertips. The resident stated staff did not file or trim the nails, that the nails needed to be trimmed, and that the resident did not know who to ask. The resident also stated not liking the nails being long. RN #13 later observed the nails and stated they were clean, long, and needed to be cut, and the resident again stated the nails were too long and wanted them cut. The record showed showers were documented during the look-back period, but nail care was inconsistently documented as provided, not applicable, or refused. The resident’s skin assessments did not document long nails, and progress notes did not show evidence that the resident refused nail care. Staff interviews indicated nail care was expected during showers, that CNAs should offer and provide nail care, and that refusals should be reported and documented. The DON stated staff were expected to ensure residents’ nails were cleaned, filed, and cut, and the facility policy stated nail care includes daily cleaning and regular trimming.
Unlabeled Tube Feeding Bag
Penalty
Summary
The facility failed to ensure an enteral nutrition tube feeding bag was labeled and dated for one resident with a feeding tube. Resident #6 was admitted with diagnoses including COPD, type 2 diabetes mellitus, heart failure, and chronic kidney disease. The quarterly MDS showed the resident had a BIMS score of 9, indicating moderate cognitive impairment, and that the resident had a feeding tube and received 26 to 50 percent of total calories via the tube. The care plan identified the resident as having a gastrostomy tube and being at risk for enteral nutrition complications, with interventions to monitor intake and output and provide enteral tube care as needed. An observation showed the resident in bed with tubing attached to an unlabeled bag of brown-colored substance running via a pump at 35 ml per hour. The bag was not labeled with the resident's name, room number, date and time hung, type or brand of formula, or nurse initials. A second observation the next day showed the same condition. An LPN confirmed the tube feeding was not labeled, dated, or initialed and should have been. The DON stated nursing staff should verify the order and label the tube feeding with the resident's name, date, nurse initials, and time started, and the Administrator stated staff were expected to follow facility policy. The facility policy required initials, date, time the formula was hung, and verification against the order.
Significant Medication Error With Midodrine Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when midodrine hydrochloride was administered outside of the physician-ordered parameters. Resident #5 was admitted with diagnoses including coronary artery bypass graft, chronic systolic congestive heart failure, and orthostatic hypotension, and had intact cognition with a BIMS score of 15. The resident’s order for midodrine 2.5 mg before meals directed staff to hold the medication if systolic blood pressure was greater than 120 mmHg. Review of the March 2026 and April 2026 MARs showed the medication was given 17 times when the resident’s systolic blood pressure was above 120 mmHg. The administrations occurred on multiple dates and times across both months, including several repeated doses on the same day. The pharmacist reviewed the MARs and acknowledged the medication had been given outside the physician parameters for 17 administrations. During interviews, nurses verified some of the administrations and stated the medication should have been held. The DON and ARDCS stated that giving midodrine outside the physician’s parameters for 17 administrations was a significant medication error. The Medical Director reviewed the MARs and stated he would expect staff to follow the orders and that the medication was given in error multiple times.
Daily Staffing Posting Was Not Accurate
Penalty
Summary
The facility failed to ensure that the daily staff posting information was accurate for staff directly responsible for resident care for 24 of 24 days reviewed, from 05/01/26 through 05/24/26. Review of the daily staffing posting documents showed they contained only scheduled nursing hours and did not reflect actual hours worked. The deficiency had the potential to affect all 99 residents who resided in the facility. During interviews, an LPN stated that the daily staff posting information only contained scheduled hours and not actual hours worked. The DON stated she expected the daily staff posting information to reflect the census, nurse hours, and nursing assistant hours, and said that if someone called off work she expected the scheduler to update the posting with actual hours worked. The Administrator stated he did not expect the daily staff posting information to include actual hours worked, only the initial scheduled hours worked. Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2006, indicated that within two hours of the beginning of each day, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care would be posted, and that the shift staffing information should include the actual time worked during that shift for each category and type of nursing staff.
