Inspection·July 10, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, record review, and policy review, the facility failed to ensure staff followed appropriate infection control procedures during wound care. This affected one (Resident #34) of three residents reviewed for skin conditions. The facility census was 77. Residents Affected - Few Findings include: Record review of Resident #34 revealed an admission date of 08/12/22 with pertinent diagnoses of type two diabetes mellitus with diabetic polyneuropathy, chronic kidney disease, atrial fibrillation, ischemic cardiomyopathy, repeated falls, anemia, hypertension, and congestive heart failure. Review of the 05/05/23 significant change Minimum Data Set (MDS) assessment revealed Resident #34 was severely cognitively impaired and required total dependence for personal hygiene, transfer, and locomotion on and off unit. The resident required extensive assistance for bed mobility, dressing, and toilet use. The resident uses a wheelchair to aid in mobility and is frequently incontinent of bladder and always incontinent of bowel. Review of the physician's order dated 06/22/23 revealed to cleanse left arm with normal saline, apply wound gel and bordered gauze dressing, change every three days and as needed. Review of the progress note dated 07/06/23 at 1:05 P.M. revealed the nurse and nurse practitioner were in the facility to see Resident #34 for wound care. The resident's wound to the left arm was unchanged at 1.0 centimeters (cm) in length by 0.8 cm in width by 0.1 cm in depth. Observation on 07/10/23 at 10:02 A.M. revealed Registered Nurse (RN) #107 performing wound care to Resident #34's left arm. RN #107 gathered her supplies, then washed her hands and put on clean gloves. Resident #34 had an arm sleeve on and RN #107 pulled down the arm sleeve and removed the old dressing that was dated 07/09. RN #107 did not remove her gloves after removing the soiled dressing. RN #107 cleaned the wound with a wound cleanser and dried it with a four by four gauze. RN #107 did not remove her gloves after cleaning the wound. RN #107 applied wound hydrogel to the dressing and placed the dressing on the wound. RN #107 then removed her gloves and washed her hands. Interview on 07/10/23 at 10:09 A.M. with RN #107 verified she did not change her soiled gloves after removing the soiled dressing, or after cleaning the wound. Review of the facility policy titled, Clean Dressing Change, dated 07/10/23, revealed the following: Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound. Loosen the tape and remove the existing dressing. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on clean gloves. Cleanse the wound (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365321 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of West Kettering The 1150 West Dorothy Lane Kettering, OH 45409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)