Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on medical record review, staff and resident interviews, review of the facility's self-reported incidents,
review of the facility's policy, the facility failed to report allegations of abuse to the State Survey Agency.
This affected five (#2, #13, #30, #62 and #96) of five residents reviewed for abuse. The facility census was
99.
Findings include
1. Medical record review for Resident #13 revealed the resident had an admission dated of 09/04/19.
Diagnoses included Alzheimer's disease, dementia and insomnia. Review of the of the admission Minimum
Data Set (MDS) assessment, dated 09/13/19, revealed the resident had severe cognitive impairment.
Medical record review for Resident #62 revealed the resident had an admission date of 02/21/19.
Diagnoses included hypertensive heart disease and atrial fibrillation. Review of the quarterly MDS
assessment, dated 01/27/20, revealed the resident had impaired cognition.
Review of an incident witness statement, dated 09/15/19, revealed at about 3:00 P.M., Resident #62 sat in
the hallway yelling at Resident #13 telling her she is not cured, and she should be locked up somewhere.
Resident #62 told Resident #13 my son will get you. Review of a second incident witness statement, dated
09/15/19, revealed Resident #62 was sitting in the hallway making threatening comments to Resident #13.
Resident #62 stated she was going to take her water cup and hit Resident #13 if she came out of her room
or near her. Resident #13 was scared to come out of her room. The two residents were separated.
Review of the facility's self-reported incidents from 09/15/19 to 03/02/20 revealed the facility did not report
the allegation of resident-to-resident abuse the occurred on 09/15/19.
Interview on 03/04/20 at 5:08 P.M. with the Administrator verified the incident between Resident #62 and
Resident #13 had not been reported to the State Survey Agency as required.
2. Medical record review for Resident #30 revealed the resident had an admission date of 05/05/19.
Diagnoses included multiple sclerosis, anxiety and depressive disorder. Review of the quarterly MDS
assessment, dated 01/03/20, revealed Resident #30 had impaired cognition.
Review of a nurse's note, dated 01/12/20, revealed Resident #30 reported to the nurse, Resident #13 came
up behind her in the hallway and pushed her wheelchair. When Resident #30 told Resident #13 to stop
pushing her, Resident #13 then hit Resident #30 on the left shoulder and right arm. The Director of Nursing
was notified.
(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 12
Event ID:
365639
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Review of an incident witness statement, dated 01/31/20, revealed Resident #30 was trying to pass through
a doorway which was blocked by Resident #13. Resident #30 asked Resident #13 to move. Resident #13
grabbed Resident #30's arm. Resident #30 pulled her arm away and told Resident #13 Don't touch me.
Resident #30 stated I want to report her every time she touches me. The Administrator was notified of the
incident.
Residents Affected - Some
Review of the facility's self-reported incidents from 01/12/20 to 03/02/20 revealed the facility did not report
the allegation of resident-to-resident abuse the occurred on 01/12/20 and 01/31/20.
Interview on 03/04/20 at 10:58 A.M. with the DON revealed on 01/12/20 Resident #30 alleged Resident #13
pushed her then hit her.
Interview on 03/04/20 at 11:11 A.M., the Administrator verified the incidents on 01/12/20 and 01/31/20
between Resident #30 and Resident #13 were not reported to the State Survey Agency.
Interview on 03/04/20 at 2:53 P.M. with Registered Nurse (RN) #10 revealed on 01/12/20, Resident #30
reported Resident #13 had hit her. RN #10 revealed she reported the incident to the Director of Nursing.
Interview on 03/05/20 at 10:50 A.M. with Resident #30 revealed another resident with dementia picked on
people. Resident #30 stated the resident ran into her, pulled on her wheelchair and hit her on two different
days. Resident #30 revealed she reported both incidents to her nurse.
3. Medical record review for Resident #96 revealed the resident had an admission date of 05/02/19.
Diagnoses included dementia and vitamin D deficiency. Review of the quarterly MDS assessment, dated
02/10/20, revealed the resident had impaired cognition.
Review of a nurse's note, dated 01/23/20 at 8:55 A.M., revealed Resident #13 was observed striking
another resident's leg with her baby doll, unprovoked.
Review of the facility's self-reported incidents from 01/23/20 to 03/02/20 revealed the facility did not report
the allegation of resident-to-resident abuse the occurred on 01/23/20.
