Inspection·February 27, 2020

F 0610 Respond appropriately to all alleged violations. 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 interview, and review of facility policy, the facility failed to ensure an allegation of staff to resident verbal abuse was thoroughly investigated. This affected one Resident (#39) of one reviewed for abuse. The facility census was 123. Residents Affected - Few Findings include: Medical record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, quadriplegia, and chronic diastolic congestive heart failure. Review of Resident #39's progress note dated 02/16/20 revealed Resident #39 reported to his brother a State Tested Nursing Assistant (STNA) threatened to harm him. Resident #39's brother called the facility and reported the allegation to Registered Nurse (RN) #625. There was no evidence RN #625 reported the allegation to the Administrator. There was no evidence the facilty reported the allegation to the state agency. Interview on 02/26/20 at 6:11 P.M. with the Administrator verified he was not aware an allegation of staff to resident verbal abuse had been made by Resident #39. The Administrator reviewed Resident #39's progress note dated 02/16/20 and confirmed Resident #39 had made an allegation of abuse. The Administrator further verified the allegation had not been investigated or reported to the State Agency. On 02/26/20 the Administrator submitted a self-reported incident (SRI) and began an investigation of the staff to resident verbal abuse. Review of facility policy titled, Abuse Reporting- Staff Treatment of Residents, with an approval date of 02/15/18, revealed all allegations or suspected cases of abuse would be investigated thoroughly, and reported to the Administrator immediately, as well as to the Ohio Department of Health. The Administrator would immediately suspend the employee alleged to be involved in the incident to prevent further potential abuse. Further review revealed an investigation would be completed within 24 hours of the allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 2 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed Resident #78 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident #78's MDS assessment dated [DATE] revealed the resident was cognitively intact. Continued review of Resident #78's medical record revealed the resident was transferred to the local hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence the resident received a copy of the facility's bed hold policy. Interview on 02/27/20 at 8:32 A.M. with the Director of Nursing (DON) verified there was no evidence Resident #78 was provided a copy of the facility's bed hold policy. Review of the facility policy titled, Bed Hold, Transfer, and Discharge Notice, approval date of September 2018 revealed at the time of transfer to an acute care facility (hospital) or as soon as practicable the resident and their representative will be issued transfer notice for Ohio facilities, or the notice of transfer discharge. A bed hold notice was required at the time of transfer or in the case of emergency within 24 hours. Based on medical record review, staff interview, resident interview, and review of facility policy, the facility failed to provide written documentation to the resident and/or responsible party of the bed hold policy upon transfer from the facility to the hospital. This affected three residents (#64, #90, and #78,) of six residents reviewed for discharges. The facility census was 123. Findings include: 1. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficits. Review of Resident #64's progress note dated 12/26/19 revealed the resident was transferred to a local hospital. There was no evidence the resident or resident representative was provided with a notice of the bed hold policy. The resident was re-admitted to the facility on [DATE]. Interview with Resident #64 on 02/24/20 at 11:00 A.M. verified he did not receive a copy of the bed hold policy at the time of his transfer to the hospital, or at any time while he was in the hospital, or upon return to the facility. Interview with the Administrator on 02/26/20 at 4:30 P.M. verified there was no documentation the resident and/or responsible party was provided with a copy of the bed hold policy. 2. Review of the medical record for Resident #90 revealed the resident was admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] revealed Resident #90 had no cognitive deficits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 3 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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 0625 Level of Harm - Minimal harm or potential for actual harm Review of progress note dated 12/20/20 at 3:56 P.M. revealed Resident #90 was transferred to the local hospital. There was no evidence the resident received a copy of the bed hold policy. Interview with the Administrator on 02/26/20 at 4:25 P.M. verified there was no documentation the facility provided the bed hold policy to Resident #90. