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Legacy Kettering

Non profit - Corporation  ·  3313 Wilmington Pike, Kettering, OH 45429  ·  See home’s Medicare page

Inspections Delayed
The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 18 months.
Ownership Change
Facility changed ownership in last 12 months.
Affiliated With Hcr Manorcare
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
No Ownership Data Provided
Home did not provide details about ownership and managerial control of the facility.
3.38
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.6
100.0%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 56.0%
115
Certified beds
Qualifying beds in the certified provider or supplier facility.
87
Average residents/day
Average number of residents based on daily census.

Inspection Reports

29

total deficiencies

2

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Nov 8, 2023
Complaint report
1 deficiency
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Oct 7, 2023
Complaint report
1 deficiency
D

Resident Rights Deficiency — F0584
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

May 25, 2023
Complaint report
1 deficiency
E

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Sep 15, 2022
Complaint report
1 deficiency
E

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Sep 1, 2022
Complaint report
1 deficiency
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jul 11, 2022
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 2, 2022
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0686
Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jan 20, 2022
Complaint report
1 deficiency
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

F

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Nov 8, 2021
Standard report
9 deficiencies
D

to E
E

Resident Rights Deficiency — F0567
Failure to: Honor the resident's right to manage his or her financial affairs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0803
Failure to: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0580
Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0692
Failure to: Provide enough food/fluids to maintain a resident's health.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0695
Failure to: Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0550
Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Sep 20, 2021
Complaint report
1 deficiency
D

Pharmacy Service Deficiency — F0755
Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Feb 28, 2019
Standard report
8 deficiencies
D

to E
E

Resident Assessment and Care Planning Deficiency — F0655
Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0578
Failure to: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0676
Failure to: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0686
Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0757
Failure to: Ensure each resident's drug regimen must be free from unnecessary drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0791
Failure to: Provide or obtain dental services for each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Dec 28, 2017
Standard report
3 deficiencies
D

to G
G

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

This home has no record of fines or payment suspensions for the past three years.