Interview on 03/05/20 at 10:56 A.M. with Resident #96 revealed Resident #13 had punched him in the leg a
while ago.
Interview on 03/05/20 at 10:59 A.M. with the Staffing Coordinator (SC) #107 revealed on 01/23/20 she was
coming up the hallway and saw Resident #13 hit Resident #96 with a baby doll with a plastic head. SC
#107 revealed Resident #13 hit Resident #96 hard and she got right between them to separate them. SC
#107 reported the incident to the resident's nurse.
Interview on 03/05/20 at 11:03 A.M. with the Staff Development Nurse (SDN) #197 revealed Resident #13
hit Resident #96 with her doll. SDN #197 revealed the residents were separated. SDN #197 revealed she
reported the incident to the Administrator.
Interview on 03/05/20 at 12:05 PM with the Administrator and Director of Nursing verified the incident on
01/23/20 between Resident #13 and Resident #96 was not reported to the State Survey Agency as
required.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 2 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
4. Medical record review for Resident #2 revealed the resident had an admission date of 11/19/18.
Diagnoses included chronic kidney disease, depressive disorder and peripheral vascular disease. Review
of the quarterly MDS assessment, dated 11/14/19, revealed Resident #2 had intact cognition.
Review of a documented interview, dated 03/03/20 at 4:45 P.M., revealed Resident #2 told the Licensed
Social Worker (LSW) #196 that Resident #13 had hit him in the arm. Resident #2 revealed he had not
reported the incident at the time it had occurred.
Interview on 03/02/20 at 10:53 A.M. with Resident #2 revealed Resident #13 had hit him six months ago
and had hit other residents in shoulder.
Interview on 03/05/20 at 10:39 A.M. with Licensed Social Worker (LSW) #196 revealed on 03/03/20,
Resident #2 stated Resident #13 hit him either when he first got here or three to four months ago.
Interview on 03/05/20 at 11:12 A.M. with the Administrator stated she just reported the allegation made by
Resident #2 on 03/03/20. The Administrator verified the allegation was not reported to State Survey Agency
within 24 hours as required.
Review of the facility's policy titled Abuse Reporting-Staff Treatment of Residents, dated 02/15/18, revealed
the Administrator or their designee would report allegations of abuse not involving bodily injury no later than
24 hours to the state agency.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 3 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interviews, the facility failed to provide written notification of the resident's
transfer to the hospital to the resident and/or resident's representative and to the Office of the State
Long-Term Care Ombudsman. This affected two (Resident #95 and #100) of two residents reviewed for
hospitalization. The facility census was 99.
Findings include:
1. Review of Resident #95's medical record revealed an admission to the facility on [DATE]. Resident #95
was hospitalized from [DATE] through 02/14/20 and was re-admitted back to the facility at that time. The
record lacked any evidence Resident #95's family was provided any written evidence of the reason for the
hospital discharge. There was no evidence the Office of the State Long-Term Care Ombudsman was
notified of Resident #95's transfer to the hospital.
Interview with the Administrator on 03/04/20 at 1:07 P.M. stated the facility receptionist should be
completing the written notifications and confirmed they were not completed for Resident #95's
hospitalization on 02/11/20. He stated the facility completed an audit and identified this occurred because
the receptionist was sick and they did not have any others.
2. Review of the medical record for Resident #100 revealed an admission date of 12/03/19 and discharge
date of 12/04/19. Diagnoses included encephalopathy, spinal stenosis and chronic obstructive pulmonary
disease. Review of the discharge summary note dated 12/04/19 revealed Resident #100 discharges to
emergency department for medical evaluation.
There was no evidence in the medical record a written notification of the resident's transfer to the hospital
was provided to the resident and the resident's representative.
Interview on 03/05/20 at 8:50 A.M. with the Administrator verified Resident #100 or representative did not
receive the written notification of the resident's transfer to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 4 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #95's medical record revealed an admission to the facility occurred on 08/07/19. Resident #95
was hospitalized from [DATE] through 02/14/20 and was re-admitted back to the facility at that time.
There was no evidence in the resident's medical record the resident and/or resident's representative was
given notice of the facility's bed hold policy upon the resident's discharge to the hospital.
Interview with the Administrator on 03/04/20 at 1:07 P.M. confirmed there was no bed hold notification
information provided to Resident #95's family at the time of his transfer to the hospital on [DATE].