Failure to Include Existing Pressure Ulcer in Baseline Care Plan
Penalty
Summary
The facility failed to ensure the baseline care plan reflected a resident’s current status of having a pressure ulcer and to create and implement a plan to meet the resident’s immediate needs within 48 hours of admission. The resident was admitted with diagnoses including gastrostomy, gastrojejunal ulcer, cognitive communication deficit, unspecified atrial flutter, and malignant neoplasm of the prostate, and was documented as cognitively intact on the most recent MDS 3.0 assessment. A Comprehensive Skin Evaluation completed shortly after admission identified a stage II pressure ulcer to the coccyx that was present on admission. However, the baseline care plan developed for the resident did not list the stage II pressure ulcer and contained no interventions related to the pressure ulcer, despite facility policy requiring a baseline plan of care to meet immediate health and safety needs within 48 hours of admission. During interview, the DON and MDS Coordinator confirmed that the care plan did not address the resident’s pressure ulcer and that no interventions were in place for this condition. This deficiency was cited as non-compliance under the referenced complaint number.
Failure to Care Plan for Residents’ Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans addressing pressure ulcers for two cognitively intact residents. Resident #106 was admitted with multiple medical diagnoses, including essential hypertension, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. The most recent MDS 3.0 assessment showed the resident had an unstageable pressure ulcer upon admission. A progress note dated 02/18/26 documented that this resident had a stage II pressure ulcer, yet review of the resident’s care plan revealed no care plan or interventions addressing the stage II pressure ulcer. Resident #107 was admitted with diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, and a cognitive communication deficit, and was also assessed as cognitively intact on the most recent MDS 3.0. A skin evaluation dated 02/05/26 documented a pressure injury to the sacrum that was present upon admission. However, review of this resident’s care plan showed no plan or interventions for a pressure ulcer. During an interview on 03/20/26, the MDS coordinator and the DON confirmed that the care plans did not address the residents’ pressure ulcers or contain related interventions. Facility policy titled “Care Planning,” dated 09/2013, requires that a comprehensive care plan for each resident be developed within seven days of completion of the resident assessment, but this was not done for these residents’ pressure ulcers.
Failure to Treat Residents With Dignity When CNA Urinated in Shared Closet
Penalty
Summary
The deficiency involves a failure to honor residents' rights to dignity and respect when a CNA urinated in the shared closet of two cognitively intact residents. One resident, admitted with diagnoses including COPD, major depressive disorder, hypertension, hyperlipidemia, anorexia, and GERD, reported that the CNA attempted to change her incontinence brief while appearing very confused and using an ill-fitting glove that did not cover his pinky finger and thumb. She stated that she then observed the CNA open the closet door and heard him urinating, recognizing the sound of the urine stream hitting a box in the closet, which led her and her roommate to begin screaming. The second resident, admitted with COPD, chronic respiratory failure with hypoxia, DM, major depressive disorder, adult failure to thrive, tachycardia, GERD, and essential hypertension, also cognitively intact, reported that she observed the CNA enter the room, open the closet door, and proceed to urinate on a box in the closet with the door left open so she could see his side profile. She stated that she began screaming loudly, saw urine on his pants, and felt very upset, scared, unsafe, and confused about why he would do this. Facility staff, including the HR manager, confirmed that the CNA urinated in the residents' closet, and documentation in the employee record identified the conduct as a violation of the facility’s code of conduct and dignity policies.
Delayed Physician Notification and Incomplete Skin Assessments Result in Harm
Penalty
Summary
The facility failed to provide timely physician notification and accurate skin assessments for residents with significant skin and wound care needs. In one case, a resident with a history of myocardial infarction, sepsis, and diabetes developed signs of dry gangrene in the left foot and ankle. Despite documentation of black and painful areas on the left foot and ankle, the physician was not notified promptly. The nurse placed a note in the doctor’s book and deferred notification to the morning shift, resulting in a delay. The physician was not made aware of the resident’s condition until two days later, at which point the resident was sent to the hospital and required an above-knee amputation due to dry gangrene and acute limb ischemia. Additionally, the facility failed to ensure the accuracy and completeness of skin assessments for two residents. For one resident, skin assessments were not performed weekly as indicated by the care plan, and documentation was inconsistent, with gaps in assessment records and failure to note significant changes. For another resident, the admission assessment and subsequent skin evaluations were incomplete and inconsistent, omitting documentation of surgical wounds, soft heels, and elbow wounds, despite these being present and referenced in hospital discharge paperwork. The DON confirmed that not all skin impairments were documented, and there was no evidence of monitoring or documentation for surgical incision sites. Interviews with staff, including the DON, LPN, and wound nurse, revealed a lack of adherence to facility policy and nursing standards regarding comprehensive skin assessments and documentation. Staff acknowledged that all skin impairments, regardless of size or type, should be documented and monitored, but this was not consistently done. The facility’s own policies required comprehensive skin assessments upon admission and as indicated, but these were not followed, leading to missed or delayed identification and treatment of significant skin and wound issues.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and review of care practices, which revealed that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report notes that residents with pressure ulcers did not receive the required care to promote healing and prevent further skin breakdown, indicating lapses in the facility's pressure ulcer management protocols.
