Oaks of West Kettering: Infection Control Failures - OH
The violation occurred during an August 19 wound care session for Resident #08, a patient admitted July 19 with a fractured left fibula, sepsis, cellulitis, end-stage renal disease, diabetes, and an abscess on their foot. The resident required regular dialysis and had developed a stage three pressure ulcer on their right buttock.
Licensed Practical Nurse #232 explained the wound care procedure to the resident, performed hand hygiene and put on gloves. The nurse removed the old dressing, washed hands again, put on fresh gloves and completed the ordered wound care — cleansing the wound, patting it dry, and applying alginate and bordered foam dressing.
But LPN #232 never put on a gown.
The resident was under "enhanced barrier precautions" specifically because of their dialysis treatments and multiple wounds. A bright yellow warning sign hung outside the room. A personal protective equipment cart sat in the hallway, stocked with the gowns, gloves and other gear required for high-contact care activities.
The nurse knew about the precautions. When inspectors interviewed LPN #232 eight minutes after the wound care session, the nurse confirmed the resident was supposed to be under enhanced barrier precautions. They acknowledged seeing the sign posted on the door and the PPE cart outside the room.
They admitted they hadn't worn the required protective equipment during wound care.
Enhanced barrier precautions exist to prevent the spread of dangerous infections between patients, staff and visitors. The facility's own policy, revised just weeks earlier on July 1, explicitly requires personal protective equipment when performing wound care on residents under these precautions.
Resident #08 presented multiple infection risks. Beyond the sepsis and cellulitis diagnoses, the patient had developed a pressure ulcer that required intensive treatment three times per week. The care plan called for weekly documentation of the wound's width, length, depth, tissue type and drainage. Nurses were supposed to evaluate the wound for signs of infection, necrosis, gangrene and other complications.
The resident's medical complexity demanded extra caution. In addition to end-stage renal disease requiring dialysis, they had diabetes, bladder dysfunction, anemia and hypertension. Their care plan identified them as at risk for further skin breakdown, with instructions to monitor for moisture and redness over bony prominences.
The facility's infection control policy states that hand hygiene alone isn't sufficient protection. Staff must perform proper hand hygiene procedures to prevent spreading infections to other personnel, residents and visitors. The policy defines hand hygiene as cleaning hands with soap and water or alcohol-based hand rub.
Crucially, the policy emphasizes that wearing gloves doesn't replace hand hygiene — staff must wash hands before putting on gloves and immediately after removing them. But for residents under enhanced barrier precautions, gloves and hand hygiene aren't enough. Gowns provide an additional barrier against infection transmission during high-contact activities like wound care.
LPN #232 followed some protocols correctly. The nurse explained the procedure to the resident, maintained proper hand hygiene throughout the process, and changed gloves after removing the old dressing. They completed the wound care as ordered, applying the prescribed alginate and foam dressing that was scheduled for Tuesday, Thursday and Saturday treatments.
The failure to don a gown represented a breakdown in the facility's infection control system. Enhanced barrier precautions don't exist as suggestions — they're medical orders based on specific patient risk factors. The July 29 order placing Resident #08 under these precautions cited their dialysis treatments and wounds as justification.
Federal inspectors discovered this violation during a complaint investigation on August 20, one day after observing the improper wound care. They classified it as an "incidental finding" — a serious safety lapse uncovered while investigating other concerns at the facility.
The timing was particularly concerning. Resident #08 had been under enhanced barrier precautions for three weeks when the violation occurred. Staff had ample time to understand and implement the required safety measures.
The resident's vulnerability made the oversight more troubling. With multiple wounds, active infections, and regular dialysis treatments that further compromised their immune system, they needed maximum protection against additional infections that could prove life-threatening.
Despite the posted warning signs and readily available protective equipment, the system failed when it mattered most — during direct patient care that posed the highest risk for infection transmission.
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.
The resident required regular dialysis and had developed a stage three pressure ulcer on their right buttock.
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.