Oaks of West Kettering: Catheter Care Skipped for Days - OH
Resident #62, who suffers from paraplegia and neurogenic bladder, told inspectors on August 19 that "staff usually do not perform catheter care on her for the night shift." She said she had "gone several days without catheter care getting done."
The 95-bed facility's own policy required nursing staff to perform catheter care every shift for residents with indwelling catheters. Medical records showed staff consistently documented the procedure from June 1 through June 6, 2025.
But after Resident #62 returned from a hospital stay on June 13, documentation vanished.
Treatment records revealed no evidence that staff performed catheter care from her readmission date until July 1 — a gap of more than two weeks. The facility's Vice President of Clinical Services confirmed to inspectors that medical records contained no documentation supporting completion of catheter care during this period.
Resident #62 first arrived at the facility in June 2024 with multiple serious conditions including chronic respiratory failure, viral hepatitis C, anemia and paraplegia. After a hospital discharge, she returned to Oaks of West Kettering in June 2025, cognitively intact but completely dependent on staff for all daily activities.
Her care plan, established in November 2024, specifically identified her urinary catheter needs related to neurogenic bladder. The intervention was clear: perform catheter care every shift.
The facility's catheter care policy, revised just months earlier in March 2025, spelled out the requirements. Staff must "ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use." The policy stated catheter care "would be performed every shift and as needed by nursing personnel."
Federal inspectors arrived following a complaint and reviewed three residents with indwelling catheters. Only Resident #62's care failed to meet facility standards.
Proper catheter care prevents urinary tract infections, a serious complication for residents with compromised immune systems. For someone with paraplegia like Resident #62, who cannot feel or control lower body functions, consistent catheter maintenance becomes critical to preventing life-threatening infections.
The inspection occurred on August 20, 2025, as part of complaint investigation number 1353687. Inspectors interviewed the resident at 11:31 a.m., then spoke with the clinical services vice president three hours later.
When confronted with the documentation gaps, the vice president acknowledged the facility had failed to meet its own standards. The admission came after inspectors presented evidence showing weeks of missing catheter care records for a resident whose medical condition made such care essential.
Resident #62's experience illustrates how documentation failures can mask neglect of basic medical needs. While facility policy promised catheter care every eight hours, the reality for this paraplegic woman was days without the procedure that prevents painful and dangerous infections.
The inspection found minimal harm to few residents, but for Resident #62, the consequences of missed catheter care could prove severe. Urinary tract infections in paralyzed patients can quickly become kidney infections or sepsis, potentially fatal complications for someone already managing multiple chronic conditions.
Federal regulators classified the violation as failure to provide appropriate care for residents with bladder incontinence and appropriate catheter care to prevent urinary tract infections. The citation affects how Medicare rates the facility's quality of care.
Oaks of West Kettering operates under complaint investigation protocols, meaning federal and state regulators will monitor correction efforts. But for Resident #62, weeks of missed medical care cannot be undone.
The facility's March 2025 policy revision suggests administrators knew catheter care standards needed clarification. Yet three months later, staff were leaving a paraplegic resident without basic medical procedures for days at a time.
Resident #62 remains at the facility, still dependent on staff who failed to provide care their own policies required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oaks of West Kettering The from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
OAKS OF WEST KETTERING THE in KETTERING, OH was cited for violations during a health inspection on August 20, 2025.
Medical records showed staff consistently documented the procedure from June 1 through June 6, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.