Kettering Heights Post Acute

Inspectors wroteBased on observation, interview, review of facility environmental and pest control documents and policy review, the facility failed to ensure an effective pest control program. This had the potential to affect all residents residing in the facility. The facility census was 99. Findings Included:Review of a facility document titled Environmental Safety/Maintenance, dated 03/16/2026 revealed a concern related to pests possible back in attic. During an interview on 05/26/26 at 11:10 AM, the Central Supply Clerk/Housekeeper (CSC) stated they had a racoon issue and had a company come out to trap them. The CSC stated two raccoons were caught about a week and a half prior. The CSC stated in January 2026, he noticed squirrels and had someone come out and trap them. He stated they heard them in the ceiling of the MedBridge B Unit. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items were stored in a sanitary manner when items in a nourishment refrigerator were not labeled with a date or a resident name. This had the potential to affect 14 (Residents #117, #37, #41, #45, #48, #52, #55, #71, #125, #84, #123, #97, #120, and #8) out of 15 residents who resided on the hall. The facility census was 99. Findings Included:An observation of the facility's resident nourishment refrigerator was conducted with the Dietary Manager (DM) on 05/25/26 at 10:19 AM. The observation of the resident nourishment refrigerator revealed: (1) opened package of frozen hot dogs - no use-by date or resident name. (1) opened box of popsicles - no use-by date or resident name. (2) pints of ice cream - no use-by date or resident name. [...]

Inspectors wroteBased on observation, interview, record review, facility document review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines review, and CDC isolation precautions signage review, the facility failed to ensure staff implemented appropriate infection control practices when staff failed to put on required personal protection equipment (PPE) when entering a room of a resident on contact precautions. This affected one (Resident #37) out of one resident reviewed for transmission based precautions. In addition, the facility failed to ensure staff performed proper hand hygiene while delivering meal trays on one (100 Hall) out of four resident halls observed. The 100 hall had 20 residents who resided on the hall. Additionally, the facility failed to ensure a catheter collection bag was kept under clean and sanitary conditions. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents' right of a dignified existence, specifically, staff failed to ensure urinary catheter bags were covered. This affected two (Resident #28 and Resident #34) out of two residents reviewed for dignity. The facility census was 99. Findings Included: 1. Review of the admission record revealed the facility admitted Resident #28 on 09/30/25. [...]

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure a resident who had a medication at their bedside and self-administered the medication was assessed by the interdisciplinary team (IDT) for safe self-administration and had an order for the medication. This affected one (Resident #12) out of one resident reviewed for self-administration of medications. The facility census was 99. Findings Include:Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/26 revealed the facility admitted Resident #12 on 03/13/26. The MDS indicated the resident had active diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure. The MDS revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff provided nail care. This affected one (Resident #37) out of two residents reviewed for activities of daily living (ADL). The facility census was 99. Findings Include:Review of an admission Record revealed the facility admitted Resident #37 on 04/08/26. According to the admission Record, the resident had a medical history that included diagnoses of cognitive communication deficit and a need for assistance with personal care. Review of a modification to an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/26 revealed Resident #37 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a enteral nutrition tube feeding bag was labeled and dated. This affected one (Resident #6) out of two residents reviewed for tube feedings. The facility census was 99. Findings Include:Review of an admission Record revealed the facility admitted Resident #6 on 01/09/26. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, heart failure, and chronic kidney disease. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/26 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were free of significant medication errors, when midodrine (a miscellaneous cardiovascular agent, used to treat a sudden drop in blood pressure) was administered 17 times between 03/01/26 and 04/30/26 when it should have been held per the physician-ordered parameters. This affected one (Resident #5) out of five residents reviewed for unnecessary medications. The facility census was 99. Findings Included:Review of an admission Record revealed the facility admitted Resident #5 on 05/19/22. According to the admission Record the resident had a medical history that included diagnoses of coronary artery bypass graft, chronic systolic (congestive) heart failure (CHF), and orthostatic hypotension (low blood pressure). [...]

