Health inspection·June 12, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview the facility failed to ensure staff provided wound care for pressure ulcers as ordered by the physician. This affected one (Resident #85) of six residents sampled for wound care. The facility census was 83 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #85 revealed an admission date of 01/07/25 with diagnoses including fibromyalgia, Alzheimer's disease, depression and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #85 dated 01/14/25 revealed the resident was severely cognitively impaired, was dependent for activities of daily living (ADLs), and had two pressure ulcers. Review of the physician's orders for Resident #85 revealed an order to cleanse the sacral pressure ulcer with wound cleanser, pat dry, apply skin prep to the perimeter of the wound bed, apply crushed Flagyl to the wound bed, pack the wound calcium alginate, and cover with a foam dressing, and change daily and as needed and an order to cleanse the pressure ulcer to the coccyx with normal saline, pat dry, apply Medihoney to the wound bed, and cover with a foam dressing, change daily and as needed. Review of Treatment Administration Record (TAR) for Resident #85 dated February 2025 revealed the pressure ulcer treatments for the resident were not signed off for 02/7/25, 02/8/25, and 02/09/25. Interview on 06/11/25 at 2:19 P.M. with the Director of Nursing (DON) confirmed the pressure ulcer treatments for Resident #85 were not signed off as completed for 02/07/25, 02/08/25 and 02/09/25. The DON further confirmed she could not verify the treatments had been completed. This deficiency represents noncompliance investigated under Complaint Number OH00166071. 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 06/12/2025 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 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, staff interview, and review of the facility failed to ensure medications were administered as ordered. This affected two (Residents #24 and #81) of six residents sampled for medication administration. The facility census was 83. Findings include: 1.Review of the medical record for Resident #24 revealed an admission date of 12/16/23 with diagnoses including Alzheimer's disease, heart failure, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 03/31/25 revealed the resident had severely impaired cognition. Review of the physician's orders for Resident #24 revealed an order dated 08/14/24 to a apply a lidocaine 4 percent (%) topical patch to the left hip, on for 12 hours, and off for 12 hours. Further review of the orders revealed an order dated 08/14/24 to apply an Aspercreme lidocaine external patch 4% to the left hip every 12 hours for pain and remove per schedule. Review of the Medication Administration Records (MARs) for Resident #24 dated August 2024 to March 2025 revealed from 08/14/24 to 03/16/25 #24 the resident was signed off for the application of two lidocaine patches daily. Interview on 06/12/25 at 1:32 P.M. with the Director of Nursing (DON) confirmed Resident #24's physicians orders were not transcribed accurately and from 08/14/24 to 03/16/25 the resident received a lidocaine patch for 12 hours which was removed and then staff applied an Aspercreme patch for 12 hours. Resident #24 had an external patch on at all times which was not the intent of the order. 2. Review of the medical record for Resident 81 revealed an admission date of 11/19/24 with diagnoses including cerebrovascular disease, narcolepsy, chronic kidney disease, dementia, and dry eye syndrome. Review of the physician's orders for Resident #81 revealed an order dated 11/19/24 for Rocklatan ophthalmic solution instill one drop in both eyes at bedtime. Review of MARs for Resident #81 dated November 2024 to March 2025 revealed Rocklatan ophthalmic solution was documented as not administered due to not being available on the following dates: ;11/20/24, 11/23/24 through 11/28/24, 11/30/24 - 12/02/24, 12/08/24, 12/12/24, 12/14/24, 12/17/24 - 12/19/24, 12/26/24, 12/27/24, 12/29/24 - 12/31/24, 01/05/25, 01/07/25, -1/08/25, 01/11/25, 01/12/25, 01/22/25, 01/30/25, 01/31/25, 02/02/25, 02/11/25, 02/19/25, 02/21/25, 02/22/25, 02/24/25, 03/05/25, 03/06/25, and 03/12/25. Review of a progress note for Resident #81 dated 03/21/25 Licensed Practical Nurse (LPN) #106 revealed the nurse contacted the pharmacy regarding the resident's Rocklatan eye drops, and the pharmacy indicated the medication required prior authorization which had never been sent. Interview on 06/10/25 at 10:05 A.M. with LPN #106 confirmed he had looked in the medication cart and could not find Resident #81's eye drops. He looked in the emergency drug supply and Rocklatan was (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 