Health inspection·February 7, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review the facility failed to ensure residents had a safe environment when they failed to complete a thorough investigation into an allegation of missing personal property. This affected one Resident (#99) of one reviewed for missing items. The facility census was 102. Findings include: Review of the medical record revealed Resident #99 was admitted on [DATE] with diagnoses to include unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing, hypotension, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, adult failure to thrive, gastro-esophageal reflux disease without esophagitis, rheumatoid arthritis, age related osteoporosis, and personal history of malignant neoplasm of cervix uteri. Review of the 30-day Minimum Data Set (MDS) dated [DATE] revealed Resident #99 had moderately impaired deficits, and required extensive assist with activities of daily living. Interview on 02/04/19 at 10:05 A.M., Resident #99 reported she was missing four pairs of black pants. She indicated she had only paid $150 for them. Resident #99 indicated she reported the missing pants to housekeeping staff. Interview on 02/07/19 at 1:30 P.M., Laundry #157 reported Resident #99 had reported missing pants and she had returned some of the missing clothes. Laundry #157 stated she had placed Resident #99's name on the items but Resident #99 was still missing one pair of pants. Laundry #157 denied completing the missing item form and turning it into social services. Interview on 02/07/19 at 1:40 P.M., Laundry #155 reported Resident #99 had reported missing garments to her. Laundry #155 denied completing the missing item form and turning it into social services. Interview on 02/07/19 at 1:50 P.M., Housekeeper (HS) #161 reported Resident #99 had informed her of missing items. HS #161 had returned some of the items but not all of them according to Resident #99. HS #161 denied completing the missing item form and turning it into social services. Interview on 02/07/19 at 2:30 P.M., Social Services Director (SSD) #132 and SSD #131 denied any staff reported missing items from Resident #99 or turning in a missing item form. Review of facility policy titled, Missing Item Policy dated 01/12/18 revealed facility staff is (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 3 Event ID: 365984 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 365984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342 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)