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 4 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to develop a plan of care for the use of a Foley catheter for one Resident (#105) of 24 reviewed for care plans. The facility census was 123. Findings include: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). The resident was noted to be admitted to the facility with an indwelling Foley catheter in place. Review of the comprehensive plan of care revealed revealed there was no care plan in place for catheter care for Resident #105. Review of the physician orders revealed the Foley catheter was discontinued for Resident #105 on 02/11/20, and to check post-void residual every eight hours, for 72 hours. On 02/14/20 a physician order revealed to restart the Foley catheter. Interview with the Director of Nursing (DON) on 02/26/20 at 10:30 A.M. verified Resident #105 had a Foley Catheter in place upon admission to the facility. The DON verified the Foley Catheter was discontinued on 02/11/20, however was restarted on 02/14/20. The DON verified there was no care in place for Resident #105's Foley catheter care until 02/26/20. Review of the facility policy titled Care Plans- Comprehensive approved November 2019 revealed an individualized comprehensive care plan shall be developed by a interdisciplinary team to include the resident and/or their representative that incorporates the resident's medical and physical care needs and is periodically re-evaluated and revised as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 5 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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 0679 Provide activities to meet all resident's needs. 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 and staff interview, resident interview, and facility policy review, the facility failed to provide an individualized activity program designed to meet the interests and social needs of nonverbal residents. This affected one Resident (#63) of one reviewed for activities. The facility census was 123. Residents Affected - Few Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, aphasia, and dementia. Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. Resident #63 was totally dependent on staff for transfer, and locomotion. Review of Resident #63's care plan revised 01/22/20 revealed supports and interventions included to pursue independent activity daily, such as television, radio, visits, and reading (large print as needed). In addition Resident #63 was to attend group activities of interest, such as, church services, bingo, bands, and socials. Resident #63 would accept friendly room-to-room activities as they were available, such as, church, music, and pet visits for added social stimulation. Staff were to supply items for independent activities as needed, offer room activities as available, assist as needed, and monitor and record progress. Review of Resident #63's State Tested Nursing Assistant (STNA) tasks for the last 30 days revealed no documented activities. Review of Resident #63's one on one activity list revealed Resident #63 had Bible reading on 12/09/19, 12/12/19, 12/24/19, 01/02/20, 01/09/20, 01/13/20, 01/15/20, 02/04/20, 02/11/20, 02/14/20, 02/18/20, and 02/24/20. Resident #63 was documented to have had 12 one on one interactions in the last 77 days. Observation on 02/24/20 at 1:32 P.M. revealed Resident #63 was in bed with his eyes open. His television was not on, and no music was playing. The resident was unable to be interviewed. Interview on 02/24/20 at 1:36 P.M. with Resident #63's roommate, Resident #44, revealed staff never did any activities with Resident #63. Resident #44 revealed Resident #63 was mostly just left in the bed. Observation on 02/25/20 at 1:22 P.M. revealed Resident #63 was in bed with his television off, and no music was playing. Observation on 02/26/20 at 8:49 A.M. revealed Resident #63 as in bed with his eyes open. There was no television or music on. Observation on 02/26/20 at 9:48 A.M. of the common lounge area found an activity staff person interacting with six residents using a [NAME]-hoop. Resident #63 was observed in his bed in his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 6 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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 0679 Level of Harm - Minimal harm or potential for actual harm Interview on 02/26/20 at 11:20 A.M. with State Tested Nursing Assistant (STNA) #533 verified Resident #63 relied totally on staff for all care and activities, and he enjoyed music as it helped soothe him. Interview on 02/27/20 at 9:35 A.M. with Activities Director (AD) #505 verified Resident #63 was not taken out of his room for activities. Residents Affected - Few Review of the facility policy titled, Activities General, dated 06/20/14 revealed the facility must provide for ongoing program of activities designed to meet in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident and the facility shall have a plan of activities appropriate to the needs of the residents of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 7 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on test tray tasting, staff interview, resident interview, and review of facility policy, the facility failed to serve food that was palatable and appealing. This affected one Resident (#215) of six reviewed for food quality. The facility census was 123. Residents Affected - Few Findings include: A test tray completed on 02/26/20 at 5:54 P.M. revealed the dinner meal consisted of chicken stir fry over rice with snap peas. The stir fry vegetables were unidentifiable and mushy. The snap peas were mushy and gray. The presentation was unappealing, grayish, and brownish in color. The temperature of the food was warm, not hot. The snap peas tasted bland with no seasoning, and the consistency was mushy. The chicken stir fry was salty. The test tray was sampled by two state surveyors and the Assistant Director of Nursing (ADON) #707. The ADON verified the snap peas were bland and mushy. Interview with Resident #215 on 02/27/20 at 10:16 A.M. verified she had the chicken stir fry with rice and snap peas for the dinner meal on 02/26/20. Resident #215 stated the snap peas were not good