Health inspection·August 31, 2023

F 0550 urinary) catheter due to a diagnosis of obstructive uropathy. Level of Harm - Minimal harm or potential for actual harm Review of Resident #61's care plan, revised on 06/21/23, revealed Resident #61 required an indwelling urinary catheter. Interventions listed in the care plan included to cover the drainage bag to promote dignity. Residents Affected - Few Observation on 08/28/23 at 11:11 A.M., revealed Resident #61 lying in bed and the urinary drainage bag was hanging on the bed uncovered, with yellow urine visible in the drainage bag. Interview on 08/28/23 at 11:15 A.M., with Licensed Practical Nurse (LPN) #891 verified the urinary drainage bag was uncovered. LPN #891 stated the drainage bag should be covered, and normally the facility used drainage bags with attached vinyl coverings. Observation on 08/28/23 at 2:13 P.M., of Resident #61 in the therapy gym on the 600 hall revealed Resident #61 seated on an exercise bike, with an unknown therapist at his side. The urinary drainage bag was hanging on the side of the bike and remained uncovered. Observation on 08/28/23 at 2:56 P.M., revealed Resident #61 lying in bed. Resident #61's drainage bag was hanging on the side of the bed frame uncovered, with yellow urine visible in the bag from the doorway. Interview on 08/28/23 at 2:56 P.M., with Environmental Services Aide (ESA) #844 verified Resident #61's urinary drainage bag was uncovered and visible from the hallway. Review of the policy titled Dignity dated 10/10/22, indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 2 of 16 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 08/31/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on staff interview and medical record review, the facility failed to ensure a resident had an accurate and consistent advance directive in place throughout the medical record. This affected one (#39) of eight residents reviewed for advance directives. The facility census was 108. Findings include: Review of Resident #39's medical record revealed an admission date of 08/10/18, with diagnoses including: cerebrovascular accident (stroke), adenocarcinoma (cancer) of lung, and dementia. Review of the Significant Change in Status Minimum Data Set (MDS) assessment, dated 08/09/23, revealed Resident #39 had severe impaired cognition, required extensive assistance of 1-2 staff for transfers, bed mobility, toileting, dressing and hygiene. The assessment further revealed Resident #39 received hospice services. Review of Resident #39's care plan, initiated on 08/11/18 and revised on 08/29/23, revealed a code status of Do Not Resuscitate Comfort Care (DNRCC). Review of the Do Not Resuscitate (DNR) Order form in Resident #39's chart revealed a selection of DNRCC, dated 06/14/23, signed by Resident #39's physician. Review of physician orders revealed Resident #39 was admitted to hospice care on 08/01/23 with a diagnosis adenocarcinoma of the lung. Resident #39 had a physician order, dated 06/14/23, of DNRCC-Arrest listed in the electronic medical record. Interview on 08/29/23 at 2:29 P.M., with Assistant Director of Nursing (ADON) #879 revealed Resident #39 received comfort care with hospice at the facility. ADON #879 verified Resident #39's medical record contained mismatched advance directives between the hard chart and the electronic medical record. ADON #879 stated Resident #39 recently signed on to hospice, and staff must not have changed the advance directive after hospice enrollment. Interview on 08/29/23 at 4:30 P.M., with Director of Nursing (DON) revealed the facility did not have an advance directives policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 3 of 16 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 08/31/2023 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 Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review, observation, staff interview, and review of policy, the facility failed to ensure a resident was safely transfered utilizing a mechanical lift. This affected two (#54 and #71) of three residents reviewed for transfers. The facility census was 108. Findings include: 1. Review of Resident #71's medical record revealed an admission dated of 11/09/20, with diagnoses including: hemiplegia, aphasia, dysphagia, unspecified convulsions, osteoarthritis, schizoaffective disorder, insomnia, obesity, and scoliosis. Review of Resident #71's quarterly Minimum Data Set (MDS) assessment, dated 06/28/23, revealed the resident was cognitively impaired and was totally dependent on the assistance of two staff for transfers. Review of Resident #71's physician orders, revealed an order dated 01/04/21 and revised 04/29/23 for assistance of two staff with mechanical lift, with full body sling for transfers into tilt in space wheelchair for proper positioning and pressure relief. Review of