Oaks of West Kettering the
1150 West Dorothy Lane, Kettering, OH 45409 · Montgomery County · 118 certified beds · avg 107 residents/day · certified since Mar 31, 1974
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 3, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 3, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 17, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 22, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 30, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 21, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 31, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 16, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (59)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 3, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Mar 3, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 3, 2026 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Mar 3, 2026 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint |
| Nov 24, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Nov 24, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jan 22, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 22, 2025 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jan 22, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Jul 30, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 30, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 30, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 30, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jul 30, 2024 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint |
| Jul 30, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jul 30, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jul 30, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| May 29, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jan 31, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 4, 2021 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 4, 2021 | E · Potential for harm, repeated | The facility did not honor residents' right to receive the visitors they choose, at the times they choose. |
| Aug 4, 2021 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 4, 2021 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 4, 2021 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 4, 2019 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 4, 2019 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Apr 4, 2019 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (15 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 16 | 0 | F |
| 2021 | 15 | 0 | F |
| 2024 | 11 | 2 | G ▲ |
| 2025 | 10 | 1 | G ▲ |
| 2026 | 7 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $75,572, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jan 22, 2025 | Fine | $10,358 |
| Jan 22, 2025 | Payment Denial | 28 days from Feb 18, 2025 |
| Jul 30, 2024 | Fine | $55,896 |
| Jan 31, 2024 | Fine | $9,318 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Ohio avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.80 | 3.45 | 3.95 | bottom 12% in Ohio; bottom 8% in the U.S. |
| Registered Nurse hours | 0.47 | 0.60 | 0.69 | bottom 33% in Ohio; bottom 33% in the U.S. |
| Weekend total nurse staffing | 2.68 | 3.07 | 3.50 | bottom 25% in Ohio; bottom 15% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.85 | 0.42 | 0.48 | top 4% in Ohio; top 9% in the U.S. |
| Total nursing staff turnover (%) | 52.1 | 48.7 | 45.8 | bottom 40% in Ohio; bottom 32% in the U.S. |
| RN turnover (%) | 44.0 | 43.9 | 42.9 | bottom 50% in Ohio; bottom 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.79, RN 0.63, weekend 3.64. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Kettering Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/31/2023 |
| Kettering Opco | Organization | 5% or Greater Indirect Ownership Interest | 81% | 12/31/2023 |
| Shapiro, Naftali | Individual | 5% or Greater Indirect Ownership Interest | 19% | 12/31/2023 |
| Hunter, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/31/2023 |
| Hunter, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 12/31/2023 |
| Kettering Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/31/2023 |
| Kettering Management | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/31/2023 |
| Kettering Management | Organization | ADP of the SNF | NOT APPLICABLE | 04/09/2025 |
| Maddix, Sarah | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/31/2023 |
| Maddix, Sarah | Individual | ADP of the SNF | NOT APPLICABLE | 12/31/2023 |
| Shapiro, Naftali | Individual | Corporate Officer | NOT APPLICABLE | 12/31/2023 |
| Shapiro, Naftali | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/31/2023 |
| Shapiro, Naftali | Individual | ADP of the SNF | NOT APPLICABLE | 12/31/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "How do you coordinate hospice care, and can residents stay here while receiving it?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| The Laurels of Kettering | 2.0 mi | Kettering, OH | ★★☆☆☆ | 1/5 | |
| Walnut Creek Nursing Center | 2.2 mi | Kettering, OH | ★☆☆☆☆ | 2/5 | |
| Sanctuary at Wilmington Place | 2.6 mi | Dayton, OH | ★★☆☆☆ | 2/5 | |
| Dunbar Health & Rehab Center | 2.7 mi | Dayton, OH | ★★★☆☆ | 2/5 | |
| Kettering Heights Post Acute | 2.9 mi | Kettering, OH | ★★☆☆☆ | 2/5 | |
| Respiratory and Nursing Center of Dayton | 3.0 mi | Moraine, OH | ★★★★☆ | 3/5 | |
| Centerville Post Acute | 3.9 mi | Centerville, OH | ★★★☆☆ | 4/5 | |
| Vienna Springs Health Campus | 4.1 mi | Dayton, OH | ★★★★★ | 4/5 | |
| Bethany Village | 4.2 mi | Dayton, OH | ★★★★★ | 5/5 | |
| Gem City Healthcare and Rehabilitation Center | 4.3 mi | Dayton, OH | ★★★☆☆ | 2/5 | |
| Grafton Oaks Nursing Center | 4.3 mi | Dayton, OH | ★★☆☆☆ | 2/5 | abuse |
| Widows Home of Dayton | 4.4 mi | Dayton, OH | ★★☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 365321.