A list of the most recent deficiencies for Oaks of West Kettering The. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-02-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-10 | 2023-07-19 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-12-13 | 2022-12-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-31 | 2022-12-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-31 | 2022-12-14 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-31 | 2022-12-14 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-31 | 2022-12-14 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-10-31 | 2022-12-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-27 | 2022-04-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-11 | 2022-03-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-30 | 2022-01-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-30 | 2022-01-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-04 | 2021-09-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-04 | 2021-09-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-04 | 2021-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-04 | 2021-09-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-04 | 2021-09-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-04 | 2021-09-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-04 | 2021-09-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-04 | 2021-09-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-04 | 2021-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-09-28 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-08-04 | 2021-09-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-04 | 2021-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-04 | 2021-09-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-04 | 2021-09-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-27 | 2021-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-27 | 2021-09-28 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-09-27 | 2021-09-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-27 | 2021-09-28 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2021-09-08 | 2021-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-08 | 2021-09-28 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-27 | 2021-09-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-08 | 2021-03-22 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-03-08 | 2021-03-22 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-04 | 2019-04-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-04 | 2019-04-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-04 | 2019-04-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-04-04 | 2019-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-04 | 2019-04-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-04 | 2019-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-04 | 2019-04-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-04 | 2019-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-04 | 2019-04-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-04 | 2019-04-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-04 | 2019-04-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-04 | 2019-04-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-04-04 | 2019-04-26 | N |
| Provide or obtain dental services for each resident. | Health | 2019-04-04 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-04 | 2019-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-04 | 2019-04-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-04-12 | 2018-05-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-12 | 2018-05-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-12 | 2018-05-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-04-12 | 2018-05-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-04-12 | 2018-05-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-12 | 2018-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-12 | 2018-05-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-12 | 2018-05-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-12 | 2018-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-12 | 2018-05-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-04-11 | 2018-05-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-04-11 | 2018-05-08 | N |
