Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oaks Of West Kettering The during CMS and state inspections, most recent first.
Surveyors found loose pills of various sizes and colors scattered in the top drawers of three medication carts beneath resident pill cards, indicating that medications were not properly stored. An LPN confirmed that pills found loose in the cart should have been discarded but were not, and the DON later acknowledged that while staff were expected to discard such pills, the facility’s medication storage and administration policies did not address procedures for handling loose medications in the carts.
A resident with cognitive impairment, CKD, and frequent urinary incontinence, who required assistance with toilet hygiene and transfers, was observed in a geri-chair with visibly wet clothing while repeatedly calling out that he needed to urinate. As staff delivered breakfast trays, a CNA acknowledged the request but deferred toileting until after the meal, repositioned the resident, and seated him at the table to eat without providing toileting care. Later incontinence care by another CNA and an LPN confirmed the resident’s pants and brief were wet with urine, contrary to facility policies on perineal care and maintaining resident dignity.
A resident with atrial fibrillation, diabetes, stage IV CKD, and an indwelling hemodialysis catheter received in-house dialysis several times per week and required staff assistance with ADLs, but the facility did not implement Enhanced Barrier Precautions (EBP) as required by its policy. The medical record contained orders for hemodialysis but no EBP or dialysis catheter assessment orders, there was no EBP signage or PPE cart near the room, and the resident reported staff never used gowns or gloves during ADL care. An LPN confirmed the presence of the dialysis port, the absence of EBP orders and signage, and acknowledged that EBP should have been in place for this device, contrary to the facility’s written EBP policy for residents with indwelling medical devices.
A resident admitted without skin issues and assessed as at risk for pressure ulcers was ordered weekly skin assessments, a pressure-reducing mattress, and later preventive heel care. Over several weeks, nursing documentation, including weekly skin assessments and bathing records by an LPN, consistently noted only blanchable redness or soft, blanchable heels with no open areas. On the same day a bathing sheet documented no heel wounds, a late-entry nursing note identified an open area on the left heel with drainage, and subsequent assessments documented a sizable open area that was later classified by a wound NP as an in-house acquired unstageable pressure ulcer with significant necrotic tissue. The facility’s own wound management policy and NPIAP guidelines cited by surveyors required comprehensive, ongoing skin assessments of bony prominences such as heels, but the resident’s heel injury was not detected until it had advanced to an unstageable pressure ulcer.
A resident with severe cognitive impairment, multiple comorbidities, and total dependence for ADLs was receiving incontinence care from a CNA while the bed was in a high position with side rails down. After care was completed, the CNA turned away to reach for the bed remote, during which time the resident rolled off the bed onto the floor, sustaining a head laceration and closed head injury requiring staples in the ER. Although the care plan noted ADL deficits and resistive behaviors, there was no specific fall risk care plan or fall-related interventions in place before the incident, and a high fall risk assessment was not completed until after the fall, despite facility policy requiring fall risk assessment and individualized interventions on admission.
Surveyors determined that the facility failed to assess multiple residents for the appropriateness of bed rail use before installing bed rails on their beds. Observation with the DON revealed numerous residents with bed rails in place, and the DON confirmed that no prior safety risk assessments or evaluations of less restrictive alternatives had been completed, despite a written policy requiring such assessments and documentation before bed rails are used.
The facility failed to ensure effective communication and documentation of hospice services with a contracted hospice provider for three residents who had revoked services from one hospice and elected another. Each resident had serious conditions such as dementia, CHF, COPD, and acute kidney failure and was documented on the MDS as needing extensive ADL assistance and, in some cases, receiving hospice services. However, facility progress notes over the review period did not reflect hospice involvement, and the hospice communication book contained only isolated RN signatures without details of visits or care provided. The DON confirmed the absence of hospice documentation, and a hospice Business Development Director acknowledged that the hospice was behind on documentation and had not recorded visits, despite contractual and policy requirements for accurate records and coordinated care.
Surveyors observed that the biohazard room was left unlocked with used sharps accessible, and the shower room contained prescription medications and Micro-Kill Two Germicidal Wipes on top of an unlocked cabinet. The DON confirmed these items should have been secured, and facility policy requires chemicals to be kept out of resident-accessible areas. These lapses had the potential to affect all residents in the memory care unit.
A resident with dementia and other cognitive disorders was observed pulling another resident's hair, but staff did not file a required Self-Reported Incident (SRI) or initiate an investigation as mandated by facility policy. Review of records and staff interviews confirmed the incident was documented in the medical record but not reported to authorities as required.
The facility did not perform comprehensive wound assessments, including required measurements and detailed documentation, for two residents with pressure ulcers and other wounds upon admission and readmission. Despite facility policy requiring full assessment and documentation, staff failed to record necessary wound details, and wounds were not measured until later by a wound NP, with incomplete documentation.
