F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include:1.Medical record review for Resident #50 revealed she
was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease
(COPD), major depressive disorder, essential primary hypertension, hyperlipidemia, anorexia,
gastro-esophageal reflux disease (GERD), mixed hyperlipidemia, and major depressive disorder.Review of
the Minimum Data Set (MDS) assessment, dated 12/01/25, for Resident #50 revealed she was cognitively
intact. Review of the progress notes dated 12/12/25 at 11:50 A.M. for Resident #50 revealed on 12/09/25
Licensed Social Worker (LSW) #113 visited Resident #50 after an alleged incident with CNA #268.
Resident #50 revealed she felt ok after the initial shock wore off.Interview on 01/05/25 at 11:48 A.M. with
Resident #50 revealed CNA #268 had attempted to change her depends and appeared to be very
confused. Resident #50 stated CNA #268 used a glove that did not fit his hand, and his pinky finger and
thumb did not fit into the glove. Resident #50 stated he acted confused. Resident #50 stated she observed
CNA #268 open the closet door and could hear him urinate as the urine stream hit a box lying in the closet.
Resident #50 stated she and her roommate, Resident #68, began to scream. 2. Medical record review for
Resident #68 revealed she was admitted to the facility on [DATE]. Her diagnoses included COPD, chronic
respiratory failure with hypoxia, diabetes mellitus (DM), major depressive disorder, adult failure to thrive
tachycardia, GERD, and essential hypertension.Review of the Minimum Data Set (MDS) assessment dated
[DATE] dated for Resident #68 revealed she was cognitively intact. Review of the progress notes on
12/12/25 at 11:57 A.M. revealed Licensed Social Worker (LSW) #113 visited with Resident #68 on 12/09/25
after an alleged incident with CNA #268. Resident #68 reported an increase in her anxiety immediately
following the incident and she reported still being somewhat in shock during the conversation.Review of the
Psychiatric Nurse note dated 12/09/25 at 1:43 P.M. for Resident #68 revealed she reported feeling shaken
up due to the incident with the CNA #268 earlier in the day. Resident #68 stated she felt scared and unsafe
due to this incident.Interview with Resident #68 on 01/05/26 at 12:00 P.M. confirmed on 12/09/25, Resident
#68 observed CNA #268 walk into her room open the closet door proceed to urinate on a box in the closet.
Resident #68 stated he left the door open and she could see his side profile as he urinated in the closet.
Resident #68 stated she began to scream loudly, and CNA #268 started to walk toward her and she did not
know why. Resident #68 stated he had urine on his pants. Resident #68 stated she was very upset and
confused regarding why CNA #268 would do this.Interview on 01/05/26 at 11:08 A.M. with the Human
Resource Manager (HRM) #123 confirmed CNA #268 urinated in the closet of Resident #50 and #68 on
12/09/25. HRM #123 confirmed the facility terminated CNA #268 on 12/15/25 related to not
(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 2
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
01/05/2026
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)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
treating Resident #50 and #68 with dignity and respect when he urinated in their closet on 12/09/25.
Review of the employee chart for Certified Nurse Aide (CNA) #268 revealed his hire date was listed as
11/08/25. CNA #268 was terminated on 12/15/25 for an incident that occurred on 12/09/25. Review of the
form titled, Employee Counseling Form, dated 12/15/25, revealed the type of violation was marked as
conduct and abuse. The violation date was listed as 12/09/25 at 9:53 A.M. The nature of infarction was
listed as the employee, CNA #268, urinated in a resident's room (Resident #50 and #68) in a cardboard box
on 12/09/25 at 10:00 A.M. This violated the PACS Code of Conduct.Review of the facility policy titled, PACS
Code of Conduct and Business Ethics, undated, revealed the facility is dedicated to providing quality care
and other services to each resident, patient, or other individual served. Each person served is an individual
entitled to dignity and respect.Review of the facility policy titled, Dignity, dated 2001 confirmed each
resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of
satisfaction with life, and feelings of self-worth and self-esteem. Residents will be treated with dignity and
respect at all times. This deficiency represents non-compliance investigated under Complaint Number
2693364.
Event ID:
Facility ID:
365616
If continuation sheet
Page 2 of 2