Kettering Health Greene Memorial
An acute care hospital in Xenia, Ohio 45385
1141 North Monroe Drive, Xenia, Ohio 45385. (937) 352-2000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 5of 5 CMS’s overall rating
- Not rated patient survey rating
- 2 deficiencies cited in the last three years (needs attention)
- 41 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Dec 14, 2023: a complaint inspection.
2 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Dec 2023. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Dec 14, 2023: complaint inspection2 deficiencies
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Nursing Services
“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 28999 Based on medical record review, and staff interview, the facility failed to ensure a registered nurse must evaluate the nursing care (A395).”
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Rn Supervision Of Nursing Care
The inspectors’ words, 874 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 28999 Based on medical record review, and staff interview, the facility failed to ensure a registered nurse must evaluate the nursing care for one of 20 patients reviewed (Patient #5). The hospital census was 4. Findings include: Review of the medical record of Patient #5 revealed the patient was transported via ambulance to the emergency department (ED) on 10/21/23 at 3:02 AM. A triage note stated the patient and friends were found unresponsive and drug use was suspected. Review of the emergency medical services (EMS) run sheet revealed the patient was medicated with Narcan five times, at 2:27 AM, 2:29 AM, 2:38 AM, 2:52 AM, and 2:54 AM, enroute to the hospital. An EMS crew member stated in a progress note that the patient had agonal respirations when they arrived. An unsuccessful attempt to intubate the patient was made by EMS crew members as the patient’s jaws were noted to be clenched shut. Bag mask ventilation was performed by the EMS crew until arrival at the hospital. The patient remained unresponsive. Upon arrival to the ED, staff placed a 20 gauge intravenous (IV) line in the patient’s left antecubital. At 3:05 AM, the ED timeline revealed the patient remained unresponsive to verbal or painful stimuli. The patient was medicated with Etomidate (a short acting intravenous anesthetic agent used for the induction of general anesthesia) 30 milligrams (mg) intravenously. Rocuronium (anesthetic medication used to relax muscles) 100 mg was administered by an ED staff registered nurse two minutes later, at 3:07 AM. The ED timeline further revealed the ED physician successfully intubated the patient at at 3:10 AM. At 3:13 AM, the ED physician placed orders for 0.9 % sodium chloride 1000 milliliter (mL) bolus, serum tox screen, urine drug screen, basic metabolic panel, arterial blood gas, complete blood count with differential, indwelling catheter, a computed tomography (CT) scan of the head, and an standard 12 lead electrocardiogram (EKG). At 3:14 AM, a portable stat chest xray confirmed the location of the endotracheal tube was appropriate. The CT scan of the head without contrast was also started at 3:14 AM. The ordered laboratory tests were drawn at 3:21 AM. A respiratory therapist placed the patient on a ventilator at 3:21 AM. At 3:23 AM, a note to the system wide transfer control center stated the ED physician called from the hospital to arrange a transfer of the patient the intensive care unit (ICU) on main campus. The indwelling catheter was placed at 3:30 AM. The Medication Administration Record (MAR) revealed the 0.9 % sodium chloride bolus was initiated at 3:37 AM. At 3:51 AM, laboratory results revealed a pH of 6.85 with the reference range being 7.35 - 7.45. At 3:51 AM, the ED physician ordered for nursing staff to monitor vital signs every 15 minutes. Vital signs were assessed at 4:37 AM and 5:10 AM. The patient’s pulse was 82 beats per minute, respirations 16 beats per minute, and blood pressure 116/69 at 4:37 AM. At 4:31 AM a second note to the system wide transfer control center stated the hospital was considering transfer of the patient to an out of network hospital. At 4:38 AM a third note to the system wide transfer control center stated the ED physician stated the family was “adamant” that the patient be transferred out of network to a tertiary facility for further care. By 5:06 AM, arrangements had been made for the patient to be transferred to an out of network tertiary facility as requested by the family. The note revealed report was given to an ICU physician at the tertiary facility. The ED physician informed the ICU physician at the outside hospital that the patient’s pupils were fixed and dilated and decorticate posturing (an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight) was observed. At 5:10 AM the patient’s pulse was 85 beats per minute, respirations 17 beats per minute, blood pressure 90/61, and oxygen saturation 100%. At 6:03 AM a cardiac assessment revealed the patient’s skin color was dusky and pale and his skin temperature was cool. The patient was discharged from the facility. The medical record lacked documentation the patient’s temperature was assessed while in the Emergency Department. Staff G was interviewed on 12/14/23 at 5:05 PM. It was confirmed that the medical record lacked documentation vital signs were assessed every 15 minutes as ordered. It was also confirmed that the medical record lacked documentation the patient’s temperature was taken. Review of the outside medical record revealed the patient was admitted to the ICU at 6:17 AM. The patient’s temperature at 6:21 AM was 93.6 degrees Fahrenheit. A nurse’s note stated a bair hugger (system consisting of a reusable warming unit and single-use disposable warming blankets used to maintain a patient’s core body temperature) was applied to maintain the patient’s temperature. By 9:00 AM, the patient’s temperature was 96.1 degrees Fahrenheit. At 10:43 AM, the flowsheet revealed the patient was arousable, making eye contact, and following commands. This deficiency represents non-compliance investigated under Substantial Allegation OH00147966.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Dec 14, 2023 | Complaint inspection | 2 deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 5 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 3; readmission, 1 better and 1 worse of 3.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- In CMS’s patient survey (Oct 1, 2024 to Sep 30, 2025): 84% rated it 9 or 10 out of 10, and 80% would definitely recommend it.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 9.7%, pneumonia 12.3%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart failure 21.4%, pneumonia 16.6%, COPD 19.6%. CMS gives no comparison with the national rate for them in this release.
- Emergency department patients spent a median of 109 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- 80% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.97 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 5 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by the Accreditation Commission for Health Care (ACHC), whose surveys stand in for the state’s routine inspections.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- 97% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Kettering Adventist Healthcare runs it.
- 20 owners or officers are people: Kevin L Sharrett (corporate director, 0%); Paul Hoover (managing employee (on the payroll), 0%); Michael Gentry (corporate officer, 0%); Michael Gentry (corporate director, 0%); Marcellus Robinson (corporate officer, 0%); Marcellus Robinson (corporate director, 0%); Keisha Stubbs-Bone (corporate director, 0%); Vanessa Oliver-Ward (corporate director, 0%); Tamara L Thomas (corporate director, 0%); Robert Weigel (corporate director, 0%); Adele Riley (corporate director, 0%); Leslie Neff (corporate director, 0%); John Sackett (corporate director, 0%); Troy Alan Tyner (corporate director, 0%); Harvey Sung Ha Hahn (corporate director, 0%); Timothy Y Ko (corporate officer, 0%); Andrew Sutton (corporate director, 0%); Cherish J Prutzman (corporate director, 0%); Robert Patterson (corporate director, 0%); Peter N Landless (corporate director, 0%).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Kettering Adventist Healthcare | Runs it (operational or managerial control) | 100% | Jul 31, 2009 |
| Kettering Adventist Healthcare | Other role (CMS gives no detail) | 0% | Jan 31, 2024 |
How does it compare nearby?
- Of the 3 hospitals CMS lists in Greene County, 2 have an overall star rating from CMS: 1 rated 5 of 5, 1 rated 4 of 5.
- CMS rates this one 5 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| 88th Medical Group (Wright-Patterson Afb) | Not given |
| Soin Medical Center | 4 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.