Resident #71's current plan of care, dated 11/20/20, revealed the resident required assistance with activities of daily living. An intervention was implemented on 04/29/23 for assistance of two, mechanical lift with full body sling for transfers into tilt in space wheelchair for proper positioning and pressure relief. Observation on 08/29/23 at 1:29 P.M., revealed Resident #71 was in her wheelchair which was located in the hallway across from her room. Resident #71 had a mechanical lift transfer sling underneath of her. State Tested Nurse Aide (STNA) #913 attached the loops of the mechanical lift sling to the mechanical lift and used the mechanical lift to lift the resident up into the air. STNA #913 then pushed the mechanical lift across the hall and into the resident's room. Once in the room, STNA #913 lowered Resident #71 into Resident #71's bed. No other staff were present to assist with the mechanical lift transfer. Interview on 08/29/23 at 1:40 P.M., with STNA #913 verified the staff member transferred Resident #71 via mechanical lift with no other staff present and pushed the resident fromt he hallway to the room while the resdient was in the lift. STNA #913 reported she always transferred Resident #71 by herself, and stated most residents only required one staff member to be present for mechanical lift transfers. STNA #913 reported STNAs found resident transfer statuses, including how many staff members were required, on a Resident Information Sheet (RIS) located at the nursing station. Review of the RIS located at the nursing station, dated 08/27/23, revealed Resident #71's transfer status was two-assist mechanical lift, full body sling. 2. Review of Resident #54's medical record revealed an admission date of 03/22/23, with diagnoses included intracranial injury, hemiparesis affecting right dominant side, dementia, and obesity. Review of Resident #54's Minimum Data Set (MDS) assessment, dated 08/12/23, revealed the resident was not assessed for cognition. The resident was totally dependent on the assistance of two staff for transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 4 of 16 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 08/31/2023 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 Review of nursing summary progress note, dated 08/13/23, revealed Resident #54 was alert and oriented to self. Review of Resident #54's physician orders, identified an order dated 08/10/23 for the use of a full body mechanical lift for transfers using a criss-cross sling with the assist of two staff. Residents Affected - Few Review of Resident #54's care plan, initiated 03/22/23, revealed Resident #54 required assistance with activities of daily living. An intervention was implemented on 08/01/23 for assistance of two staff with use of mechanical lift for transfers into a tilt in space wheelchair. Observation on 08/28/23 at 2:00 P.M., revealed Resident #54 in his wheelchair in the 300 hallway across from his room. Resident #54 had a mechanical lift transfer sling underneath him. STNA #913 attached the loops of the mechanical lift sling and lifted the resident up into the air. STNA #913 then pushed the mechanical lift into Resident #54's room, to his bed which was positioned by the window, approximately 15 feet. STNA #913 then lowered Resident #54 into his bed. No other staff were present to assist STNA #913 with the mechanical lift transfer. Observation on 08/28/23 at 2:04 P.M., revealed Resident #54 lying in his bed with the mechanical lift sling still underneath him. STNA #913 remained in Resident #54's room and returned the mechanical lift device to the hallway directly outside of Resident #54's room. STNA #954 then entered Resident #54's room and closed the door. Interview on 08/28/23 at 2:11 P.M., with STNA #913 verified she transferred Resident #54 alone and in the mechanical lift for approximately 15 feet. STNA #913 further stated she always transferred Resident #54 alone and did not need another STNA's assistance while using the mechanical lift. STNA #913 verified STNA #954 entered the room after the transfer was complete and was only needed to assist with Resident #54's personal care. Review of the RIS located at the nursing station, dated 08/27/23, revealed Resident #54's transfer status was two-assist mechanical lift, full body sling. Review of the policy titled Patient/Resident Transfer Policy, dated 2020, revealed transfers would be conducted following the principles of proper body mechanics and resident safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 5 of 16 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 08/31/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #62 revealed an admission date of 03/27/21, with diagnoses including: chronic respiratory failure, osteoarthritis, chronic obstructive pulmonary disease (COPD) type II diabetes, osteoporosis, and history of falling. Residents Affected - Few Review of the plan of care dated 06/12/23 revealed the resident had impaired gas exchange related to chronic respiratory failure. Interventions included to administer respiratory treatments and to elevate the head of the bed to facilitate breathing. