Health inspection·September 19, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed medication reconciliation was completed to prepare predischarge medications, a current medication list was provided to the resident and resident representative and medications and supplies were sent home with the resident. The assessment was signed by Resident #97. The progress note dated 06/30/25 revealed Resident #97 discharged home on [DATE]. Review of Resident #97's Medication Administration Record (MAR) from 06/01/25 to 06/28/25 revealed Resident #97 was prescribed Thiamine Mononitrate 100 milligrams (mg) give one tablet by mouth in the evening for a supplement; Prevacid 30 mg give one tablet by mouth one time a day for gastroesophageal reflux disease (GERD), Melatonin (a sleep aide) five mg give two tablets by mouth at bedtime, levetiracetam 750 mg give one tablet by mouth two times a day for seizures, Fluoxetine 20 mg give one tablet by mouth one time a day for an anti-depressant, Cholestyramine oral packet four grams (gm) give one packet by mouth two times a day for hyperlipidemia, atorvastatin calcium 40 mg give one tablet by mouth at bedtime for hyperlipidemia, and Aspirin 81 mg give one tablet by mouth one time a day for a preventative. The medical record from 06/18/25 to 06/28/25 revealed no documentation that any of Resident #97's prescriptions were sent to the pharmacy upon discharge from the facility on 06/28/25.Interview with RN #501 on 09/19/25 at 10:25 A.M. revealed RN #501 was not aware that Resident #97 was discharging on 06/28/25 until Resident #97's husband came to the facility and demanded that Resident #97 be discharged . RN #501 stated she contacted the supervisor, and the supervisor stated Resident #97 and her husband informed the facility that they were debating on appealing the insurance NOMNC and they still had not decided about the appeal at the end of the day on 06/27/25. RN #501 reported Resident #97's husband must have decided that he did not want to appeal the NOMNC and that he wanted Resident #97 discharged from the facility on 06/28/25. RN #501 reported that an order was obtained to discharge Resident #97 by the physician on call and Resident #97 was sent home with all her medications except for narcotics. RN #501 was not sure how many days' worth of medications were sent with Resident #97. RN #501 reported the facility typically sent electronic prescriptions of medications to the pharmacy upon discharge. RN #501 stated she did not receive any information that Resident #97 was not able to obtain her medications or that she ran out of her medications after discharge. Interview with the Director of Nursing (DON) on 09/19/25 at 10:30 A.M. revealed Resident #97 and her husband were saying that they wanted to appeal the NOMNC on 06/27/25 but then Resident #97's husband came to the facility and wanted her discharged on 06/28/25 because he did not want to pay if the appeal was denied. The DON stated Resident #97's husband reached out to the Administrator after the discharge for some paperwork, but she was not aware of Resident #97 not having her medication upon discharge. The DON stated Resident #97's Levetiracetam 750 mgs was a medication that Resident #97 had been taking prior to her hospital admission. The DON reported Resident #97 had Levetiracetam 750 mg at home prior to the hospital admission and the prescription at the pharmacy from the neurologist. Interview with the Administrator on 09/19/25 at 11:09 A.M. revealed Resident #97 discharged from the facility on a Saturday and Resident #97's husband called her on the following Tuesday and stated Resident #97 was at the hospital. The Administrator stated Resident #97's husband wanted the facility to send a copy of Resident #97's medications to the hospital. The Administrator had the medication list sent to the hospital. The Administrator stated Resident #97's husband reported no concerns with Resident #97 receiving her medications upon discharge from the facility. Interview with the DON on 09/19/25 at 2:22 P.M. verified NP #502's telephone order on 06/28/25 stated Resident #97 was to be discharged with her remaining medications and to send Resident #97 with a two-week supply of prescriptions. The DON verified the facility did not have any documentation of any electronic prescriptions being sent and Resident #97 only discharged with the remaining amount of medications to be given on 06/28/25. Review of the facility's team (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 2 of 3 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 09/19/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm discharge planning process policy dated January 2018 revealed all staff should communicate the same message with the resident and the facility regarding the goal for a safe and successful discharge. The amount of medications to be sent with the resident upon discharge from the facility was not listed in the policy. This deficiency represents non-compliance investigated under Complaint Number 2621217. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365984 If continuation sheet Page 3 of 3