Inspectors wroteBased on review of the facility staffing documents, interview and policy review, the facility failed to ensure the daily staff posting information was accurate for staff directly responsible for resident care for 24 (05/01/26 through 05/24/26) of 24 days reviewed. This had the potential to affect all 99 residents who resided in the facility. Findings Included:Review of the facility's daily staffing posting documents for the timeframe from 05/01/26 through 05/24/26 revealed the documents only contained scheduled nursing hours and not actual hours worked. During an interview on 05/25/26 at 4:02 PM, Licensed Practical Nurse (LPN) #7 stated that the daily staff posting information only contained scheduled hours and not actual hours worked. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the care plan represented the resident's current status of having a pressure ulcer. This affected one (Resident #49) of three residents reviewed for care planning. The census was 99.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to develop a comprehensive person-centered care plan for pressure ulcers for two residents (#106 and #107). This affected two residents (#106 and #107) of three residents reviewed for care planning. The facility census was 99.

Inspectors wroteBased on record review, staff interview, resident interview, and policy review the facility failed to treat residents with dignity and respect when Certified Nurse Aide (CNA) #268 was observed urinating in Resident #50 and #68's closet. This affected two Residents (#50 and #68) out of three residents reviewed for dignity and respect. The facility census was 97.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to timely notify the physician of signs and symptoms of dry gangrene toes and ankle which in turn resulted in delayed treatment. This resulted in actual harm when Resident #98's toes on the left foot began to show signs and symptoms of dry gangrene and the facility staff had not notified the physician in a timely manner. Resident #98 required a left above knee amputation (AKA) the same night he was sent to the hospital for acute limb ischemia and dry gangrene. This affected one (Resident #98) of three residents reviewed for wound care. Additionally, the facility also failed to ensure the accuracy of skin assessments. This affected two (#98 and #99) of three reviewed for skin assessments. The facility census was 95.1. [...]

Inspectors wroteBased on record review, staff interviews, review of hospital records, and policy review, the facility failed to ensure timely treatments and interventions were completed for a resident's pressure ulcer. This resulted in Actual Harm on 01/14/25 when Resident #99 was hospitalized with a pressure ulcer to the sacrum which deteriorated in condition and developed purulent drainage and necrotic tissue from a delay in treatment. This affected one (Resident #99) of three residents reviewed for wounds. The facility identified six residents (#8, #11, #51, #76, #83 and #92) with pressure ulcers. The facility census was 95.

Inspectors wroteBased on record review, staff interview, and policy interview, the facility failed to ensure resident records were provided timely upon request. This affected two residents (#97 and #101) of three reviewed for record requests. Facility census was 95. 1. Review of the medical record for Resident #97 revealed an admission date of 05/31/23 and discharge date of 10/15/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13, indicating intact cognition. Review of the authorization to disclose health information dated 06/23/25 revealed a record request was made for the entire electronic nursing home chart from dates 05/28/23 to 10/15/24 by an attorney handling the estate of Resident #97. Review of the letter dated 06/24/25 revealed a records request for Resident #97 requesting the electronic nursing chart. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to address a resident's representative concerns regarding care concerns. This affected one (#105) out of the three residents reviewed for timely response to resident and/or resident representative concerns. The facility census was 93.

Inspectors wroteBased on medical record reviews, staff interview, and policy review, the facility failed to conduct quarterly care conferences. This affected two (#08 and #38) out of the three residents reviewed for care conferences. The facility census was 93.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to timely provide a therapeutic diet as per speech therapy recommendations. This affected one (#105) out of the three residents reviewed for diets. The facility census was 93.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in significant medication errors. This affected three (#08, #95, and #100) out of the five residents reviewed for medication administration. The facility census was 93.

Inspectors wroteBased on medical record reviews, staff interview and policy review, the facility failed to ensure surgical wound care was completed as ordered. This affected one (#95) out of the three residents reviewed for wound care. The facility also failed to ensure peripherally inserted central catheter (PICC) line dresses were changed as ordered. This affected two (#95 and #96) out of the three residents reviewed for intravenous (IV) or PICC line placement. The facility census was 87.

Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to ensure a new pressure ulcer was assessed, measured, and physician notified timely. This affected one (#51) out of the three residents reviewed for wound care. The facility census was 87.

Inspectors wroteBased on medical record reviews, staff interviews, observations and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#04 and #14) out of the four residents reviewed for medication administration. The facility census was 87.

Inspectors wroteBased on medical record reviews, staff interviews, observations, and review of facility policies, the facility failed to follow infection control procedures during wound care. This affected one (#04) out of the three reviewed for wound care. The facility also failed to follow infection control procedures during medication administration. This affected one (#24) out of the three residents observed for medication administration. The facility census was 87.