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance from staff for bed mobility and transfers. Review of the physician orders for August 2023 revealed an order to administer continuous oxygen at a rate of two liters to four liters to maintain an oxygen saturation greater than 92 percent (%). There was an order for Respiratory Therapy to change oxygen tubing every Tuesday. Review of the respiratory therapy administration record for August 2023 revealed the oxygen tubing was changed on 08/15/22, 08/22/23 and 08/29/23. Observation on 08/28/23 at 9:16 A.M., of Resident #62 revealed she was laying in her bed receiving oxygen by nasal cannula from an oxygen concentrator. The oxygen tubing was dated 08/18/23. Resident #62 had a portable oxygen canister located on the back of her wheelchair. The nasal cannula tubing to the portable oxygen canister was rolled up and shoved into the holder with the oxygen tank. The nasal cannula tubing was not stored in a way to prevent contamination and infections. Interview at the time of the observation with Clinical Manager #984, verified the tubing was dated 08/18/23. Observation on 08/28/23 at 9:30 A.M., of Resident #62 revealed Respiratory Therapist (RT) #984 changing out the tubing to the oxygen concentrator and the tubing for the portable oxygen container. The nasal cannula for the portable oxygen container was stored in a plastic bag. Interview on 08/28/23 at 10:51 A.M., with RT #984 stated she is responsible for changing out oxygen tubing every Tuesday on Resident #62's hall. However, she delegates the task to the RT's that work as needed (PRN). RT #984 stated she was not sure when the last time the tubing was changed. Further observation on 08/29/23 at 5:23 P.M., of Resident #62's wheelchair revealed the nasal cannula to the portable oxygen container was rolled up and shoved into the holder for the oxygen tank. The nasal cannula was not stored in a way to prevent contamination and infection. Interview at the time of the observation, with Licensed Practical Nurse (LPN) #993, verified the nasal cannula was not stored properly. Interview on 08/30/23 at 12:52 P.M., with RT #984 verified she changed Resident #62's oxygen tubing on 08/28/23 and documented as completed on 08/29/23. RT #984 stated the computer only lets her document oxygen changes on Tuesdays even though it was changed on Monday 8/28/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 6 of 16 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 08/31/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy titled Disposable Equipment Replacement, dated July 2022 revealed equipment storage bags and oxygen delivery systems such as masks, nasal cannula, oxygen supply tubing is to be changed weekly or as needed. Based on medical record review, observation, staff interview, and review of the policy, the facility failed to ensure infection control was maintain for oxygen tubing, by storing nasal cannula's to prevent contamination and changing oxygen tubing as ordered. This affected two (#22 and #62) of two residents reviewed for oxygen. The facility census was 108. Findings include: 1. Review of Resident #22's medical record revealed an admission date of 11/19/16, with diagnoses including: chronic obstructive pulmonary disease (COPD), respiratory failure, heart disease with heart failure, obstructive sleep apnea, and asthma. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. The resident received oxygen. Review of Resident #22's physician orders for August 2023, identified current orders for oxygen saturation level while on three liters nasal cannula during the day, four liters nasal cannula at bedtime, and respiratory therapy to change oxygen tubing, nebulizer, set-up, and/or non-invasive ventilation supplies every Tuesday. Observation on 08/28/23 at 9:42 A.M., revealed Resident #22's oxygen tubing with nasal cannula and oxygen extension tubing were dated 08/18/23. Observations on 08/28/23 at 11:03 A.M., on 08/29/23 at 1:24 P.M., on 08/29/23 at 4:37 P.M., and on 08/30/23 at 7:46 A.M. revealed the oxygen/extension tubing were dated 08/18/23. Review of the respiratory administration record for August 2023, revealed the order for oxygen tubing to be changed was documented as completed on 08/01/23, 08/08/23, 08/15/23, 08/22/23, and 08/29/23, which were all Tuesdays. The administration record did not indicate the oxygen tubing was changed on Friday, 08/18/23 or on Monday 08/28/23. Interview on 08/30/23 at 12:52 P.M., with Respiratory Therapist (RT) #984, verified Resident #22's