06/12/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not available. LPN #106 stated he called the pharmacy and was told the medication required prior authorization which had never been sent. LPN #106 confirmed he reported to the DON he was concerned nurses were signing off that the med had been given when it was not available and others had been marking the medication as unavailable and failed to follow through with pharmacy to find out why. Interview on 06/11/25 at 11:47 A.M. with the DON confirmed Resident #81 did not receive multiple doses of Rocklatan eye drops. The DON confirmed nursing staff should have followed up with the pharmacy to ensure the medication was available and should have notified the provider. Review of the facility policy titled Administering Medications dated February 2023 revealed medications were to be administered in a safe and timely manner and as prescribed. If a dosage was believed to be inappropriate or excessive, the person preparing the medication should contact the Medial Director to discuss concerns. This deficiency represents noncompliance investigated under Complaint Number OH00166071. 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 06/12/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure narcotic medications were stored properly. This affected one (Resident #60) of nine residents sampled for medication administration. The facility census was 83 residents. Findings include: Review of the medical record for Resident #60 revealed an admission date of 04/29/25 with diagnoses including acute lymphadenitis, cerebral infarction, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #60 dated 05/03/25 revealed the resident had severely impaired cognition. Review of the physician's orders for Resident #60 revealed an order dated 06/10/25 for oxycodone five milligrams (mg) by mouth three times daily for pain. Observation on 06/11/25 at 8:23 A.M. of medication administration revealed revealed a narcotic card for Resident #60 containing 42 tablets of oxycodone 5 mg was stored in the medication cart on C-Hall in the drawer adjacent to the locked narcotic storage compartment. The card had a requisition sheet secured to it with a rubber band. Interview on 06/11/25 at 8:38 A.M. LPN #117 confirmed Resident #60's oxycodone was not properly stored in the C-Hall cart. LPN #117 confirmed narcotic medication such as oxycodone must be stored under double lock in the narcotic drawer. Interview on 06/11/25 at 8:39 A.M. with LPN #105 confirmed the Assistant Director of Nursing (ADON) had delivered Resident #60's oxycodone earlier in the morning. LPN #105 confirmed she did not have the keys to the narcotic compartment of the C Hall cart, and she was unable to appropriately store the medication. Review of the facility policy titled Controlled Substance Storage dated August 2014 revealed all schedule II-V medications were stored in a permanently affixed, double-locked compartment separate from all other medications per state regulation. 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 06/12/2025 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure laboratory services were provided in a timely manner. This affected one (Resident #31) of five residents sampled for laboratory services. The facility census was 83 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #31 revealed an admission date of 02/07/22 with diagnoses including peripheral vascular disease, major depressive disorder, chronic kidney disease, and dry eye syndrome. Review of the physician's orders for Resident #31 revealed an order dated 02/07/25 timed at 12:47 P.M. for a stat (immediate) chest x-ray due to rales in the left lower lobe of the lungs. Review of progress note for Resident #31 dated 02/07/24 timed at 11:40 P.M. revealed Licensed Practical Nurse (LPN) #106 called the lab service to check on the status of the resident stat chest x-ray ordered on 02/07/25. The company was unable to locate an order, and LPN #106 notified the lab of the stat chest x-ray order for Resident #31. Review of the lab results revealed Resident #31 had a chest x-ray completed on 02/08/25 at 1:23 PM. Interview on 06/12/25 at 3:28 P.M. with the Director of Nursing (DON) confirmed the physician ordered a stat chest x-ray for Resident #31 on 02/07/25 but the x-ray was not done until 02/08/25. Review of the facility policy titled Lab and Diagnostic Test Results - Clinical Protocol dated 12/15/23 revealed the facility provided lab, diagnostic, and radiology services to meet the needs of its residents. The facility was responsible for quality and timeliness of services. This deficiency represents noncompliance investigated under complaint number OH00166071 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 6 of 6