A resident with an indwelling catheter and complex medical needs did not receive catheter care every shift as required by facility policy. Documentation was missing for catheter care after the resident's readmission, and the resident reported that care was often not performed, especially during the night shift. Facility leadership confirmed the lack of documentation and non-compliance with the established catheter care policy.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Surveyors observed that staff failed to follow infection control procedures during wound and incontinence care for two residents. In one case, a staff member did not perform hand hygiene after removing gloves or before donning new gloves, and did not change gloves between cleaning different areas during catheter and incontinence care. In another case, an LPN did not wear a gown while providing wound care to a resident on enhanced barrier precautions, despite facility policy and posted signage requiring PPE. These lapses were confirmed by staff interviews and policy review.
A resident with multiple chronic conditions and moderate cognitive impairment was found to have ongoing issues with flies in their room, as confirmed by staff observations and interviews. Multiple rooms were reported to have similar pest problems, and although maintenance and pest control treatments were in place, flies and gnats persisted in resident areas.
A resident with moderate cognitive impairment was injured when a floating sink fell on him in a facility restroom, causing a laceration that required 17 sutures. The sink was not properly secured, posing a hazard. The incident was reported after a CNA noticed the resident bleeding. The facility's maintenance director confirmed the sink's improper installation, and the resident's family insisted on hospital evaluation. The facility's policy on accident investigation was reviewed.
A resident with cognitive impairment sustained a laceration when a floating porcelain sink fell from the wall in a bathroom, causing injury. The incident occurred after the resident used the bathroom following a smoking break. Facility staff initially treated the wound, but the resident's family insisted on hospital evaluation due to continued bleeding, resulting in 17 sutures. The sink was identified as a floating type, prone to tilting if weight was applied, and the deficiency was investigated under a complaint number.
A resident with multiple medical conditions sustained a laceration from a broken sink, requiring sutures. The facility failed to notify the resident's representative of the incident, despite policy requirements. The family discovered the injury during a visit and called 911, leading to hospital treatment.
The East Unit crash cart was found lacking essential equipment, including a suction machine canister and a backboard, affecting 49 residents. Observations and staff interviews revealed that the crash cart had not been regularly checked, and necessary equipment was missing or improperly stored. The facility's CPR policy requires maintaining necessary equipment at all times, which was not followed.
A resident with a history of cerebral infarction and schizoaffective disorder was sexually abused by a frequent visitor in the facility's smoking area. Despite the resident's verbal refusals, the visitor inappropriately touched her and exposed himself, leading to her feeling traumatized. The incident was captured on security footage and reported to the police, resulting in the visitor's arrest. The facility's failure to prevent this incident constitutes a deficiency in protecting residents from abuse.
The facility failed to ensure the dishwashing machine sanitized at the correct temperature, potentially affecting 85 residents. The Dietary Director suspected a broken thermostat, while a Dietary Aide checked the wrong thermostat. The Service Technician found the final rinse temperature was too low, and some dish racks didn't engage the rinse cycle. The DON and Administrator expected staff to check and report malfunctions, as per facility policy.
A long-term care facility failed to implement an effective infection control program, as evidenced by the lack of Enhanced Barrier Precautions for two residents and improper handling of soiled linens and respiratory equipment for another. Staff were unaware of EBP guidelines, and no training had been conducted, leading to non-compliance with infection control protocols.
A resident with intact cognition reported being inappropriately touched by a family member at the facility. Although the police were notified and the family member was arrested, the facility failed to report the incident to the state agency, as required by their policy. Staff interviews revealed that the decision not to report was influenced by instructions from the corporate office.
A resident with intact cognition reported being sexually abused by a family member. The facility failed to conduct a thorough investigation, lacking documentation of interviews, statements, and evidence analysis. The facility's policy required these actions, but they were not followed, resulting in a deficiency.
A resident in a persistent vegetative state receiving enteral nutrition through a feeding tube did not have their formula labeled with the date and time of infusion. Observations showed that the containers lacked this information, contrary to facility policy and physician orders. Interviews with staff confirmed the oversight, highlighting a failure to follow established procedures.
A resident with dementia on a pureed diet received an incorrect portion size, as the facility failed to follow the planned menu. The resident was served half the required serving of pureed Marzetti. Staff interviews revealed that the menu system change led to the omission of portion sizes on printed menus, although they were available on meal tickets.
A resident with multiple medical conditions and an indwelling urinary catheter had abnormal lab results, prompting a physician to order repeat tests. However, the facility failed to obtain the necessary blood specimen for these tests. Interviews revealed lapses in communication and documentation among staff, and the physician noted the resident's rapid decline and discussions about hospice care.
A resident with moderately impaired cognition had their debit card stolen and used by a former STNA for personal expenses, totaling about $1,600. The facility's investigation and a police report confirmed the misuse, leading to the STNA's termination.