Failure to Provide Timely Access to Resident Records
Penalty
Summary
The facility failed to provide timely access to resident records upon request, affecting two residents who had requested their medical records or had requests made on their behalf. In the first case, a resident with intact cognition had an attorney request the entire electronic nursing home chart for estate purposes. Despite multiple written requests and follow-up communications, the records were not provided for over a month. Facility staff, including the medical records staff and the administrator, were uncertain about procedures for records from before a recent change in facility ownership. Staff communications with the regional legal department revealed confusion and delays, with instructions to wait for a subpoena before releasing records, and no clear direction on handling records from the previous ownership. The attorney eventually threatened to subpoena the records due to the lack of response. In the second case, a resident with impaired cognition requested all records, and a subpoena was later issued for the documents. The medical records staff confirmed that no records had been provided since the change in ownership and was unaware of the request or the requirement to provide records in a timely manner, even for residents admitted under previous ownership. Facility policy required that records be provided within two business days of a written or oral request, but this policy was not followed. The deficiency was identified through record review, staff interviews, and policy review, confirming that the facility did not comply with its own procedures or regulatory requirements for timely access to resident records.
Failure to Address Resident Representative's Grievance
Penalty
Summary
The facility failed to address the concerns of a resident's representative, which led to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal. The medical record for a resident, who had been admitted with multiple medical diagnoses including diabetes mellitus and congestive heart failure, indicated moderate cognitive impairment and required assistance with daily activities. The resident's daughter expressed concerns about the care provided and felt her concerns were being dismissed. Despite the facility's policy stating that residents have the right to voice grievances and receive responses, the Director of Nursing (DON) did not return the daughter's call after she left a voicemail expressing her concerns. The DON acknowledged speaking with the resident's daughter about care concerns and issues with staff communication but did not follow up on a subsequent voicemail due to the use of foul language and the resident's discharge to the hospital. The facility's failure to respond to the grievance was documented in a nurse's note and confirmed during an interview with the DON. This deficiency was investigated under two complaint numbers, indicating non-compliance with the facility's grievance policy.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for two residents, as required by their policy and regulatory standards. Resident #08, who has medical diagnoses including dementia, COPD, hypertensive heart and chronic kidney disease, anxiety, CHF, and atrial fibrillation, was admitted on an unspecified date. The resident's quarterly MDS assessment dated 11/07/24 indicated cognitive intactness and varying levels of dependency on staff for daily activities. However, the last documented care conference for this resident was on 09/11/24, with no subsequent conferences conducted or offered. Similarly, Resident #38, with medical conditions such as COPD, CHF, chronic respiratory failure, morbid obesity, and hypertensive heart disease, was admitted on an unspecified date. The resident's quarterly MDS assessment dated 11/14/24 showed cognitive intactness and independence in daily living activities. The last care conference for this resident was documented on 05/14/24, with no further conferences conducted or offered. The Regional Nurse confirmed the absence of documentation for the required care conferences, indicating non-compliance with the facility's policy and regulatory requirements.