oxygen tubing was supposed to be changed on a weekly basis. RT #984 also verified the Treatment Administration Record (TAR) was not signed off on the dates the tubing was changed, and was subsequently signed off on dates the tubing was not changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 7 of 16 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 08/31/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #62's medical record revealed an admission date of 03/27/21, with diagnoses including chronic respiratory failure, osteoarthritis, chronic obstructive pulmonary disease (COPD) type II diabetes, osteoporosis, and history of falling. There was no evidence of consent for side rails. Review of the plan of care dated 06/12/23 revealed the resident requires assistance with activities of daily living related to inflammatory lumbar spondylopathy, and osteoporosis. Intervention included the use of assist rails as needed for bed mobility and positioning. Review of the quarterly MDS assessment, dated 06/26/23 revealed the resident had intact cognition and required extensive assistance from staff for bed mobility and transfers. The assessment indicated bed rails were not used. Review of the quarterly assessment dated [DATE], revealed the assessment indicated bilateral assist rails. Review of the medical record, both physical chart and electronic medical record, did not contain an informed consent for bedrail use. Interview on 08/31/23 at 11:54 A.M., with the DON stated the facility does not have a consent for side/assist rails. Review of the titled, Bed Safety/Maintenance, dated June 2023, revealed if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative. The staff shall obtain consent for the use of side rails from the resident or the resident's representative prior to their use, including the benefits and potential hazards associated with side rails. Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure bedrail consents were obtained and assessments were accurate. This affected three (#40, #13, and #62) of three residents reviewed for bedrails. The facility idenitfied 103 residents with orders for assist rails. The facility census was 108. Findings include: 1. Reviw of Resident #40's medical record revealed an admission date of 05/26/22, with diagnoses including: Parkinson's Disease, dementia, osteoporosis, and polyneuropathy. Review of Resident #40's Significant Change in Status Minimum Data Set (MDS) assessment, dated 07/25/23, revealed Resident #40 was severely cognitively impaired. Resident #40 required extensive assist of 1-2 staff with bed mobility, toileting, and hygiene. Resident #40 was dependent on two staff for transfers. Review of Resident #40's physician orders, identified an order dated 05/26/22 for assist rails. The order further specified one or two rails could be used for turning and repositioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 8 of 16 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 08/31/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #40's current plan of care identified the need for assistance with activities of daily living (ADLs). Resident #40's ADL care plan listed an intervention of assist rails as needed for bed mobility and positioning. Review of Resident #40's Bed Assist/Side Rail (SR) Assessment, dated 07/28/23, revealed Resident #13 did not express a desire to have rails raised while in bed for her own safety and/or comfort. The assessment further identified recommendations for the resident to use no side rails. Observation on 08/30/23 at 10:20 A.M., revealed Registered Nurse Clinical Manager (RNCM) #945 and Registered Nurse (RN) #841 performed ordered wound care to Resident #40's sacral wound. Resident #40 was lying in bed and was repositioned by RNCM #945 and RN #841. Resident #40's bed had metal bedrails on both sides of the bed and both rails were in the raised position. Throughout wound care observation, Resident #40 was not observed to grasp the side rail nor assist in her own positioning. RN #841 held Resident #40 on her left side throughout the duration of wound care. RNCM #945 stated two staff members are needed when performing Resident #40's wound care as Resident #40 is not able to turn on her side on her own or aid in her own positioning. Review of the medical record, both physical chart and electronic medical record, did not contain an informed consent for bedrail use. Interview on 08/31/23 at 10:01 A.M., with the Director of Nursing (DON) verified the facility does not complete consents for the use of side/assist/bedrails. 2. Review of Resident #13's medical record revealed an admission date of 03/24/21, with diagnoses including ataxia (loss of coordination of voluntary movements) following cerebrovascular accident (stroke), osteoporosis, and chronic kidney disease. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment, dated 08/16/23, revealed Resident #13 was cognitively intact. Resident #13 required extensive assist of 1-2 staff for bed mobility, toileting, and hygiene. Resident #13 was dependent on two staff for transfers. Review of Resident #13's physician orders, identified an order dated 05/26/22 for assist rails. The order further specified one or two rails could be used for turning and repositioning. Review of Resident #13's current plan of care identified the need for assistance with activities of daily living (ADLs). Resident's ADL care plan listed an intervention of assist rails as needed for bed mobility and positioning. Review of Resident #13's Bed Assist/SR Assessment, dated 08/16/23, revealed Resident #13 did not express a desire to have rails raised while in bed for her own safety and/or comfort. The assessment further identified recommendations for the resident to only utilize a left bed rail. Review of the medical record, both physical chart and electronic medical record, did not contain an informed consent for bedrail use. Observation and interview on 08/31/23 at 10:25 A.M., with Resident #13 revealed the resident in bed, with both metal side rails in the raised position on the bed. Resident #13 stated she uses both bedrails to aid in her own positioning, and the bedrails have been on the bed since her admission to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 9 of 16 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 08/31/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 08/31/23 at 10:27 A.M., with State Tested Nurse Aide (STNA) #954 revealed she is familiar with Resident #13's care. STNA #954 verified Resident #13 uses bilateral bedrails to help her turn and reposition in the bed during care. STNA #954 stated Resident #13 always has both bedrails in the raised position while she is in bed. Interview on 08/31/23 at 10:01 A.M., with the Director of Nursing (DON) verified the facility does not complete consents for the use of side/assist/bedrails. Event ID: Facility ID: 365639 If continuation sheet Page 10 of 16 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 08/31/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, policy review and staff interview, the facility failed to ensure medications were administered to residents as prescribed by physician's orders. This affected one (#48) of five resident reviewed for medication administration. The facility census was 108 residents. Findings include: Review of Resident #165's medical record revealed an admission date of 08/13/22, with diagnoses including ulcerative colitis with rectal bleeding, essential hypertension, atherosclerotic heart disease, left and right shoulder osteoarthritis, atrial fibrillation, diverticulitis of intestine, anxiety disorder, unilateral inguinal hernia, adult failure to thrive, acute kidney failure, anxiety, and depression. Review of Resident #48's physician orders revealed an order for Tofacitinib Citrate 10 milligrams (mg), twice a day for gastrointestinal issues. Review of Resident #48's August 2023 Medication Administration Record (MAR) revealed the morning dose of Tofacitinib Citrate 10 mg was not administered on 08/21/23, 08/22/23, 08/23/23, 08/24/23, 08/25/23, 08/26/23, 08/27/23 and 08/28/23. The evening dose of Tofacitinib Citrate 10 mg was not administered on 08/20/23, 08/21/23, 08/22/23, 08/23/23, 08/24/23, 08/25/23, 08/26/23, 08/27/23 and 08/28/23. Interview on 08/01/23 at 1:00 P.M., with the Director of Nursing (DON) indicated Resident #48 did not receive the prescribed doses of Tofacitinib Citrate from 08/20/23 through 08/28/23 due to the medication being misplaced after delivery. The DON indicated the night shift nurse signed for the medication that was included with other medication. When the medication was scheduled to be administered, the medication could not be found. The DON stated the facility ultimately had to pay for a new shipment of the prescribed medication which did not arrive until 08/28/23. The DON indicated that Resident #48 experienced no adverse effects from the missed medication administration and additional gastrointestinal medications were prescribed during that period of time. Review of the policy titled, Administering Medications, dated February 2023, indicated medications must be administered in accordance with the orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 11 of 16 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 08/31/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were stored securely. This affected one (#61) and had the potential to affect four additional residents (#35, #54, #68, and #79) the facility identified as cognitively impaired and independently mobile on the 300 hall. The facility census was 108. Findings include: Review of Resident #61's medical record revealed an admission