Oaks of West Kettering the

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to properly store the resident's medications in the medication carts. This affected three of three medications carts observed. The facility had a total of six medication carts. The facility census was 106.

Inspectors wroteBased on medical record review, observations, staff interviews, and policy reviews, the facility failed to provide a resident who required assistance with activities of daily living (ADL) timely assistance with toileting hygiene. This affected one (#8) of three residents reviewed for ADLs. The facility census was 106.

Inspectors wroteBased on record review, observations, staff and resident interviews, and policy review, the facility failed to initiate Enhanced Barrier Precautions (EBP) for a resident with a dialysis catheter per the facility's policy. This affected one (#23) of three residents reviewed for infection control. The facility census was 106.

Inspectors wroteBased on record review, observations, staff interviews, facility policy review, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to timely identify pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. [...]

Inspectors wroteBased on record review, review of emergency room (ER) records, staff interview, review of the facility's investigation and policy review, the facility failed to ensure a resident was safely turned in bed during incontinence care resulting in the resident falling out of bed. This resulted in Actual Harm when Certified Nursing Assistant (CNA) #355 was providing incontinence care to Resident #116 and the resident rolled out of the bed onto the floor. Resident #116 was sent to hospital and was diagnosed with a head injury which required staples. This affected one (Resident #116) of the three residents reviewed falls. The facility census was 107.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to assess residents for the use of bedrails prior to application of bed rails to the residents' beds. This affected 19 (Residents #3, #5, #6, #7, #9, #10, #13, #58, #61, #62, #65, #66, #67, #68, #69, #71, #72, #73, #74) of 19 residents reviewed for bed rails. The facility census was 107 residents.

Inspectors wroteBased on medical record review, staff interview, hospice interview, review hospice contracts, and review of the facility policy, the facility failed to ensure a communication process with the hospice company regarding documentation and coordination of care. This affected three (Residents #14, #70, #73) of six residents on hospice. The facility census was 71 residents.

Inspectors wroteBased on observation, staff interview, review of chemical safety data sheet, and facility policy review, the facility failed to ensure chemicals were stored properly. This had the potential to affect all 21 residents on the memory care unit. The facility census was 112.

Inspectors wroteBased on record review, staff interview, facility policy review, and review of Enhanced Information Dissemination and Collection system (EIDC) the facility failed to ensure an allegation of abuse was investigated and reported. This affected one Resident (#103) of three residents reviewed for falsification of medical records. The facility census was 112. Findings Include:Record review for Resident #103 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease with late onset, vascular dementia with agitation, psychotic disorder with delusions, and delirium (confusion). Review of nurses note dated 10/17/25 at 9:55 P.M. revealed Resident #103 was observed walking up to another resident and pulled their hair. Staff immediately intervened and helped Resident #103 to their room. Review of EIDC records on 11/24/25 at 2:05 P.M. [...]

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to comprehensively assess pressure ulcer wounds upon admission. This affected two (#08 and #100) of four residents reviewed for pressure ulcer care and services. The facility census was 95.

Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to complete indwelling catheter care as per policy. This affected one (#62) rout of three residents reviewed for indwelling catheter care. The facility census was 95.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to complete pre-dialysis assessments thoroughly and failed to completed post dialysis assessments. This affected three (#07, #08, and #100) out of the three residents reviewed for dialysis. The facility census was 95.

Inspectors wroteBased on medical record reviews, staff and resident interviews, observations, and policy reviews, the facility failed to follow infection control procedures during wound and incontinence cares. This affected two (#08 and #62) out of three residents observed for infection control procedures. The facility census was 95.

Inspectors wroteBased on medical record review, observations, and staff and resident interviews, the facility failed to ensure resident room was free from flies. This affected one (#11) out of three residents reviewed for pests/insects in rooms. The facility census was 95.

