Kettering Heights Post Acute: Wound Care Failure - OH
The resident, identified in inspection records as Resident #99, was admitted to the facility while it was in the middle of a staffing crisis. The wound nurse had been terminated on December 30, 2024. A replacement had not yet started. The wound nurse practitioner, who visited the facility once a week, was working from a list carried over from the prior week, supplementing it with nursing reports about new admissions and new wounds.
Resident #99's stage four pressure wound did not make that list.
The wound nurse practitioner, identified as WNP #362, first visited Resident #99 on January 2, 2025. She saw the foot wound. She did not see the pressure wound. She told inspectors she was never informed it was there, and she was direct about what that meant: she would definitely want to see a resident with a stage four pressure wound during her rounds.
She did not see it until January 8.
That six-day gap, from January 2 to January 8, is the period during which the wound had no treatment orders at all. No dressing protocol. No documented intervention. The care plan contained nothing about relieving interventions for the pressure wound. The wound nurse practitioner's first assessment of it did not happen until that second visit, and treatment orders did not exist before that moment.
By the time inspectors investigated, the wound had worsened. It had moved from stage four to unstaged, a classification used when a wound is too deep or too obscured to measure accurately. The administrator, interviewed on August 11, 2025, said she thought the wound had improved. Inspectors noted the measurements told a different story: the wound had grown. The administrator acknowledged, when pressed, that the progression from stage four to unstaged represented a decline.
The director of nursing told inspectors she had no explanation for why the wound nurse practitioner had not been informed of the pressure wound during that first January visit, even though she had assessed Resident #99's foot wound the same day. She also had no explanation for why treatment and interventions were delayed until January 8.
In a later interview that included the administrator, the director of nursing, a regional nurse, and the newly hired wound nurse, facility leadership acknowledged they had identified errors and non-compliance in Resident #99's care. They pointed to the changes they had made: terminating the previous wound nurse, bringing in a replacement, implementing new practices. They noted the facility was also going through a change in ownership during this period.
Resident #99 had been admitted, they confirmed, during the window between those two wound nurses.
The wound nurse practitioner described her process clearly to inspectors. She rounded with the director of nursing or bedside nurses when there was no wound nurse. She worked from the prior week's list and added residents based on what nursing reported. The system depended entirely on someone flagging a new wound and communicating it to her. For Resident #99's pressure wound, that communication never happened.
A stage four pressure wound is among the most serious classifications. It indicates tissue loss deep enough to expose muscle, bone, or supporting structures. Going six days without any treatment orders is not a documentation gap. It is an absence of care.
The inspection was conducted as part of a complaint investigation. Resident #99's wound, which arrived at the facility already severe, left the facility's care planning system entirely invisible for nearly a week, during a staffing transition that leadership knew was underway and did not account for.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kettering Heights Post Acute from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
KETTERING HEIGHTS POST ACUTE in KETTERING, OH was cited for violations during a health inspection on August 12, 2025.
The resident, identified in inspection records as Resident #99, was admitted to the facility while it was in the middle of a staffing crisis.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.