date of 02/01 22, with diagnoses including: dementia without behaviors, obstructive uropathy and urinary retention. Review of Resident #61's admission Assessment/Observation, dated 02/01/22, revealed Resident #61 did not wish to administer his own medications. Review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 07, which indicated a severe cognitive impairment. Resident #61 required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. Observation on 08/28/23 at 11:11 A.M., revealed Resident #61 in bed, with overbed table within reach. On the overbed table, a plastic medication cup contained twelve multi-colored pills. Resident #61 stated they were his medications but was unable to state when the nurse brought him the medications. Interview on 08/28/23 at 11:15 A.M., with Licensed Practical Nurse #891 verified the medications on Resident #61's overbed table had been left unattended. LPN #891 stated she did not bring the medications to Resident #61; it must have been the nurse before her. LPN #891 stated she began her shift at 8:00 A.M., so the medications were brought to Resident #61 prior to that time. LPN #891 verified Resident #61 requires all medications to be administered by the nurse and medications should not have been left at Resident #61's bedside. Review of the policy titled Storage of Medications, dated 01/07/21, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 12 of 16 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 08/31/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, staff interview, and review of policy, the facility failed to ensure proper portion sizes were served to residents. This had the potential to affect all residents, except for Resident #19 and #28 who were identified as consuming nothing by mouth. The facility census was 108. Findings include: Review of the dinner meal spreadsheet for 08/28/23, revealed that sloppy joe should be served using a number 10 (three-ounce) scoop. Observation of tray line on 08/28/23 at 4:40 P.M., revealed Dietary [NAME] #867 served sloppy joe with a number 16 (two-ounce) scoop instead of a number 10 scoop, as indicated on the spreadsheet. Interview on 08/28/23 at 4:43 P.M., with Dietary Manager #884 verified at time of observation, Dietary [NAME] #867 had been using the incorrect scoop size. Dietary Manager #884 then instructed Dietary [NAME] #867 to begin using two number 16 scoops (four ounces) in place of one number 10 scoop. Review of the facility-provided list revealed Resident #19 and #28 received nothing by mouth and did not receive food from the kitchen. Review of the facility policy titled Dietary/Nutritional Care Services/Meal Service, dated April 2014, revealed the dietary manager would perform meal rounds daily, as deemed appropriate and would observe meals for preferences, portion sizes, temperature, flavor, variety, and tray pass for accuracy. This deficiency represents non-compliance investigated under Complaint Number OH00144401. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 13 of 16 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 08/31/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation, staff interview, and review of policy, the facility failed to safely store resident food items in the refrigerator/freezer located in the staff break room. This had the potential to affect all residents, except for Resident #19 and #28 who were identified as consuming nothing by mouth. The facility census was 108. Findings include: Interview on 08/29/23 at 8:48 A.M., with Registered Nurse (RN) #703, revealed resident food items were stored in a refrigerator/freezer located in the staff breakroom. Interview on 08/29/23 at 8:56 A.M., with Dietary Manager #884, revealed the environmental service department was responsible for maintaining the specified refrigerator/freezer. Interview on 08/29/23 at 9:00 A.M., with Housekeeper #971 revealed housekeeping staff were responsible for maintaining the refrigerator located in the staff breakroom. Housekeeper #971 reported she knew the refrigerator needed a good cleaning. Observation of the refrigerator on 08/29/23 at 9:00 A.M., with Housekeeper #971, revealed the refrigerator had an internal temperature of 41 degrees Fahrenheit. There was no temperature log present in the area. The top three shelves of the refrigerator were stuffed full of miscellaneous items. Observation of food items contained inside of the refrigerator revealed: a container of chili fries was labeled with Resident #70's name and room number and was undated; a container of unidentified meat with onions which were covered in a mold like substance, labeled with a resident room number where no resident currently resided, and was undated; a container of ravioli was labeled with a resident room number and was undated; a bag containing chicken with a mold like substance in a paper