Inspectors wroteBased on record review, staff, and resident interviews the facility failed to ensure medications were administered as per physician order. This affected one Resident (#10) of three reviewed. The facility census was 92.

Inspectors wroteBased on record review and interview, the facility failed to ensure routine medication was available for administration. This affected one (Resident #67) of 24 sampled residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure the posted staffing document included the total number and the actual hours worked for each discipline and failed to ensure the staffing document reflected any staff absences due to call-offs or illness. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on record review and staff and Pharmacist interviews, the facility failed to administer medications as physician ordered. This affected two (#100 and #60) of three residents reviewed for medication administration. Facility census was 101.

Inspectors wroteBased on observation, staff interview, record review, the facility failed to ensure the medication were administered as ordered resulting in three medications errors out of 30 opportunities or a ten percent (%) medication error rate. This affected one (#64) out three residents observed for medication administration. The facility census was 101.

Inspectors wroteBased on medical record review, observations, staff and staff interviews and policy review, the facility failed to ensure proper medication storage. This affected one (#65) out of three residents observed for medication storage. The facility census was 101.

Inspectors wroteBased on medical record review, observations and staff interview, the facility failed to follow proper infection control procedures during incontinence care. This affected one (#14) out of three residents reviewed for infection control. The facility census was 86.

Inspectors wroteBased on observations, staff and resident interviews and record review, the facility failed to maintain a clean and homelike environment. This affected three (#03, #12 and #36) residents of the six residents reviewed for homelike environment. The total facility census was 84. Findings Include: Record review of Resident #03 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, muscle weakness and osteoarthritis of the knee. Review of the Minimum Data Set, (MDS) assessment for Resident #03 dated 09/28/23, revealed the resident had intact cognition and required supervision with activities of daily living (ADLs). Record review of Resident # 12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included lack of coordination, and pain of the left and right knees. [...]

Inspectors wroteBased on record review, policy review, resident and staff interviews, the facility failed to provide residents' access to their personal funds daily, including weekends. This affected one (#47) of three reviewed for management of resident funds and the potential to affect 41 resident's accounts the facility manages. The facility census was 78.

Inspectors wroteBased on observation, staff interview, facility policy review, and review of the planned menus approved by a Registered Dietitian (RD) #53 revealed the facility failed to follow planned menus for resident's on pureed and mechanically soft diets. This had the potential to affect 13 (#56, #43, #63, #13, #27, #35, #60, #49, #53, #20, #59, #36, #52) of 13 residents who had orders for either a pureed or mechanically soft diet. The facility census was 78.

Inspectors wroteBased on observation, staff interview, and review of facility policy, revealed the facility failed to hold food prepared for service at acceptable temperatures. This had the potential to 77 of 77 residents who receive food from the kitchen with the exception of one resident (#12) who received nothing by mouth. The facility census was 78.

Inspectors wroteBased on observations, record review, policy review and staff interview, the facility failed to maintain dignity and respect for a resident when the resident was not assisted with dressing in daily clothes. This affected one ( #12) of three residents reviewed for dignity and respect. The facility census was 78.

Inspectors wroteBased on record review, staff and resident interview, and review of policy, the facility failed to notify the physician according to the physician's orders when a resident's blood glucose level exceeded parameters defined by the order. This affected one (#47) of five residents reviewed for unnecessary medication. The facility census was 78.

Inspectors wroteBased on medical record reviews, policy review and staff interview, the facility failed to ensure residents were weighed per physician order. This affected two (#58 and #430) of seven residents reviewed for weight. The facility census was 78.

Inspectors wroteBased on observations, record review, resident and staff interviews and policy review, the facility failed to provide physician ordered nutritional supplementation to prevent further weight loss and/or promote weight gain. This affected one (#36) of six residents reviewed for nutrition. The facility census was 78.

Inspectors wroteBased on medical record review, observation, policy review and staff interviews, the facility failed to ensure residents oxygen tubing was dated and documented as changed weekly per facility policy. The affected two (#58 and #430) of three residents reviewed for respiratory treatments. The facility identified 16 residents who received respiratory treatments. The facility census was 78.

Inspectors wroteBased on observation, record review, resident interview, and review of facility policies, revealed the facility failed to keep all medications in locked compartments except when being administered by licensed nursing staff. This affected one (#42) and an undetermined number of residents who potentially could have had accessed the medications. The facility census of 78.