Inspectors wroteBased on medical record review, staff interviews, observation, review of maintenance logs, and review of facility policy, the facility failed to ensure a resident was free from accidents/hazards. This resulted in Actual Harm when Resident #66 utilized the first-floor restroom on 12/15/24 and while washing his hands, the floating handwashing sink fell on him resulting in a laceration to the left knee that required 17 sutures, the use of antibiotics for infection prevention and continued wound care. This affected one (#66) of three residents reviewed for accidents. The facility census was 101.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure a floating porcelain sink was maintained in a safe manner. This affected one (#66) resident of three residents reviewed for physical environment. The facility census was 101.

Inspectors wroteBased on medical record review, staff interviews, observation, and review of facility policy, the facility failed to ensure a resident's representative was notified when a resident had a change in condition by sustaining a laceration which required sutures and continued wound care. This affected one (#66) of three residents reviewed for notification of change in condition. The facility census was 101.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure the facility's East Unit crash cart included an assembled suction machine with canister, and a backboard. This affected 49 residents (#26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73 and #74) who resided on the East Unit out of the 112 residents at the facility. The facility census was 112.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the high temperature dishwashing machine sanitized at the proper temperature. This failure had the potential to affect 85 of 88 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection control program to prevent the transmission/development of infection for three (Resident #139, Resident #37, and Resident #5) of seven residents reviewed for infection control. Specifically, the facility failed to ensure that staff implemented Enhanced Barrier Precautions (EBP) for Resident #37 and #139 and failed to appropriately handle dirty linens and store respiratory equipment properly for Resident #5.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident #37) of six residents who required tube feedings received enteral nutrition in a manner that minimized the risk of complications. Specifically, the facility failed to ensure that Resident #37's enteral nutrition (tube feeding) formula was labeled with the date and time the infusion began.

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to obtain laboratory services ordered by the physician for one (Resident #74) of five residents reviewed for urinary catheter/urinary tract infection.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to follow the planned menu for the pureed diet for one (Resident #54) of seven residents who received pureed diets.

Inspectors wroteBased on observation, interview, record review, review of a police report, review of facility document, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a visitor for one (Resident #137) of three resident's reviewed for abuse. This resulted in Actual Harm on 04/09/24 when Resident #48's significant other, Family Member (FM) #16, touched Resident #137's breasts and private area and exposed his genitalia to the resident on a patio in the facility courtyard where residents smoked. FM #16 admitted to the police that he committed the actions against the resident, despite Resident #137 telling him, No. The failure resulted in Resident #137 being tearful and so traumatized by this event, that it felt like she was raped.

Inspectors wroteBased on record review, interview, review of facility documentation, and review of facility policy, the facility failed to report an allegation of sexual abuse to the state agency. This affected one (Resident #137) of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, a review of a police report, review of facility documentation, and policy review, the facility failed to have evidence that an allegation of abuse was thoroughly investigated for one (Resident #137) of three residents reviewed for abuse. Specifically, Resident #137 alleged Family Member (FM) #16 sexually abused the resident on 04/09/24. The facility failed to have documented evidence they reviewed facility video [NAME] footage from the time of the incident; failed to have documented evidence they interviewed/obtained statements from the resident, the alleged perpetrator, witnesses, and staff who worked closely with Resident #137; and failed to determine whether abuse was substantiated.

Inspectors wroteBased on medical record review, review of facility investigation, review of Self-Reported Incident (SRI), review of police report, staff interview, review of personnel files, and policy review, the facility failed to ensure residents were free from misappropriation of property. This affected one (#41) out of three residents reviewed for misappropriation. The facility census was 89.

Inspectors wroteBased on medical record review, review of facility investigations, review of hospital documentation, observations, staff interviews, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being cognitively impaired and at risk for elopements did not elope from the facility. This resulted in Actual Harm when Resident #04 eloped from the secured memory care unit on 01/23/24 without staff knowledge, and was found outside the facility by a generator. Resident #04 sustained injuries from a fall that occurred during the elopement which required hospital evaluation and treatment for the placement of a suture to a lip laceration and for treatment of a right thigh contusion. This affected one (#04) of three residents reviewed for elopement risk. The census was 84.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the ice machine in a manner to protect against the spread of food borne illness. This had the potential to affect all 90 residents in the facility. The facility census was 90.