box was unlabeled and undated; a burrito wrapped in saran wrap was unlabeled and undated; a bag containing strawberry yogurt with an expiration date of 07/12/23; a clear plastic container containing sliced sausage and potatoes which was undated and unlabeled; a frosted cake was unlabeled, undated, and uncovered aside from a paper towel which was stuck to the frosting; dried up chicken wrapped in a paper towel was unlabeled and undated; a nutritional bar with an expiration date of 11/15/22; a Tupperware container with pot roast and a mold like substance was unlabeled and undated; a pizza fold over was unlabeled and undated; a white Styrofoam container containing meat and vegetables which were covered in mold like substance was unlabeled and undated; a plastic grocery bag containing a storage container with an unidentified food substance was unlabeled and undated; a container of salsa with a mold like substance and was undated and unlabeled; a clear plastic container of salad which was covered in a mold like substance and was unlabeled and undated; a clear plastic container with cabbage rolls which were covered in a mold like substance was unlabeled and undated; a container with two pizza slices which were covered in a mold like substance and was unlabeled and undated; and a dried up donut wrapped in a paper towel was unlabeled and undated. Continued observation of the attached freezer revealed: a pink container with a frozen white substance was uncovered, unlabeled, and undated; a clear plastic cup which was filled with a pinkish-brown substance was unlabeled and undated; a clear plastic container with a frozen white substance was labeled with Resident #33's name and was undated; an ice cream sundae was labeled with an unidentified resident name and room number and was undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 14 of 16 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 08/31/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview at the time of observation, with Housekeeper #971, verified the aforementioned findings. Housekeeper #971 also verified staff and resident food items were stored in the refrigerator/freezer and that temperature checks had not been completed/documented. Review of the facility-provided list revealed Resident #19 and #28 received nothing by mouth and did not receive food from the kitchen. Review of the policy titled Food Storage, dated May 2018, revealed leftover food would be stored in covered containers or wrapped carefully and securely, each item would be clearly labeled and dated before being refrigerated, and leftover food would be used within two to three days or discarded. The policy also stated each nursing unit with a refrigerator/freezer unit would be monitored for appropriate temperatures and all refrigerated foods would be covered, labeled, and dated. The policy further stated all food items in the freezer would be covered, labeled, and dated, and temperatures would be checked daily and recorded. This deficiency represents non-compliance investigated under Complaint Number OH00144401. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 15 of 16 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 08/31/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, review of policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure the pneumococcal vaccine was offered according to guidelines. This affected one (#62) of five residents reviewed for immunizations. The facility census was 108. Residents Affected - Few Findings include: Review of the medical record for Resident #46 revealed an admission date of 05/05/19, with diagnoses including: multiple sclerosis, anxiety, osteoarthritis, type II diabetes, neuromuscular bladder, kyphosis, and depression. Review of the immunization tab revealed the Pneumococcal conjugate vaccine (PCV13) was administered on 10/14/23. The Pneumococcal polysaccharide vaccine (PPSC23) was documented as not eligible on 10/14/23. Interview on 08/30/23 at 4:15 P.M., with the Infection Control Preventionist (ICP) #880 stated Resident #46 received the PCV13 on 10/14/23 and at that time the PPCV23 was sign off as not eligible due to the immunization needed to be administered a year apart. ICP # verified the facility did not follow up to offer the PPCV23 at a later date. Review of the website for Centers for Disease Control and Prevention (CDC) titled Pneumococcal Vaccine Recommendations, dated 02/13/23 recommended for adults 65 and older, routine administration of pneumococcal conjugate vaccine (PCV15 or PVC20) for all adults 65 years or older who have ever received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. Review of the policy titled Pneumococcal Vaccine dated 08/22/22 revealed administration of the pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365639 If continuation sheet Page 16 of 16