The resident, identified in inspection records as Resident 1, left the facility on December 10, 2025 for a home visit.
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The inspection, conducted November 24, 2025, turned up two deficiencies at the Fairfield facility.
Two certified nursing assistants, identified in the report as CNA L and CNA D, were fired four days after the incident.
That was the scene inspectors found at the Oaks of West Kettering on the morning of November 24, 2025.
Inspectors rated the harm level as minimal or potential for actual harm.
A new company had taken over oversight of the kitchen.
Inspectors classified the problem as a pattern, meaning it was not an isolated incident.
facility on December 30, 2025, following a complaint.
Federal inspectors cited the Dallas nursing home on November 25, 2025, following a complaint investigation.
The level of harm was classified as minimal harm or potential for actual harm, and inspectors noted that few residents were affected.
When a state inspector observed the resident at 11:00 that morning, the oxygen concentrator was running at 2.5 liters per minute.
The inspector had requested the files at 12:48 p.m.