Inspectors wroteBased on medical record review, observation, resident, visitor and staff interviews, review of facility policy, and review on online resources per the Center for Medicare and Medicaid Services (CMS) nursing home memos, the facility failed to permit resident visitation at the time of their choosing and provide privacy for visits. This affected four(#54, #68, #79 and #31) of four residents reviewed for visitation practices. The census was 90.

Inspectors wroteBased on medical record review, observations and staff interviews the facility failed to ensure care plans were updated or revised for residents residing on the secured unit. This affected six (#8, #22, #50, #54, #68 and #85) of 37 sampled residents. The facility identified thirty residents who reside on the secured unit. The facility census was 90.

Inspectors wroteBased on record review, observations, staff interview, and review of facility policy the facility failed to ensure expired house stock insulin was discarded. The facility failed to ensure topical medication was stored separately from oral inhalers. This had the potential to affect seven (#5, #19, #33, #35, #64, #80, #339) insulin-dependent residents on the Central Unit. This affected one (#9) of one resident receiving topical ointments. The census was 90.

Inspectors wroteBased on medical record review and staff interview, the facility failed to have the required information on discharged notices. This affected two (#1 and #19) of four reviewed for hospitalizations. The census was 90.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to ensure dependent residents were provided with adequate nail care. This affected one (#68) of three residents reviewed for activities of daily living (ADLs). The facility identified 62 residents dependent on staff assistance with ADLs. The census was 90.

Inspectors wroteBased on medical record review, policy review and staff interview, the facility failed to ensure wounds were provided treatments as ordered and regularly assessed. This affected one (#78) of four residents reviewed for wound care. The facility census was 90.

Inspectors wroteBased on record review, staff interview, and review of facility policy the facility failed to regularly assess pressure sores, obtain physician orders for new developed pressure sores and apply pressure relieving devices This affected three (#78, #68 and #41) of four residents reviewed for wound care. The census was 90.

Inspectors wroteBased on observations, medical record review, and staff interviews, the facility failed to provide treatment of physician ordered splint devices to maintain range of motion and prevent contractures. This affected one (#41) of three residents reviewed for limited range of motion. The facility identified 26 residents residing in the facility with contractures. The facility census was 90.

Inspectors wroteBased on medical record review, observations, resident interview, staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place and environmental hazards were not present in a room for a resident assessed at risk for falls. This affected two (#68 and #8) of seven residents reviewed for accidents and hazards. The census was 90.

Inspectors wroteBased on medical record review, staff interview, observation, and review of facility policy, the facility failed to provide timely incontinence care for a resident and ensure a resident with a nephrostomy tube was provided care and treatment per physician orders. This affected two (#15 and #19) of three reviewed for care and treatment of bladder and bowel. The census was 90.

Inspectors wroteBased on the medical record review and staff interview, the facility failed to ensure medications were administered per physician orders. This affected two (#15 and #20) of six resident medical records reviewed for pharmacy. The facility census was 90.

Inspectors wrote2. Review of the medical record of Resident #05 revealed an admission date of 10/17/20. Diagnoses included muscle weakness, type 2 Diabetes Mellitus with diabetic neuropathy, morbid obesity, essential hypertension, paroxysmal atrial fibrillation, major depressive disorder, COVID-19, polyneuropathy, gastroesophageal reflux, and sleep apnea. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician's orders revealed an order dated 06/11/21 for hydroxyzine hcl tablet 25 milligrams (mg) as needed (PRN) every 8 hours for anxiety. Review of the pharmacy medical record review dated 06/24/21 revealed a notification of the order for hydroxyzine PRN required a 14-day stop with an in-person physician evaluation prior to re-ordering the medication. [...]