Improper Storage and Handling of Loose Medications in Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and handled in medication carts, as required for drugs and biologicals. During an observation of the Central One medication cart with an LPN on 04/07/26 at 9:23 A.M., surveyors found 20 loose pills of various sizes and colors scattered on the bottom of the top drawer under resident pill cards. A subsequent observation of the Central Two medication cart with the same LPN revealed eight loose pills, also of different sizes and colors, scattered on the bottom of the top drawer under pill cards. The LPN confirmed that both carts contained scattered pills and acknowledged that the medications were not properly stored, stating that the expectation was for staff to discard any medications that fell from pill cards into the drawer. Later that day at 12:00 P.M., an observation of another medication cart ([NAME] Two) with a different LPN revealed ten loose pills of varying sizes and colors scattered on the bottom of the top drawer under pill cards. This LPN also confirmed that the pills were not stored properly and should have been discarded. In an interview on 04/08/26 at 8:46 A.M., the DON stated the facility had a total of six medication carts and confirmed that staff were expected to discard any pills found on the bottom of the medication cart drawers. The DON further confirmed that the facility’s medication storage and medication administration policies did not address staff procedures for handling loose pills found in the medication carts. This non-compliance was investigated under Complaint Number 2806644.
Failure to Provide Timely Toileting Assistance and Incontinence Care
Penalty
Summary
The deficiency involved the facility’s failure to provide timely assistance with toileting hygiene for a resident who required help with activities of daily living. The resident, admitted with diagnoses including encephalopathy, chronic kidney disease stage III, and anxiety, was documented on the nursing admission assessment as alert and oriented to person only, needing set-up assistance with toilet hygiene and bed mobility, and substantial/maximum assistance for transfers. The assessment also indicated the resident was frequently incontinent of bladder and always continent of bowel. During an observation period in the morning, the resident was seen lying back in a geri-chair in a common area with sweatpants that appeared wet in the peri-area and buttocks, while repeatedly yelling out that he had to urinate. As staff passed breakfast trays, the resident continued to call out for help to use the bathroom. A CNA approached with the breakfast tray, was informed by the resident that he needed to go to the bathroom, and responded that she would assist with bathroom needs after breakfast. The CNA then repositioned the resident upright in the geri-chair and moved him to the table to eat, without addressing his toileting request. Interviews with an LPN confirmed that staff were expected to provide toileting care on routine rounds and as needed, including prior to breakfast when requested. The CNA later confirmed she had heard the resident’s request but did not provide toileting assistance before breakfast and stated she had not noticed the pants were wet. Subsequent observation of incontinence care by another CNA and an LPN revealed the resident’s sweatpants and incontinent brief were wet with urine. Facility policies on perineal care and promoting/maintaining resident dignity required provision of perineal care as needed to promote cleanliness and comfort and to treat residents with respect and dignity.
Failure to Implement Enhanced Barrier Precautions for Resident with Dialysis Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a hemodialysis catheter as required by its own infection prevention and control policy. The resident was admitted with diagnoses including atrial fibrillation, diabetes mellitus, and stage IV chronic kidney disease, and received in-house hemodialysis four times per week. The admission MDS showed the resident was cognitively intact and required supervision or touching assistance with toilet hygiene, bathing, transfers, and bed mobility. Review of the medical record revealed physician orders for in-house hemodialysis but no orders for EBP or for assessment of the dialysis catheter, despite the presence of a dialysis port in the left chest. During observation, the resident was seen sitting on the side of the bed eating breakfast with no EBP signage posted and no PPE cart located near the room. The resident reported receiving dialysis four times per week, having a dialysis port in the left chest, and receiving staff assistance with ADLs and port assessment after dialysis, and also stated that staff had never worn gowns or gloves when providing ADL assistance. In an interview, an LPN confirmed the presence of the dialysis port, the absence of EBP orders in the medical record, and the lack of EBP signage and PPE cart outside the room, and acknowledged that EBP should have been in place due to the dialysis port. Review of the facility’s EBP policy showed that EBP, including availability of gowns and gloves near or outside the resident’s room for use during high-contact care activities such as dressing, bathing, transfers, device care, and wound care, was required for residents with indwelling medical devices including hemodialysis catheters, even without known infection or colonization.