Review of the facility's policy titled Bed Hold, Transfer,and Discharge Notice, dated 09/2018, revealed a bed
hold notice is also required at the time of transfer or, in case of an emergency with in 24 hours.
Review of the Ohio and Federal Nursing Home Residents' [NAME] of Rights handbook, dated 02/01/18,
provided to all residents revealed at the time of transfer of a resident for hospitalization, the facility must
provide the resident and the resident's representative written notice which specified the duration the
bed-hold policy.
Based on medical record review, staff interview, review of the Ohio and Federal Nursing Home Residents'
[NAME] of Rights handbook and review of the facility's policy, the facility failed to provide a notice to the
resident and/or resident's representative of the facility's bed hold policy upon the resident's discharge to the
hospital. This affected two (#95 and #100) of two residents reviewed for hospitalization. The facility census
was 99.
Findings include:
1. Review of the medical record for Resident #100 revealed an admission date of 12/03/19 and discharge
date of 12/04/19. Diagnoses included encephalopathy, spinal stenosis and chronic obstructive pulmonary
disease. Review of the discharge summary note, dated 12/04/19, revealed Resident #100 was discharged
to the emergency department for medical evaluation.
There was no evidence in the resident's medical record the resident and/or resident's representative was
given notice of the facility's bed hold policy upon the resident's discharge to the hospital.
Interview on 03/05/20 at 8:50 A.M. with the Administrator verified the facility did not provide written notice of
the facility's bed hold policy to Resident #100 and/or representative at the time of transfer to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 5 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of the Resident Assessment instrument (RAI) manual and staff interviews,
the facility failed to ensure the residents had accurate Minimum Data Set (MDS) assessments. This affected
11 (Resident #4 #14, #16, #18, #23, #26, #40, #59, #60, #67 and #77) of 32 resident reviewed for MDS
assessments. The facility census was 99.
Residents Affected - Some
Findings include:
1. Review of Resident #18's medical record revealed an admission to the facility occurred on 10/24/19.
Review of the Minimum Data Set (MDS) assessment, dated 02/01/20, revealed in section C, for the Brief
Interview for Mental Status (BIMS) (test of the cognition function), it was marked as not assessed.
2. Review of Resident #40's medical record revealed an admission to the facility occurred on 10/12/19.
Review of the MDS assessment, dated 01/09/20, revealed section C was marked as not assessed.
3. Review of Resident #67's medical record revealed an admission to the facility occurred on 07/12/13.
Review of the MDS assessment, dated 01/23/20, revealed section C was marked as not assessed.
4. Review of Resident #77's medical record revealed admission to the facility occurred on 10/25/19. Review
of the MDS assessment, dated 02/21/20, revealed section C was marked as not assessed.
5. Medical record review for Resident #23 revealed an admission date of 10/22/10. Diagnoses included
atrial fibrillation and major depression.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/20, revealed section C was
marked as not assessed.
6. Medical record review for Resident #14 revealed the resident had an admission date of 09/10/18.
Diagnoses included depressive disorder and anxiety.
Review of the quarterly MDS assessment, dated 12/18/19, revealed section C was marked as not
assessed.
7. Medical record review for Resident #16 revealed the resident had an admission date of 12/15/18.
Diagnoses included convulsions and hemiplegia and hemiparesis following cerebral infarction affecting left
non-dominant side.
Review of the significant change MDS assessment, dated 12/19/19, revealed section C was marked as not
assessed.
8. Medical record review for Resident #60 revealed the resident had an admission date of 10/18/19.
Diagnoses included dementia.
Review of the quarterly MDS assessment, dated 01/25/20, revealed section C was marked as not
assessed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 6 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
9. Medical record review for Resident #26 revealed the resident had an admission date of 07/13/12.
Diagnoses included depressive disorder.
Review of the quarterly MDS assessment, dated 12/29/19, revealed section C was marked as not
assessed.
Residents Affected - Some
10. Medical record review for Resident #4 revealed the resident was admitted to the facility on [DATE].
Diagnoses included emphysema, chronic respiratory failure and major depressive disorder
Review of the comprehensive MDS assessment, dated 11/24/19, revealed section C was marked as not
assessed.
11. Record review for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses
included chronic kidney disease, high cholesterol and major depressive disorder
Review of the comprehensive MDS assessment, dated 01/22/20, revealed section C was marked as not
assessed.