and she did not eat them. She also revealed the chicken stir fry and rice was not good either. Review of facility policy titled, Dietary/Nutritional Care Services/Meal Service, revealed the dietary manager will perform meal rounds daily to determine if meals are attractive and meet the needs of the residents. The dietary manager will observe meals for preferences, temperature, and flavor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 8 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 02/26/20 at 5:18 P.M. revealed DM #500 was in the kitchen cooking at the stove, and plating food for hall trays. DM #500 had a hair net on, however did not have her bangs and approximately two inches of the front of her hair covered. Interview with DM #500 at the time of the observation verified the hair nets were required in the kitchen and her hair was not fully covered. Review of the facility policy titled Dietary Infection Control approval date April 2014 revealed hair restraints are required and should cover all hair. 3. Observation on 02/24/20 at 12:29 P.M. of hall trays being served by State Tested Nursing Assistant (STNA) #587 to room [ROOM NUMBER] revealed she assisted the resident with set up of her food tray with bare hands touching several surfaces on, and around the tray. The STNA touched several personal items of the resident in assisting the resident to reposition to eat more comfortably. STNA #587 did not do any hand hygiene before leaving room [ROOM NUMBER]. The STNA #587 went into room [ROOM NUMBER] who had just received their lunch tray. The STNA #587 entered the room and did not do hand hygiene, assisted the resident with set up of her food items on the tray with bare hands, and left the room without doing hand hygiene. The STNA #587 was requested to assist STNA #508 with the roommate in room [ROOM NUMBER]. The STNA #587 did not do hand hygiene and assisted in transfer and incontinence care. STNA #587 left the room [ROOM NUMBER] and did not do any hand hygiene. Interview on 02/24/20 at 12:50 P.M. with the STNA #587 confirmed during food service and personal care she had not performed hand hygiene. The STNA #587 confirmed she should have either washed her hands or used hand sanitizer. Review of a facility policy titled, Infection Control, dated August 2019, revealed the facility objective is to prevent, detect, and maintain a sanitary and comfortable environment for residents, staff, and visitors. The policy further revealed all staff would be trained on all infection control practices upon hire and periodically. The depth of employees training would depend on the degree of direct resident contact and job responsibilities. Based on observation, interview, and review of facility policy, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect 118 residents of 123 residents of the facility. Residents' #221, #63, #24, #104, and #265 received no food by mouth, and no food from the kitchen. Findings include: 1. Observations on 02/24/20 from 10:17 A.M. to 10:34 A.M. revealed two 24 packs of pita bread with green spots, eight butternut squash with black spots and white fuzz, and were soft to the touch, three tomatoes with white fuzz and brown spots, and soft to the touch. Observation of the freezer revealed there was a bag of biscuits, open to the air with white, frost, and ice crystals. Interview at the time of the observation with the Dietary Manager (DM) #500 verified the above observations. Review of policy titled, Dietary/Nutritional Care Services/Sanitation and Infection Control, with an approval date of April 2014, under the section food storage, food was to be protected from contamination and growth of any pathogenic organisms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 9 of 10 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 366305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Care Center of Sylvania 4121 King Road Sylvania, OH 43560 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to maintain infection control practices during a dressing change. This affected one Resident (#214) of three reviewed for pressure ulcers. The facility census was 123. Residents Affected - Few Findings include: Review of the medical record for the Resident #214 revealed an admission dated of 02/06/20 with diagnoses including acute kidney failure, congestive heart failure, type two diabetes, dependence on renal dialysis, and peripheral vascular disease (PVD). Review Resident #214's pressure injury review dated 02/06/20 revealed an unavoidable stage two pressure ulcer of the right lateral heel. Observation on 02/26/20 at 12:15 P.M. with the Assistant Director of Nursing (ADON) of the right lateral heel dressing change for Resident #214 revealed after removing the old dressing and cleaning the wound, the ADON placed the Resident #214's uncovered right heel on the bed. The ADON left the room to check the dressing change order, returned to the room, completed hand hygiene, and paced a dressing over the wound. Interview on 02/26/20 at 12:29 P.M. with the ADON confirmed she had laid Resident #214's right heel directly on the bed and the wound was contaminated. Review of a facility policy titled, Infection Control, dated August 2019, revealed the facility objective is to prevent, detect, and maintain a sanitary and comfortable environment for residents, staff, and visitors. The policy further revealed all staff would be trained on all infection control practices upon hire and periodically. The depth of employees training would depend on the degree of direct resident contact and job responsibilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 10 of 10