Oaks of West Kettering: Infection Control Failures - OH
The inspection, completed August 20, 2025, was a complaint investigation. What inspectors found with the nurse was an incidental discovery made while they were already in the building looking into something else.
The resident, identified in inspection records as Resident 8, had been admitted to the facility on July 19, 2025. The list of diagnoses was long and serious: a fractured left fibula, sepsis, cellulitis, end-stage renal disease, type two diabetes, a bladder condition, anemia, an abscess of the foot, dependence on renal dialysis, and hypertension. The resident had arrived at the facility with a stage three pressure ulcer already present.
By early August, the care plan documented two active wound concerns. One was a pressure ulcer on the right buttock. The other was described as a venous or stasis ulcer. Orders called for wound care to the right buttock every Tuesday, Thursday, and Saturday, using an alginate and bordered foam dressing. A separate order, dated July 29, placed the resident under enhanced barrier precautions specifically because of the dialysis and the wounds.
Enhanced barrier precautions exist for a reason. Dialysis patients carry elevated infection risk. Open wounds create pathways for pathogens to move in both directions, from patient to caregiver and from caregiver to patient. The facility's own policy, revised as recently as July 1, 2025, stated that protective equipment is required during high-contact care activities, and it listed wound care by name.
An inspector watched Licensed Practical Nurse 232 perform wound care on the resident at 10:03 in the morning on August 19. The nurse explained the procedure to the resident, performed hand hygiene, and put on gloves. She removed the old dressing, washed her hands again, put on fresh gloves, and completed the wound care as ordered. The hand hygiene steps were done correctly.
She did not put on a gown at any point.
The enhanced barrier precaution sign was posted on the door. The PPE cart was in the hallway outside the room. Eight minutes after the observation ended, an inspector spoke with the nurse directly. She confirmed the resident was under enhanced barrier precautions. She confirmed the sign was on the door. She confirmed the equipment was outside. Then she confirmed she had not worn it.
The inspection report does not describe any consequence to the resident from the lapse, and the harm level is listed as minimal or potential for actual harm. But that framing reflects what inspectors could document, not what the risk was in the room that morning. A resident on dialysis, fighting sepsis, with a stage three pressure ulcer and a stasis ulcer, was receiving wound care from a nurse who had skipped the layer of protection the facility itself had ordered for exactly that situation.
The facility's hand hygiene policy, also reviewed by inspectors, makes clear that gloves do not replace hand hygiene and that staff must clean their hands before putting gloves on and immediately after taking them off. The nurse followed that part of the protocol. The gown, which would have protected both her clothing and the resident from cross-contamination during a procedure involving open wounds, was left on the cart in the hall.
Resident 8 remained in the facility as of the inspection date, still dependent on dialysis, still carrying wounds that required scheduled treatment three days a week.
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 22, 2026 · Our methodology
OAKS OF WEST KETTERING THE in KETTERING, OH was cited for violations during a health inspection on August 20, 2025.
The inspection, completed August 20, 2025, was a complaint investigation.
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.