Oaks of West Kettering: Catheter Care Gaps Found - OH
The inspection report, completed August 20, 2025, documents what happened after the resident, identified only as Resident #62, was readmitted to the facility on an unspecified date in June 2025. She has paraplegia, chronic respiratory failure with hypoxia, and a neurogenic bladder that requires an indwelling urinary catheter. She depends entirely on staff for her daily care. The facility's own care plan, written in November 2024, called for catheter care every single shift, around the clock.
The records show staff completed that care consistently from June 1 through June 6. Then she was discharged to a hospital. When she came back, the documentation stops. According to the facility's Treatment Administration Record for June 2025, there is no evidence that staff performed catheter care for Resident #62 at any point following her readmission until July 1, a gap of more than two weeks.
The resident confirmed it herself. Speaking with an inspector on August 19 at 11:31 in the morning, she said staff usually do not perform catheter care on her during the night shift. She said she has gone several days without it getting done.
That same afternoon, the facility's Vice President of Clinical Services acknowledged the problem directly. In an interview at 2:30 p.m., the administrator confirmed that the expectation was for staff to complete catheter care every shift for any resident with an indwelling catheter, and confirmed that the medical record for Resident #62 did not support that the facility had met that standard after her June readmission.
The facility's own catheter care policy, revised as recently as March 2025, states that catheter care is to be performed every shift and as needed by nursing personnel.
Inadequate catheter care carries real consequences. Indwelling catheters are a leading source of urinary tract infections in care settings, and residents with neurogenic bladders, like Resident #62, are already at elevated risk. Infections that begin in the urinary tract can spread to the kidneys and bloodstream. For someone with her combination of diagnoses, including chronic respiratory failure and anemia, an untreated infection can become a serious medical event quickly.
The inspection was triggered by a complaint, filed under complaint number OH00165443. Inspectors reviewed three residents with indwelling catheters. The documentation failure affected one of them.
The facility census at the time of inspection was 95 residents.
CMS classified the violation as causing minimal harm or potential for actual harm, the lower end of the agency's harm scale. The deficiency was cited under the federal standard requiring nursing homes to provide appropriate catheter care and take steps to prevent urinary tract infections.
What the records do not show is whether Resident #62 developed an infection during those weeks. The inspection report does not say. What it does show is a woman who cannot move or care for herself, who depends entirely on the staff around her, telling an inspector that the care her own facility promised her in writing simply does not happen at night. She said it matter-of-factly, the way someone describes something they have long since stopped expecting to change.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
OAKS OF WEST KETTERING THE in KETTERING, OH was cited for violations during a health inspection on August 20, 2025.
She has paraplegia, chronic respiratory failure with hypoxia, and a neurogenic bladder that requires an indwelling urinary catheter.
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.