Failure to Timely Identify and Assess Unstageable Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess a resident’s skin and to timely identify a pressure ulcer on the left heel, despite the resident being known to be at risk for pressure-related skin breakdown. The resident was admitted without pressure ulcers and with no history of skin integrity issues, and an initial Braden Scale assessment identified a moderate risk for pressure sores. Physician orders at admission included weekly skin assessments and use of a pressure-reducing mattress, and later orders added bilateral heel cleansing and skin prep every shift as a preventive measure. Weekly skin assessments and multiple bathing/skin documentation entries over several weeks consistently recorded only soft, blanchable heels or blanchable redness to the heels, with no open areas or wounds documented. In the weeks leading up to the discovery of the wound, weekly skin assessments dated 11/25, 12/02, 12/06, and 12/12 documented no open areas on the left heel, and bathing documentation on multiple dates recorded only blanchable redness to the bilateral heels and no additional skin issues. Preventive heel care ordered on 11/24 was documented on the Treatment Administration Record as being completed twice daily on several dates. However, on the same day that a bathing sheet documented no wounds or skin integrity issues on the left heel, a late-entry nursing note recorded that an open area on the left heel with slight drainage was identified, measuring 4.5 cm by 3 cm by 0.1 cm. A weekly skin assessment and a skin breakdown assessment completed the following day documented the same open area and measurements, and a subsequent wound evaluation identified the wound as an in-house acquired unstageable pressure ulcer with 90% necrotic tissue and 10% granulation tissue. The wound nurse later stated that the left heel wound was discovered during a facility-wide skin sweep initiated because of an increase in self-reported incidents and wounds, and that she had started daily skin sweeps in the memory care unit. She also stated that the resident had no wound NP visits during two earlier weeks because a previous skin issue at a different site had resolved. The wound NP confirmed that the resident developed an in-house unstageable pressure ulcer to the left heel identified by staff. The facility’s wound management policy required accurate documentation of treatments and focused wound assessments weekly and as needed with changes in condition, and NPIAP guidelines cited by surveyors emphasized comprehensive, ongoing skin assessment, including head-to-toe inspection with particular focus on bony prominences such as heels and the use of each repositioning opportunity to assess skin. Despite these requirements and guidelines, the resident’s left heel pressure injury was not identified until it had progressed to an unstageable pressure ulcer.
Failure to Provide Safe Supervision During Incontinence Care Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care, resulting in the resident falling from the bed. The resident had multiple diagnoses including toxic liver disease, congestive heart failure, anxiety disorder, Alzheimer’s disease, osteoarthritis, chronic kidney disease, sepsis due to E. coli, and dementia, with severely impaired cognition and dependence on staff for all ADLs. The comprehensive care plan identified an ADL self-care performance deficit related to confusion/dementia and noted the resident could be resistive to care, with interventions such as monitoring and anticipating care needs, using a scoop mattress, and assessing for fall risks. However, there was no specific fall risk care plan or fall-related interventions in place prior to the incident. During incontinence care, CNA #355 provided personal care to the resident while the bed was in a high position. After completing care, CNA #355 turned away from the resident to reach for the bed remote to lower the bed, at which point the resident shifted or rolled and fell from the bed to the floor. According to staff interviews and documentation, the bed rails were down at the time of the fall, and the CNA had diverted attention away from the resident while the bed remained elevated. RN #134 was called to the room and found the resident on the floor with a laceration to the head and a significant amount of bleeding. The nurse’s note documented that the resident had decided to roll toward the floor during personal care while the bed was up high and the bed rails were down. The resident was transferred to the ER, where records showed a closed head injury, scalp laceration measuring 3.2 cm, and cervical strain, with four staples placed in the scalp wound. Review of facility documentation showed that a fall risk assessment identifying the resident as high risk for falls was not completed until after the incident. The DON reported that falls were not reviewed by the full IDT and that, at the time of the incident, the nurse on duty was responsible for completing the fall risk assessment and immediate interventions, with only the DON reviewing falls afterward. The facility’s fall prevention policy required that each resident be assessed for fall risk upon admission and receive individualized interventions based on their level of risk, but the resident did not have a fall risk care plan or related interventions implemented before the fall occurred.
Failure to Assess Residents Prior to Bed Rail Use
Penalty
Summary
Surveyors found that the facility failed to assess residents for the use of bed rails prior to their application, contrary to the facility’s own policy. Observation conducted with the Director of Nursing (DON) showed that 19 identified residents had bed rails on their beds, and the DON confirmed that these residents had not been assessed for the appropriateness of bed rail use before the rails were applied. The facility’s written policy, dated 02/05/26, states that staff will assess residents for the appropriateness of bed rails prior to use and will attempt and document less restrictive measures before implementing bed rails. Despite this policy, the required safety risk assessments and consideration of less restrictive alternatives were not completed or documented for any of the 19 residents observed with bed rails in place. This deficiency affected 19 residents reviewed for bed rails out of a total facility census of 107 residents. The DON’s interview corroborated the observation findings and confirmed noncompliance with the facility’s policy regarding pre-use assessment of bed rails and documentation of attempts at less restrictive measures.
