Health inspection·October 29, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #95 revealed an admission date of 09/26/24 with medical diagnoses of chronic multifocal osteomyelitis, methicillin resistance staphylococcus aureus (MRSA), disorder of kidney and ureter, and conduct disorder. The medical record review revealed a discharge date of 10/14/24. Review of the medical record for Resident #95 revealed an admission Minimum Data Set (MDS) assessment, dated 10/02/24, which indicated Resident #95 was cognitively intact and was independent with toileting, bed mobility, and transfers. Review of the MDS revealed Resident #95 received IV medications. Review of the MDS indicated Resident #95 had a surgical wound. Review of the medical record for Resident #95 revealed hospital discharge orders dated 09/26/24 which contained an order to change dressing to PICC line weekly unless it becomes loose, damp, or soiled. Further review of the hospital discharge orders revealed an order for wound care- dressing to be removed three days after surgery and replace dry dressing daily. Review of the medical record for Resident #95 revealed an order dated 10/09/24 for wound care to right shoulder with 33 staples to apply xeroform and island dressing every other day and as needed. Review of the physician orders for Resident #95 revealed no documentation to support there was an order for surgical wound care prior to 10/09/24 or any orders for PICC line dressing change. Review of the medical record for Resident #95 revealed the September 2024 Treatment Administration Record (TAR) did not contain documentation to support the facility completed surgical wound care or PICC line dressing change as per hospital orders. Review of the October 2024 TAR revealed documentation to support wound care was completed on 10/11/24 as ordered. The October TAR did not have documentation to support the facility completed the dressing change to the PICC line as per hospital orders. Interview on 10/28/24 at 1:56 P.M. with Administrator confirmed Resident #95's medical record did not contain documentation to support Resident #95's surgical wound care or PICC line dressing was changed as per hospital discharge orders. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 365616 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)