Interview on 03/03/20 at 2:42 P.M. with the MDS Nurse #17 verified the BIMS assessments were not
completed and the resident's cognition status was not assessed.
Interview with Registered Nurse (RN) #17 on 03/03/20 at 2:45 P.M. revealed as of 10/01/19 the therapy
department was responsible for completing section C of the MDS. The interview revealed in 01/2020 it was
determined there were many missing assessments and the therapy director was notified.
Interview with Speech Therapist/Rehabilitation Director #156 on 03/04/20 at 7:54 A.M. confirmed therapy
started completing section C of the MDS in 10/2019. The interview revealed in January 2020 they revealed
the assessments were not getting completed timely and provided some education to the staff. The interview
confirmed the assessments were still not getting completed timely so the education apparently did not
work.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 7 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interview and record review, the facility failed to ensure the restorative nursing was implemented for
Resident #47. This affected one (#47) of two residents reviewed for limited range of motion and mobility.
The facility census was 99.
Findings include:
Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included hemiplegia, hemiparesis, following cerebral infarction (stroke) affecting left
(non-dominant side), vascular dementia without behavioral disturbance, history of falling, pain in left hip,
and displaced fracture of acromial process of right shoulder.
Review of the Minimum Data Set (MDS) assessment, dated 10/08/19, revealed the resident had upper
extremity impairment on both sides and no impairment on the lower extremity.
Further review of the resident's medical revealed Resident #47 was readmitted to the facility following
hospitalization on 01/04/20. She received physical therapy (PT) and occupational therapy (OT) from
01/05/20 until she was discharged from therapy on 01/23/20.
Review of the PT/OT discharge summaries, dated 01/23/20, revealed the recommendations were to
continue with Stand Pivot Transfer (SPT) with pivot disc, two person assistance in and out of bed, a stand
up lift on and off the toilet, and restorative nursing program for lower extremity active assistance range of
motion to prevent further knee flexion contracture. The OT discharge summary, also dated 01/23/20,
recommended restorative dining with one-person assistance to ensure proper nutritional intake.
Review of the facility's order summary report, dated 01/27/20, revealed orders for Resident #47 to receive
transfers via stand-up lift with one-person assistance on and off toilet and SPT using pivot disc on and off
bed with two-person assistance every shift. The order date was 01/23/20 and the start date was also
01/23/20.
Interview with Resident #47 on 03/02/20 at 2:37 P.M. revealed her knees were problematic and cause pain.
She stated that she walks behind her wheelchair short distances with assistance.
Interview on 03/04/20 at 7:56 A.M. with Physical Therapist (PT) #183 confirmed upon discharge, Resident
#47 was referred for restorative nursing program.
Interview on 03/04/20 at 12:57 P.M. with the Administrator and the DON confirmed the restorative program
was not established based on the therapy recommendations from 01/23/20.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 8 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observations, medical record review and staff interview, the facility failed to implement fall
interventions for one (Resident #18) of three residents reviewed for falls. The facility census was 99.
Residents Affected - Few
Findings include:
Review of Resident #18's medical record revealed an admission to the facility occurred on 03/13/18. The
assessment, dated 12/21/19, identified Resident #18 to be at a high risk for falling and a written plan of
care was developed.
Review of the resident's fall care plan, dated 12/2019, revealed interventions including for fall mats to both
sides of the resident's bed and pad an protect the side rails.
Review of the physician orders, dated March 2020, revealed orders for fall interventions of mats on bilateral
sides of Resident #18's bed and padded side rails.
Observations of Resident #18 on 03/02/20 at 11:38 A.M. and 2:00 P.M. and on 03/03/20 at 11:10 A.M.
revealed he was lying in bed and there was no mat to the left side of the resident's bed or a padded rail to
the right side.
Interview with the Director of Nursing on 03/03/20 at 2:04 P.M. confirmed Resident #18's physician orders
and care plan were not being following as Resident #18 did not have the floor mat on the left side of the
bed or the padded side rail on the right side.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 9 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, staff interview and policy review, the facility failed to ensure a resident's
anchoring device was in place to attempt to prevent accidental trauma, pain or injury from excessive
tension or removal of a indwelling catheter. This affected one (Resident #200) of one resident reviewed for
catheter care. This facility identified nine residents who had with indwelling catheters. The facility census
was 99.
