Kettering Heights Post Acute

In the surveyor’s words

From the most serious findings on record at Kettering Heights Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 12, 2025

  Based 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. […]

• Actual harm, isolatedF686Aug 12, 2025

  Based 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. Findings include:Review of the medical record for Resident #99 revealed an admission date of 01/01/25 and a discharge date of 01/14/25. […]

• No harm, potential for more than minimal, widespreadF925May 28, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jan 20, 2022

  Based on medical record review, observations, staff interview, facility policy review and review of information from the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS), the facility failed to implement infection control practices to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to to affect all 96 residents residing in the facility. The facility census was 96. Findings include: 1. Medical record review for Resident #06 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #06 admitted to the facility on [DATE] and did not have a complete minimum data set assessment (MDS) completed. […]

• No harm, potential for more than minimal, patternF812May 28, 2026

  Based 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. […]