Failure to Coordinate and Document Hospice Services With Contracted Provider
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective communication process and proper documentation of hospice services and coordination of care with Hospice Company A, as required by facility policy and the hospice contract. For one resident with hypertension, chronic kidney disease, dementia, and anorexia, the record showed admission to Hospice Company B and later revocation of those services, followed by election and admission to Hospice Company A for senile degeneration of the brain. However, the resident’s MDS did not reflect receipt of hospice services, facility progress notes for the relevant months contained no documentation of hospice involvement, and the hospice communication book for Hospice Company A contained only a single RN signature for a visit with no additional information about services provided. A second resident with CHF, dysphagia, adult failure to thrive, hypertension, and peripheral vascular disease was initially admitted to Hospice Company B and later revoked those services and elected Hospice Company A with a diagnosis of COPD. The MDS for this resident indicated severe cognitive impairment, dependence in ADLs, and receipt of hospice services, yet the facility’s progress notes for the same time period did not document hospice services. The hospice communication book for Hospice Company A again contained only one RN signature for a visit and no further documentation of hospice care or coordination. A third resident with acute kidney failure, hypertension, CHF, generalized anxiety disorder, and vascular dementia was admitted to Hospice Company B, revoked those services, and then elected Hospice Company A with a terminal dementia diagnosis. The MDS reflected that this resident was severely cognitively impaired, dependent in ADLs, and receiving hospice services, but the facility’s progress notes for the review period lacked any hospice-related documentation. The hospice communication book for Hospice Company A contained only a single RN signature for a visit and no other information. The DON confirmed the lack of hospice documentation in the facility records and hospice communication book for all three residents, and the hospice Business Development Director acknowledged that Hospice Company A was behind on documentation and had failed to document visits, despite a contract and facility policy requiring accurate records and a communication process for coordination of care.
Improper Storage of Chemicals and Sharps in Memory Care Unit
Penalty
Summary
During an observation of the memory care unit, surveyors found that the biohazard room was left unlocked with sharps containers containing used needles and other medical supplies accessible. Additionally, the shower room was unlocked, and prescription Nystatin powder, Zinc/Nystatin cream, and Micro-Kill Two Germicidal Wipes were found on top of an unlocked cabinet. The label on the Micro-Kill Two Germicidal Wipes specifically stated to keep the product out of reach of children. The Director of Nursing confirmed that these items should have been stored in a locked cabinet. Review of the Safety Data Sheet for the germicidal wipes indicated the product is classified as acutely toxic if ingested and should be kept out of reach of children. Facility policy also requires that chemicals must never be left unattended or stored in resident-accessible areas. These findings had the potential to affect all 21 residents on the memory care unit.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident diagnosed with Alzheimer's disease, vascular dementia with agitation, psychotic disorder with delusions, and delirium. According to the nurses note, the resident was observed pulling another resident's hair, and staff intervened immediately. However, a review of the Enhanced Information Dissemination and Collection system (EIDC) revealed that no Self-Reported Incident (SRI) was filed for this event. Interviews with the DON and Executive Director confirmed the existence of the incident in the medical record and acknowledged that an SRI should have been completed, but was not. The facility's policy requires immediate investigation and reporting of abuse allegations to the appropriate agencies within 24 hours, which was not followed in this case.
Failure to Complete Comprehensive Pressure Ulcer Assessments on Admission
Penalty
Summary
The facility failed to comprehensively assess pressure ulcer wounds upon admission for two residents. For one resident with multiple complex medical diagnoses, including end stage renal disease, diabetes, and a history of sepsis and cellulitis, the admission assessment and subsequent skin assessments documented the presence of multiple wounds, such as pressure ulcers and necrotic lesions. However, these assessments did not include required measurements or detailed descriptions of the wounds, despite facility policy mandating full documentation and measurement of wounds upon admission. Another resident, also with significant medical conditions including end stage renal disease, congestive heart failure, and dementia, was admitted and readmitted multiple times. Upon readmission, the resident had documented pressure ulcers and arterial ulcers, but the nursing evaluation and weekly skin assessments failed to include measurements or adequate descriptions of the wounds. The wounds were not measured until later by a wound nurse practitioner, and even then, only one measurement was recorded for both wounds, rather than individual measurements as required. Interviews with the DON and review of facility policies confirmed that the required comprehensive skin and wound assessments, including measurements and detailed documentation, were not completed as per protocol for these residents. The facility's own policies specified that wound assessments must include type, stage, measurements, and wound bed description, but these elements were missing from the records reviewed.
Failure to Provide Indwelling Catheter Care per Policy
Penalty
Summary
The facility failed to provide indwelling catheter care as required by its own policy for a resident with significant medical needs, including chronic respiratory failure, neurogenic bladder, and paraplegia. The resident was dependent on staff for all activities of daily living and had an indwelling catheter. The care plan specified that catheter care should be performed every shift. Documentation showed that catheter care was completed every shift prior to the resident's discharge to the hospital, but after the resident's readmission, there was no documentation of catheter care being performed for an extended period. Interviews with the resident revealed that catheter care was often not performed during the night shift, and the resident reported going several days without receiving this care. The President of Clinical Services confirmed that the medical record lacked documentation of catheter care following the resident's readmission, which was not in accordance with facility policy. Review of the facility's catheter care policy confirmed that care was to be provided every shift and as needed, but this standard was not met for the resident in question.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Follow Infection Control Procedures During Wound and Incontinence Care
Penalty
Summary
Surveyors identified failures in infection control procedures during wound and incontinence care for two residents. For one resident with chronic respiratory failure, neurogenic bladder, and an indwelling catheter, staff did not follow proper hand hygiene protocols. During observed catheter and incontinence care, a State Tested Nursing Assistant (STNA) failed to perform hand hygiene after removing soiled gloves and before donning new gloves, and did not change gloves between cleaning different areas or before using clean towels. The STNA confirmed these lapses during an interview, and facility policy required hand hygiene before and after glove use. For another resident with multiple diagnoses including end stage renal disease, diabetes, and a stage three pressure ulcer, a Licensed Practical Nurse (LPN) did not don a gown while performing wound care, despite the resident being on enhanced barrier precautions due to wounds and dialysis. The LPN performed hand hygiene and changed gloves as required, but omitted the use of a gown, which was required by facility policy for high-contact care activities under enhanced barrier precautions. The LPN confirmed awareness of the precautions and the presence of PPE and signage, but did not use the gown during the procedure. Facility policies reviewed by surveyors specified the need for hand hygiene in conjunction with glove use and the use of appropriate PPE, including gowns, for residents on enhanced barrier precautions. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and resident records.