Inspectors wroteBased on medical record review, policy review and staff interview, the facility failed to ensure gradual dosage reductions were attempted for residents receiving psychotropic medications and failed to ensure antipsychotic medications were given for an appropriate indication. This affected three (#54, #68 and #15) of six residents reviewed for unnecessary medications. The facility identified 23 residents with orders for antipsychotic medications. The facility census was 90.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policies, the facility failed to ensure staff practiced appropriate hand hygiene during medication administration. This affected one (#31) of five residents observed for medication administration. The census was 90.

Inspectors wroteBased on review of the facilities water management program, observations, staff interview, and policy review, the facility failed to properly sanitize the blood glucose monitoring system between resident use. This affected one (#282) of two resident using the glucometer during medication administration. The facility identified ten resident who use the glucometer from the west medication cart. Additionally, the facility failed to implement a water management program for the prevention and spread of Legionella. This had the potential to affect all 86 resident who reside at the facility. The census was 86.

Inspectors wroteBased on medication storage area observation and staff interviews, the facility failed to properly label and store medications. Additionally, the facility failed to adequately secure narcotic medication. This affected one (#26) resident medication that was expired, one medications with no residents identification information or prescription label, and one multi-use vial of medication that was opened and undated located in two (central one medication cart and east one medication cart) of five medication storage areas observed. The census was 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure advanced directives being stored in the hard chart and electronic health record (EHR) were consistent. This affected one (#32) of 24 residents reviewed for consistency of advanced directives. The census was 86.

Inspectors wroteBased on medical record review, family, nurse practitioner and staff interview, and review of facility policy, the facility failed to notify resident representatives and/or the provider of a change in a resident's status or refusals of care. This affected three Residents (#36, #51, and #77) of three residents reviewed for notification of changes. The facility census was 86.

Inspectors wroteBased on record review and staff interview, the facility failed to provide written transfer notification to one (#84) resident when they were hospitalized and failed to notify the Ombudsman of the transfer. This affected one (#84) of one residents reviewed for hospitalization and had the potential to affect all residents. The facility census was 86.

Inspectors wroteBased on medical record review, policy review and staff interview, the facility failed to issue written notice of the bed hold policy when a resident was transferred to the hospital. This affected one (#84) of one residents reviewed for hospitalizations. The total facility census was 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected one (#32) of 20 resident reviewed for accuracy of the MDS assessment. The census was 86.

Inspectors wroteBased on medical record review, resident and staff interview, and review of policy and procedures, the facility failed to ensure 48 hours baseline care plan were completed and failed to ensure a copy was provide to the resident/resident representative as required. This affected three Residents (#4, #59 and #60) out of nine residents in the investigative sample. The facility census was 86.

Inspectors wroteBased on medical record review, staff and nurse practitioner interview and policy review, the facility failed to obtain blood work as ordered for one resident which resulted in a delay in treatment. This affected one (#51) of five residents reviewed for medications. The census was 86.

Inspectors wroteBased on medical record review, observations and staff interview, the facility failed to ensure a physician ordered splint device was available for resident use. This affected one (#32) of one resident reviewed for limited range of motion. The census was 86.

Inspectors wroteBased on policy review, medical record review and staff interview, the facility failed to investigate one resident's fall with injury to identify contributing factors to possible prevent future falls. This affected one (#36) of two residents review for accidents. The census was 86.

Inspectors wroteBased on medical record review, observation and resident and staff interview, the facility failed to implement a fluid restriction as recommended for a dialysis resident. This affected one (#182) out one resident review for dialysis care. The facility identified two residents currently residing in the facility who receive dialysis treatments. The census was 86.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident was free from unnecessary medications regarding prescribing antibiotics for the appropriate signs and symptoms of infection. This affected one (#48) of five resident reviewed for unnecessary medication. The census was 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure physician ordered laboratory tests were completed. This affected one (#48) of five resident reviewed for unnecessary medication. The census was 86.

Inspectors wroteBased on medical record review and resident representative and staff interview, the facility failed to provide routine dental services. This affected one (#35) of one resident reviewed for dental services. The census was 86.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed implement their antibiotic stewardship protocols to ensure appropriate antibiotic use. This affected one (#48) of three resident's reviewed for antibiotic use. The census was 86.