Oaks of West Kettering the

In the surveyor’s words

From the most serious findings on record at Oaks of West Kettering the, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Dec 13, 2022

  Based on medical record review, resident interview, staff interview, review of hospital records, review of staff statements, review of hospice notes, review of an Emergency Medical Services (EMS) run report, observations, and policy review, the facility failed to provide adequate behavioral health services for one Resident (#78) who voiced suicidal ideations. This resulted in Immediate Jeopardy and the potential for serious life-threatening injury, harm, impairment, and/or death, when Resident #78 told Hospice Nurse #150 maybe someday they'll come in and find me hanging, was left unsupervised on 10/17/22 from 2:43 P.M until 3:28 P.M. and was subsequently found unresponsive with a call light cord wrapped around his neck. […]

• Actual harm, isolatedF686Mar 3, 2026

  Based 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. This resulted in Actual Harm for Resident #116 on 12/22/25, when the resident was admitted to the facility without pressure ulcers, was assessed to be at risk for development of pressure ulcers and developed an avoidable unstageable pressure ulcer (a full-thickness wound where damage depth is hidden by slough [a soft, moist, yellow or… […]

• Actual harm, isolatedF689Mar 3, 2026

  Based 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.Findings included: Review of the medical record review for Resident #116 revealed an admission date of 11/12/25 and discharged home on [DATE]. […]

• Actual harm, isolatedF689Jan 22, 2025

  Based 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. Findings included: Review of the medical record for Resident #66, revealed an admitted [DATE]. […]

• Actual harm, isolatedF600Jul 30, 2024

  Based 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. […]