Failure to Maintain Pest-Free Resident Room
Penalty
Summary
The facility failed to ensure that a resident's room was free from flies, resulting in a deficiency related to pest control. During observations, six flies were seen either flying in the room or sitting on the resident's bedsheets. The resident, who had a history of diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and hypertension, reported ongoing issues with flies in his room since admission. The resident was assessed as having moderate cognitive impairment and required varying levels of staff assistance for daily activities. Staff interviews confirmed the presence of flies in the resident's room, with one LPN verifying the observation and another LPN stating that several rooms had ongoing issues with flies and gnats. The Maintenance Director, who had recently started at the facility, acknowledged the problem and noted that treatments had been applied to sinks and drains, with some improvement observed. The pest control company provided monthly treatments to common areas and the kitchen, and spot treatments to rooms as needed. Despite these efforts, the deficiency was identified due to the continued presence of pests in resident rooms.
Resident Injured by Falling Sink in Facility Restroom
Penalty
Summary
The facility failed to ensure a safe environment for Resident #66, resulting in an accident that caused actual harm. On December 15, 2024, Resident #66, who had moderate cognitive impairment and required assistance with transfers, used a first-floor restroom where a floating handwashing sink fell on him. This incident resulted in a laceration to his left knee that required 17 sutures, antibiotics for infection prevention, and continued wound care. The resident's medical history included toxic encephalopathy, schizophrenia, and other conditions that may have contributed to his vulnerability. The incident was reported by a CNA who noticed Resident #66 bleeding upon returning from smoking. The resident stated that the sink broke and cut him while he was washing his hands. The facility's maintenance director confirmed that the sink was a floating type, which could tilt and fall if too much weight was applied. The sink was not directly bolted to the wall, which posed a hazard. The maintenance director replaced the sink and repaired the bathroom following the incident. Interviews with facility staff, including the Administrator and DON, revealed that the resident's family was not initially notified of the injury, as Resident #66 was considered his own responsible party. However, the family later insisted on hospital evaluation, where the laceration was treated. The facility's policy on investigating and reporting accidents was reviewed, indicating a need for thorough investigation and reporting of such incidents. This deficiency was part of a complaint investigation, highlighting a lapse in ensuring a hazard-free environment for residents.
Unsafe Maintenance of Floating Sink Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a floating porcelain sink in a safe manner, resulting in an incident involving a resident. The resident, who had a history of moderate cognitive impairment and required assistance with transfers, sustained a significant laceration on the left knee when the sink fell from the wall while the resident was using the bathroom. The incident was reported by a CNA who noticed the resident bleeding upon returning from a smoking break. The resident was initially treated at the facility, but due to continued bleeding, the family insisted on hospital evaluation where the laceration was closed with 17 sutures. The resident's medical history included diagnoses such as toxic encephalopathy, schizophrenia, and muscle weakness, which may have contributed to the resident's vulnerability during the incident. The resident reported that the sink fell on him while washing hands, causing the injury. The facility's staff, including the Administrator and DON, were aware of the incident, and the bathroom was subsequently locked to prevent further access. The Maintenance Director confirmed that the sink was a floating type, which could tilt and fall if excessive weight was applied. Interviews with staff revealed that the resident was taken to smoke by an Activities Aide, who did not initially notice the injury. The aide observed red drops in the elevator but did not realize it was blood until later. The facility's response included notifying the physician and applying initial wound care, but the family was not satisfied with the facility's handling of the situation, leading to the resident's transfer to the hospital. The deficiency was investigated under a specific complaint number, indicating non-compliance with safety standards.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative when the resident experienced a change in condition due to a laceration that required sutures and continued wound care. The incident involved a resident with a history of toxic encephalopathy, schizophrenia, chronic viral hepatitis-C, and other conditions, who sustained a large laceration on the left shin and a small cut under the right eye after a bathroom sink broke and injured him. The incident report noted that the resident's physician was informed, but there was no documentation indicating that the resident's representative was notified. The deficiency was further highlighted when the resident's family, upon visiting the facility, observed the injury and called 911, leading to the resident's transport to the hospital. The hospital records confirmed that the resident required 17 sutures for a five-centimeter laceration on the left knee. The Director of Nursing confirmed that the family was not notified initially, as the resident was considered his own responsible party. The facility's policy mandates notifying the resident, physician, and representative of any changes in medical condition, which was not adhered to in this case.
