Health inspection·March 5, 2020

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interviews, the facility failed to provide quarterly care plan meeting for one Resident (#46) of two reveiwed for care plans. The facility census was 103. Findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis of the right side, and chronic kidney disease stage 3. The last documented care conference was on 10/24/20 with family in attendance. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Interview on 03/02/20 at 2:49 P.M. with Resident #46's spouse revealed she had not been invited to attend a care plan meeting for Resident #46 in a long time. She revealed she was very involved in the resident's care and liked to stay up to date on care/services provided to him. Interview on 03/03/20 at 12:39 P.M. with Social Services Designee (SSD) #214 confirmed the last care conference was held in October 2019 for Resident #46. SSD #214 revealed Resident #46 should have had a care conference within the last quarter, however with the changes in social services staff he must have been missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 2 of 6 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 03/05/2020 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, observation, staff interview, resident interview, and review of facility policy, the facility failed assist dependent residents with keeping fingernails and toenails maintained. This affected two Residents (#3 and #49) of two reviewed for Activities of Daily Living (ADLs). The facility census was 103. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #3 was admitted to the on 01/07/17 with diagnoses including dementia, heart failure, osteoarthritis, and flexion deformity of finger joints. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive one-person assistance with personal hygiene. Observation on 03/02/20 at 1:29 P.M. and again on 03/04/20 at 11:15 A.M., revealed Resident #3's left hand was observed with fingernails approximately one-half inch in length above fingertip, with three fingers contracted into the palm of his hand with deep indentation noted into the palm. The resident's right hand was observed with the middle finger contractured underneath of the right ring finger, with deep indentation noted to right palm. Observation and interview on 03/02/20 at 1:29 P.M. with Licensed Practical Nurse (LPN) #312 verified Resident #3's fingernails were overgrown and needed trimmed. Observation and interview on 03/04/20 at 11:15 A.M., with the Director of Nursing (DON) confirmed Resident #3's fingernails were digging into his left hand leaving deep indentations in palm. 2. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, and obsessive compulsive disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. The resident required extensive one-person assistance with hygiene. Observation and interview on 03/02/20 at 2:16 P.M., and 8:10 A.M. revealed Resident #49 was observed with fingernails about one-half inch in length on her left hand and toenails about one-quarter in length on both feet, some were noted to be curling around over her toes. Resident #49 revealed she did not like her nails to be that long and no one had came in and offered to trim her fingernails or toenails. Interview on 03/04/20 at 8:10 A.M. with the Administrator verified Resident #49's fingernails and toenails were overgrown. Interview on 03/04/20 at 12:30 P.M. with State Tested Nursing Assistant (STNA) #252 revealed nails were observed on shower days twice a week and nail care was performed as needed. Review of the facility policy titled Care of Fingernails/Toenails dated 01/20 revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 3 of 6 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 03/05/2020 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)

F 0677 would provide nail care including daily cleaning and regular trimming, with documentation recorded in the medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 4 of 6 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 03/05/2020 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)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files and staff interview, the facility failed to provide 12 hours of nurse aide in-service for two State Tested Nursing Assistants (#86 and #158) of two reviewed for in-service training. The facility census was 103. Residents Affected - Few Findings include: Review of personnel files revealed State Tested Nursing Assistants (STNAs) #86 and #158 did not have the required 12 hours of yearly in-service hours of education. Interview on 03/05/20 at 11:18 A.M. with the Licensed Nursing Home Administrator (LNHA) verified STNA #86 only had 8.25 hours of inservice and STNA #158 only had 7.25 hours. The LNHA verified the facility had not met the yearly requirement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 5 of 6 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 03/05/2020 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)

F 0791 Provide or obtain dental services for each resident. 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, staff and resident interviews, the facility failed to provide dental services for one Resident (#49) of two reviewed for dental services. The facility census was 103. Residents Affected - Few Findings include: Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, obsessive compulsive disorder, and history of falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. The resident was noted with no dental issues. There was no evidence the resident was provided any dental services. Observation and interview on 03/02/20 at 2:11 P.M., with Resident #49 revealed she had not been offered to see the dentist since admission, and needed to be seen for a broken tooth. Resident #49 was observed with a broken tooth located on upper left side. Interview on 03/03/20 at 1:17 P.M., with Social Services Designee (SSD) #214 revealed Resident #49 was informed the facility provided ancillary services on admission, however had not been offered to be seen. SSD #214 verified the residents would have no way of knowing when services are coming into the facility, to request to be added to the visit, since they do not notify resident's of upcoming ancillary service visits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 6 of 6