Failure to Implement Speech Therapy Diet Recommendations
Penalty
Summary
The facility failed to timely provide a therapeutic diet as per speech therapy recommendations for a resident with multiple medical diagnoses, including diabetes mellitus, metabolic encephalopathy, hypertensive heart disease, congestive heart failure, and dysphagia oropharyngeal. The resident was admitted with moderate cognitive impairment and required assistance with daily activities. Initially, the resident was on a mechanically altered diet with no swallowing or chewing problems and no weight loss. A speech therapy note dated 12/06/24 indicated that the resident tolerated a trial tray of a dysphagia advanced diet well, and a diet order was given to upgrade the resident's diet. However, the diet was not updated, and the nursing staff and director of rehabilitation were notified on 12/11/24. Interviews with the speech therapist and regional nurse confirmed that the resident's physician was not notified of the speech therapy recommendation to upgrade the diet. The facility's policy on therapeutic diets, revised in October 2017, states that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care. The deficiency was identified during a complaint investigation, indicating non-compliance with the facility's policy and procedures for managing therapeutic diets.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in significant medication errors affecting three residents. Resident #08, who was cognitively intact and had multiple medical diagnoses including dementia and COPD, received an extra dose of oxycodone instead of Lyrica due to a mistake by LPN #240. The error was documented in the nurse's notes, and the facility's investigation revealed that the LPN had not followed the physician's orders or the Five Rights of Medication Pass. Resident #95, who was also cognitively intact and had a history of chronic osteomyelitis and diabetes, did not receive doxycycline as ordered for six days due to an issue with the pharmacy discontinuing the previous order. The medication error was identified when the Nurse Practitioner noted the discrepancy, and the facility's investigation confirmed the lack of documentation for the administration of doxycycline during the specified period. Resident #100, with diagnoses including COPD and myasthenia gravis, did not receive multiple medications as ordered on a specific date, and there was no documentation to support the administration of gabapentin over several days. Additionally, the resident received lisinopril despite having a systolic blood pressure below the ordered parameter. Interviews with the Regional Nurse confirmed these discrepancies, highlighting failures in medication administration and documentation.
Deficiency in Wound and PICC Line Care
Penalty
Summary
The facility failed to ensure that surgical wound care and PICC line dressing changes were completed as ordered for residents. Specifically, Resident #95, who was admitted with chronic multifocal osteomyelitis and other conditions, did not receive surgical wound care or PICC line dressing changes as per hospital discharge orders. The medical record lacked documentation to support that these care procedures were performed according to the orders. The Treatment Administration Record (TAR) for September 2024 did not show evidence of the required care, and although wound care was documented on October 11, 2024, there was no documentation for the PICC line dressing change. Additionally, Resident #97, who had medical diagnoses including diabetes mellitus and osteomyelitis, also did not have PICC line dressing changes documented as ordered. The August and September 2024 TARs lacked evidence of the dressing changes on specified dates. Interviews with facility staff confirmed the absence of documentation for these required care procedures. The facility's policies on dressing changes and catheter care were reviewed, highlighting the importance of preventing infection and ensuring proper care, but these were not adhered to in practice.
Failure to Timely Assess and Notify Physician of Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment, measurement, and physician notification of a new pressure ulcer for Resident #51, who was admitted with multiple medical conditions including hypertensive heart disease, chronic kidney disease, diabetes mellitus with neuropathy, bipolar disorder, and chronic obstructive pulmonary disease. Upon admission, Resident #51 was at risk for skin breakdown but had no pressure ulcers. Despite having orders for protective skin measures, a weekly wound assessment on 10/14/24 indicated no skin breakdown. However, a subsequent assessment revealed an unstageable pressure ulcer on the left buttock, measuring 3 cm by 2.5 cm with 95% slough present, and new treatment was ordered. Interviews revealed that a State tested Nursing Assistant (STNA) observed a small open area on Resident #51's buttock on 10/22/24 but did not document it on the shower sheet, although she informed the nurse. The wound nurse was notified on 10/24/24 and conducted an assessment, notifying the physician and obtaining new treatment orders. However, Resident #51 was sent to the hospital for altered mental status before the new treatment orders were entered into the system. The facility's policy required timely assessment and physician notification for skin changes, which was not adhered to in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as ordered, affecting two residents. Resident #04, who was admitted with medical diagnoses including atherosclerosis and left hemiplegia, had a physician order for metoprolol with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 110 or heart rate was less than 60. However, the facility's Medication Administration Record (MAR) for October 2024 showed that Resident #04 received metoprolol on several occasions without documentation of blood pressure checks prior to administration. Additionally, on one occasion, the medication was administered despite the resident's SBP being 104/42, which was below the threshold set by the physician's order. Resident #14, who had diagnoses including Alzheimer's disease and hypertensive chronic kidney disease, had a physician order for a lidocaine patch to be applied to the left shoulder in the morning and removed in the evening. An observation revealed that a lidocaine patch from the previous day was still on Resident #14's shoulder when a new patch was being applied, indicating a failure to remove the patch as ordered. Interviews with staff confirmed these findings, and the facility's policy on medication administration emphasized adherence to prescriber's written orders, which was not followed in these instances.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to adhere to infection control procedures during wound care for a resident with a Stage III pressure ulcer. The resident was under Enhanced Barrier Precautions (EBP) due to the risk of multidrug-resistant organisms. During an observation, an LPN was seen performing wound care without wearing a gown, as required by EBP. Additionally, the LPN did not change gloves or perform hand hygiene after removing soiled dressings and before applying new ones, which is a violation of the facility's policy on dressing changes. In another incident, the facility did not follow proper infection control procedures during medication administration for a resident. An LPN was observed dropping a gabapentin tablet onto the medication cart, picking it up with bare hands, and placing it into the resident's medication cup. This action was contrary to the facility's medication administration policy, which requires good hand hygiene and the use of gloves if direct contact with medications occurs. These deficiencies were identified during a complaint investigation.