Deficiency in Crash Cart Equipment on East Unit
Penalty
Summary
The facility failed to ensure that the East Unit crash cart was properly equipped with an assembled suction machine with a canister and a backboard, affecting 49 residents residing on that unit. During an observation, it was noted that the suction machine was present on the crash cart but lacked a collection canister, and there was no backboard available. The Emergency Crash Cart Checklist was found to be incomplete, with no documentation of checks for several dates, indicating that the crash cart had not been regularly inspected. Interviews with staff, including RN #56 and the Director of Nursing (DON), confirmed the absence of the necessary equipment on the crash cart and the lack of regular checks. RN #56 acknowledged that the collection canister was stored in the medication room rather than on the crash cart, and the DON was informed by an agency nurse about the missing backboard and the need to restock the crash cart. The facility's CPR policy, dated February 2018, mandates the maintenance of necessary equipment and supplies for CPR at all times, which was not adhered to in this instance.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a visitor, resulting in actual harm. Resident #137, who had a medical history including cerebral infarction, schizoaffective disorder, and anxiety, was admitted to the facility and had intact cognition as per the Minimum Data Set (MDS) assessment. On the day of the incident, Resident #137 was outside in the smoking area when Family Member (FM) #16, a frequent visitor to another resident, inappropriately touched her breasts and private area and exposed his genitalia, despite her verbal refusals. This incident was captured on security footage, although without audio, and was reported to the police by the facility's Administrator. The police report detailed the sequence of events, including FM #16's admission to the police of his actions and Resident #137's account of the incident, which left her feeling traumatized. The report also noted that another male was present during part of the incident but was unable to provide a statement due to mental disabilities. Interviews with staff and other residents confirmed the occurrence of the incident, and the facility's Director of Nursing (DON) and Administrator took immediate action by involving the police, leading to FM #16's arrest. Despite the immediate response, the facility's failure to prevent the incident from occurring in the first place constitutes a deficiency. The facility's policy on abuse, neglect, and exploitation clearly states a zero-tolerance approach, yet the incident occurred, resulting in significant emotional harm to Resident #137. The deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with regulations designed to protect residents from abuse.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the high temperature dishwashing machine sanitized at the proper temperature, potentially affecting 85 of 88 residents who received food from the kitchen. The Dietary Director (DD) acknowledged that the dishwashing machine rinse temperature should be 180 degrees Fahrenheit but suspected the thermostat was broken. However, a Dietary Aide (DA) reported that the temperature reached 190 degrees Fahrenheit, indicating a misunderstanding of which thermostat to check. The Service Technician clarified that there were two thermostats, and the DA had been checking the incorrect one. An observation revealed that the final rinse temperature was only 120 degrees Fahrenheit, far below the required temperature for proper sanitation. The Service Technician noted that some dish racks were too small to engage the final rinse cycle. The Director of Nursing (DON) and the Administrator both stated that staff should routinely check the dishwashing machine's temperature and report any malfunctions. The facility's policy required staff to ensure proper functioning and temperatures of the dishwashing machine before meals, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for two residents and improper handling of dirty linens and respiratory equipment for another resident. Resident #139, who had a urinary catheter due to a neurogenic bladder, did not have EBP signage posted, and the registered nurse providing catheter care did not wear a gown, which is part of the EBP protocol. The staff's lack of awareness and training on EBP contributed to this deficiency. Resident #37, who was in a persistent vegetative state and required tracheostomy care, also did not receive care under EBP guidelines. The registered nurse providing tracheostomy care did not wear a gown, and both the nurse and a state-tested nursing assistant were unaware of the EBP requirements. The Assistant Director of Nursing, who was also the Infection Preventionist, mistakenly believed that EBP was voluntary, and no training had been conducted for the staff, leading to non-compliance with infection control protocols. For Resident #5, the facility failed to properly handle soiled linens and store respiratory equipment. The resident's BiPAP mask and nebulizer mask were left uncovered, and the BiPAP tubing was on the floor, which is against the facility's policy for storing respiratory supplies. Additionally, a nursing assistant placed soiled washcloths on the floor during incontinence care, contrary to the facility's policy that requires soiled linens to be bagged immediately. These actions indicate a lack of adherence to infection prevention protocols, further compromising the facility's infection control program.
