Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
KETTERING HEIGHTS POST ACUTE
KETTERING, OH · 115 certified beds · Last Life Safety survey June 14, 2024
CMS Certification Number 365616 · first certified January 1984
Ownership
Operated by PACS GROUP · For profit - Corporation
- New ownershipOwnership changed December 1, 2024 (change of ownership)from LEGACY KETTERING OPERATING COMPANY, LLC
Position within OH
25 citations — more than 77% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: February 2026 to February 2027. This facility’s last Life Safety survey was June 2024. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 25 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 25 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 28, 2019 | 3 |
| November 8, 2021 | 16 |
| June 14, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 3 | 2024-06-14 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-06-14 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2021-11-08 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-06-14 |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | 1 | 2019-02-28 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2024-06-14 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2024-06-14 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2021-11-08 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 4
- Miscellaneous Deficiencies 4
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Miscellaneous Deficiencies | 4 |
| Services Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 14, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (July 3, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 3, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 3, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 3, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 3, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 3, 2024) |
November 8, 2021 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0928 | Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Deficient, Provider has date of correction (December 17, 2021) |
February 28, 2019 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has date of correction (April 1, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 1, 2019) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 1, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.