Medication Administration Deficiency Due to Pharmacy Availability Issues
Penalty
Summary
The facility failed to ensure medications were administered as per physician orders for a resident with multiple diagnoses, including type two diabetes mellitus, diabetic retinopathy, bipolar disease, and peripheral vascular disease. The resident, who had intact cognition and required assistance for various activities, had active physician orders for Combigan Ophthalmic and Rocklatan Ophthalmic solutions to manage eye conditions. However, the September 2024 Medication Administration Record (MAR) indicated that the resident did not receive the prescribed doses of these medications on specific dates. The MAR noted 'OT' for these missed doses, which was identified as 'other' in the MAR key. Progress notes revealed that the Combigan Ophthalmic solution was unavailable from the pharmacy on two occasions, and the Rocklatan Ophthalmic solution was also not available and had to be reordered. Interviews with the resident and the Director of Nursing confirmed concerns about the availability of medications from the pharmacy. The Director of Nursing acknowledged ongoing communication efforts to address these medication issues, which were described as a work in progress. This deficiency was investigated under a specific complaint number.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that routine medication was available for administration, affecting one resident. The resident, who was admitted with diagnoses including legal blindness and bipolar disorder, had an order for Rocklatan Ophthalmic Solution to be administered at bedtime. However, the medication administration record indicated that the eye drops were not available on multiple occasions in May. Interviews with the resident, their family member, and nursing staff confirmed that the medication was not reordered on time, leading to missed doses. The Director of Nursing stated that most medications were on automatic refill, but there were instances when they had to repeatedly contact the pharmacy due to delays. The pharmacy representative confirmed that the medication was ordered and dispensed on specific dates, but the facility staff did not have it available for administration. The Nurse Practitioner emphasized the importance of the medication for the resident's eye pressure, and the Administrator expected timely reordering of medications. The deficiency was investigated under a specific complaint number.
Inaccurate Staffing Documentation
Penalty
Summary
The facility failed to ensure that the posted staffing document accurately reflected the total number and actual hours worked for each discipline, as well as any staff absences due to call-offs or illness. This deficiency was identified during a review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, covering the period from May 13, 2024, to June 13, 2024. The report did not include RN hours for specific dates, and discrepancies were found between the posted staffing document and the Daily Coverage Report, which indicated RN coverage that was not reflected in the posted forms. Interviews with facility staff revealed a lack of understanding regarding the requirements for posting staffing information. The Scheduler and the Director of Nursing (DON) both indicated they were unaware that the total number of actual hours worked needed to be included on the form and that updates were required per shift to reflect any call-ins. The Administrator also confirmed that the forms should include the census and staffing numbers but was unaware of the need to include actual hours worked per shift. The facility's policy on Staffing & Scheduling, last reviewed in June 2022, mandates compliance with CMS staffing requirements and the posting of staffing information at the beginning of each shift, but it appears this was not adequately followed.
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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.
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Nursing homes near Kettering
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Kettering | 0.9 mi | ★★★★★ | 9 | 0 |
| Village At The Greene | 2.2 mi | ★★★★★ | 4 | 0 |
| Oak Creek Terrace Inc | 2.4 mi | ★★★★★ | 2 | 0 |
| Sanctuary At Wilmington Place | 2.8 mi | ★★★★★ | 4 | 0 |
| Oaks Of West Kettering The | 2.9 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.