Findings include:
Review of Resident #200's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included neurogenic dysfunction of bladder.
Review of the care plan, dated 03/02/20, revealed the resident had an indwelling catheter due to a
neurogenic bladder and an intervention included to secure the catheter to the thigh or abdomen to avoid
urinary tension on urinary meatus and trauma to urethra. The indwelling catheter leg strap was to be
applied to the thigh to be used at all times.
Observation on 03/04/20 at 1:39 P.M. of catheter care with State Tested Nursing Assistant (STNA) #124
and #153 and License Practical Nurse (LPN) #65 revealed Resident #200 was without a leg strap.
Interview on 03/04/20 at 1:40 P.M. with License Practical Nurse #65 verfiied the resident was to have a
device to secure the indwelling to prevent from accidentally removing the tubing. LPN #65 verified was no
anchoring device was in place for Resident #200's indwelling catheter.
Review of the facility's policy titled Perineal Care, dated 02/21/18, revealed the purpose of this procedure
was to provide cleanliness and comfort to the resident, prevent infections and skin irritation, and to observe
the resident's skin condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 10 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on record review, staff interview and review of the facility's policy, the facility failed to ensure the
resident-to-resident incidents were documented in the medical record. This affected three (#13, #30 and
#62) of 32 resident's record reviewed. The facility census was 99.
Findings include
1. Medical record review for Resident #13 revealed the resident had an admission dated of 09/04/19.
Diagnoses included Alzheimer's disease, dementia and insomnia. Review of the of the admission Minimum
Data Set (MDS) assessment, dated 09/13/19, revealed the resident had severe cognitive impairment.
Medical record review for Resident #62 revealed the resident had an admission date of 02/21/19.
Diagnoses included hypertensive heart disease and atrial fibrillation. Review of the quarterly MDS
assessment, dated 01/27/20, revealed the resident had impaired cognition.
Review of an incident witness statement, dated 09/15/19, revealed at about 3:00 P.M., Resident #62 sat in
the hallway yelling at Resident #13 telling her she is not cured, and she should be locked up somewhere.
Resident #62 told Resident #13 my son will get you. Review of a second incident witness statement, dated
09/15/19, revealed Resident #62 was sitting in the hallway making threatening comments to Resident #13.
Resident #62 stated she was going to take her water cup and hit Resident #13 if she came out of her room
or near her. Resident #13 was scared to come out of her room. The two residents were separated.
Review of the nurses notes, dated 09/15/19, revealed there was no documentation of the incident in the
medical records of Resident #13 and Resident #62.
Interview on 03/05/20 at 10:43 A.M. with the Administrator verified all observations and incidents should be
documented in the residents' medical record per the facility's policy.
Interview on 03/05/20 at 12:05 P.M. with the Administrator and the Director of Nursing (DON) verified the
incident was not documented in the residents' medical records.
2. Medical record review for Resident #30 revealed the resident had an admission date of 05/05/19.
Diagnoses included multiple sclerosis, anxiety and depressive disorder. Review of the quarterly MDS
assessment, dated 01/03/20, revealed Resident #30 had impaired cognition.
Review of an incident witness statement, dated 01/31/20, revealed Resident #30 was trying to pass through
a doorway which was blocked by Resident #13. Resident #30 asked Resident #13 to move. Resident #13
grabbed Resident #30's arm. Resident #30 pulled her arm away and told Resident #13 Don't touch me.
Resident #30 stated I want to report her every time she touches me. The Administrator was notified of the
incident.
Review of the nurses notes, dated 01/31/20, revealed there was no documentation of the incident in the
medical record for Resident #13 and Resident #30.
Interview on 03/05/20 at 12:05 PM, the Administrator and the Director of Nursing verified the incident was
not documented in the residents' medical records.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 11 of 12
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
365639
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kingston of Vermilion
4210 Telegraph Lane
Vermilion, OH 44089
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's policy titled Charting and Documentation, dated 04/2014, revealed all services
provided to the resident, or any changes in the resident's medical or mental condition shall be documented
in the resident's medical record. All incidents, accident or changes in the resident's condition must be
recorded.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365639
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F688 - Mobility
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the March 5, 2020 survey of Kingston Health Center of Vermilion?
This was a inspection survey of Kingston Health Center of Vermilion on March 5, 2020. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Kingston Health Center of Vermilion on March 5, 2020?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.