Failure to Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency, as required by their policy. The incident involved a resident with a medical history of cerebral infarction, schizoaffective disorder, and other conditions, who reported being inappropriately touched by a family member on the facility's smoking patio. The resident had intact cognition, as indicated by a BIMS score of 13. The police were notified, and the family member was arrested, but the facility did not report the incident to the state agency. Interviews with facility staff revealed that the Director of Nursing and the Administrator were aware of the incident and acknowledged it as an allegation of sexual abuse. However, they did not report it to the state agency due to instructions from their corporate office. The facility's policy, dated 2016, clearly stated that allegations of abuse should be reported to the state agency. This deficiency was investigated under a specific complaint number, indicating non-compliance with the reporting requirements.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident, identified as Resident #137, who reported being inappropriately touched by a family member, FM #16. The incident occurred while the resident was outside smoking, and the police were called immediately after the resident reported the incident to the Director of Nursing (DON). The police report indicated that security camera footage captured the inappropriate actions of FM #16, but the facility did not have documented evidence of reviewing this footage or conducting a comprehensive investigation. Resident #137, who had a medical history including cerebral infarction, schizoaffective disorder, and hemiplegia, was admitted to the facility in 2022 and had intact cognition as per a recent assessment. Despite the serious nature of the allegation, the facility's investigation lacked documentation of interviews or statements from the resident, the accused, or any witnesses, including staff and other residents who may have been in contact with Resident #137 on the day of the incident. The facility also failed to document the analysis of evidence or make a determination regarding the substantiation of the abuse allegation. The facility's policy on abuse, neglect, and exploitation required a thorough investigation, including interviews and documentation, which was not followed in this case. The DON and Administrator acknowledged the lack of documentation and the absence of a saved video recording of the incident. The deficiency was identified during a survey, highlighting the facility's non-compliance with its own policies and procedures for handling abuse allegations.
Failure to Label Enteral Nutrition Formula
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a feeding tube had their formula labeled with the date and time the infusion began. This deficiency was identified for one resident who was in a persistent vegetative state and relied on tube feedings for more than half of their caloric intake. The resident's care plan and physician orders specified the use of Isosource 1.5 formula at a specific rate and duration, but observations revealed that the containers of formula were not labeled with the required information. During interviews, a registered nurse admitted to not labeling the formula container with the date and time, and the Director of Nursing and the Administrator confirmed the necessity of such labeling to prevent the formula from going bad. The facility's policy on enteral tube feeding also required documentation of the date and time on the formula label, which was not adhered to in this case.
Failure to Follow Planned Menu for Pureed Diet
Penalty
Summary
The facility failed to adhere to the planned menu for a resident on a pureed diet, resulting in a deficiency. Resident #54, who has a medical history of dementia, was admitted to the facility and had an active order for a regular diet with pureed texture. On a specific date, the resident was observed receiving only one #8 scoop of pureed Marzetti, which is half of the required serving size according to the facility's planned menu. This discrepancy was confirmed by Dietary staff who acknowledged the error in portion size. Interviews with the Registered Dietitian, Dietary Director, Director of Nursing, and the Administrator revealed that the staff were expected to follow the menus and serve the correct portion sizes. However, due to a recent change in the menu system, the Dietary Director had not been printing menus with portion sizes, although this information was available on residents' meal tickets. The failure to serve the correct portion size was acknowledged as potentially leading to weight loss and malnutrition, as stated by the facility's staff.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services ordered by the physician for a resident who was reviewed for urinary catheter/urinary tract infection. The resident, who had a history of multiple fractures and other medical conditions, was admitted with an indwelling urinary catheter. The resident's care plan included obtaining laboratory work as ordered and notifying the physician of any abnormal results. On a specific date, the resident's laboratory results showed abnormalities, and the physician ordered repeat tests to be conducted as soon as possible. However, there was no documented evidence that the blood specimen was obtained for the repeat laboratory testing. Interviews with staff revealed that the registered nurse did not recall whether the physician ordered new laboratory tests, and the Director of Nursing was unable to provide any laboratory results for the specified date. The physician, when interviewed, did not remember the laboratory tests due to the time elapsed but mentioned that the resident was declining rapidly and discussions about hospice care had occurred with the family. This deficiency was investigated under a specific complaint number.
Misappropriation of Resident Property by Staff
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of property, affecting one resident. Resident #41, who had moderately impaired cognition and multiple medical conditions, had their debit card stolen and used by a former State tested Nursing Assistant (STNA) #254. The family of Resident #41 reported the missing debit card and provided bank statements showing unauthorized transactions. The facility's investigation and a police report confirmed that STNA #254 used the card for personal expenses, including a car payment and purchases from a local store. The facility's investigation revealed that STNA #254 admitted to using Resident #41's debit card, leading to their termination. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property, which includes stealing personal items, was reviewed. The Administrator and Director of Nursing confirmed the total charges made by STNA #254 amounted to approximately $1,600. This deficiency was investigated under Control Number OH00153530.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 569 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kettering
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Kettering | 2 mi | ★★★★★ | 9 | 0 |
| Walnut Creek Nursing Center | 2.2 mi | ★★★★★ | 13 | 0 |
| Sanctuary At Wilmington Place | 2.6 mi | ★★★★★ | 1 | 0 |
| Dunbar Health & Rehab Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Kettering Heights Post Acute | 2.9 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.