Kettering Heights: Surgical Wound Monitoring Failed - OH
Federal inspectors found that Kettering Heights Post Acute violated wound care standards when admitting a resident on January 2nd with multiple serious skin conditions, including a stage four pressure sore and a surgical incision that required ongoing monitoring.
The Director of Nursing told inspectors she completed the facility's second skin assessment the same day but included only two of four documented skin issues. She omitted the surgical incision with 36 staples and a "soft heel" condition from the comprehensive assessment.
"We don't always have dressings for surgical incisions," the DON explained to investigators, defending her decision not to include surgical wounds on skin assessments.
The facility's own wound nurse had told inspectors just hours earlier that all skin impairments must be documented and followed until healed, specifically including "scratches, bruising, skin tear, pressure wounds, and surgical incisions."
Licensed Practical Nurse #312 confirmed this standard during his August 11th interview. He told inspectors that if wound treatment appeared on hospital discharge paperwork, "the facility should make a note if they did not see the skin impairment on facility admission skin exam and get clarification from medical provider."
The DON acknowledged that staff would monitor incision sites each shift for signs of infection. But when pressed by investigators, she admitted the facility had no evidence of orders or documentation to monitor the areas. She confirmed no record existed of staff actually documenting this monitoring.
The wound nurse, employed since January 20th, explained the facility's admission protocol to inspectors. Every resident should receive a full skin assessment completed by two staff members, with findings documented in the medical record. A nurse practitioner visits weekly and remains available for questions on other days.
Hospital records showed the resident arrived with significant wounds requiring specialized care. Treatment recommendations included Santyl for enzymatic debriding with bordered gauze daily and as needed for proper healing.
The soft heel condition that the DON dismissed as not needing documentation particularly concerned LPN #312. He emphasized to investigators "the importance of documenting a soft heel due to higher risk of developing a pressure sore and stated it would need increased monitoring or interventions."
Beyond the surgical incision, the resident's admission assessment documented a stage four pressure sore to the coccyx and sacrum area. Stage four represents the most severe category of pressure wounds, extending through skin and tissue to underlying muscle and bone.
The facility's own policy, titled "Prevention of Pressure Injuries" and dated April 2020, explicitly requires staff to "identify risk factors as well as interventions" and "conduct a comprehensive skin assessment upon admission and as indicated."
By August 11th, the Administrator acknowledged the facility had identified non-compliance for skin and wound care. She told inspectors they were "back in compliance," defining this as completing "wound assessments according to nursing standards."
The Administrator confirmed that during the August 7th interviews with the DON, "the expectations for staff did not meet standards of practice." She verified that staff should document "any and all skin impairments including scratches, bruising, soft heels, and surgical wounds."
The violation represents actual harm to residents according to federal inspection findings. The deficiency emerged from two separate complaint investigations, suggesting multiple incidents prompted the review.
Federal regulations require nursing homes to provide wound care that promotes healing and prevents complications. Proper documentation enables staff to track wound progression and adjust treatment as conditions change.
The gap between the facility's written policies and actual practice created risks for vulnerable residents requiring complex wound care. Without comprehensive documentation, staff cannot adequately monitor healing progress or identify deteriorating conditions requiring immediate medical intervention.
The resident's case illustrates broader systemic issues with the facility's wound care protocols. Staff failed to follow their own policies for admission assessments while simultaneously lacking documentation systems to verify ongoing monitoring of serious surgical wounds.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 16, 2026 · Our methodology
KETTERING HEIGHTS POST ACUTE in KETTERING, OH was cited for violations during a health inspection on August 12, 2025.
The Director of Nursing told inspectors she completed the facility's second skin assessment the same day but included only two of four documented skin issues.
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.
Frequently Asked Questions
- What happened at KETTERING HEIGHTS POST ACUTE?
- The Director of Nursing told inspectors she completed the facility's second skin assessment the same day but included only two of four documented skin issues.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in KETTERING, OH, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from KETTERING HEIGHTS POST ACUTE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 365616.
- Has this facility had violations before?
- To check KETTERING HEIGHTS POST ACUTE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.