Inspection·September 11, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident #1 was unable to describe what happened, just stating Get me off the floor. At 12:38 P.M. EMS arrived and at 12:50 P.M. Resident #1 was transported to the hospital. On 07/30/23 at 4:50 P.M. LPN #300 documented Resident #1 was being admitted to the hospital with the diagnosis subdural hematoma. Review of a witness statement on 07/30/23 by STNA #200 revealed STNA #200 and STNA #201 entered Resident #1's room and brought in the Hoyer lift. The STNAs pushed the lift up to the resident and hooked the black sling (pad) loops on top and the green loops on the bottom with the sling legs criss crossed. They then raised the resident all the way up until the lift stopped. STNA #201 was holding onto the Hoyer as STNA #200 pulled the resident's chair out of the was to allow STNA #201 to push the resident over to her bed. As soon as the chair was moved back, the Hoyer pad came loose and dropped the resident. STNA #201 went to get a nurse while STNA #200 stayed with the resident. STNA #200 stated the Hoyer pad was observed with no obvious rips or tears. Review of a witness statement on 07/30/23 by STNA #201 revealed STNA #200 and STNA #201 were getting Resident #1 from her chair to bed. They hooked the resident to the Hoyer pad, which had no rips,and crossed the pad between her legs and supported her. The STNAs hooked the black loops on top and green loops on the bottom. Resident #1 was stable going up and did not move the Hoyer. Then as she was lifted up all the way, STNA #200 moved the chair back. Resident #1 was not touching on the chair any longer and the top of the Hoyer pad came loose and Resident #1 fell. The STNAs immediately got the nurse and STNA #201 stayed with Resident #1 as nurse came to assess and Emergency Medical Technicians came. Review of LPN #300's statement dated 07/30/23 noted LPN #300 to respond to Resident #1's room after STNA #201 yelled for her. Resident #1 was observed laying on the floor. Resident #1 mumbled something and Registered Nurse (RN) #400 also arrived in the room. LPN #300 called 911. RN #400 had assessed Resident #1 for injuries and measured her scalp wound with no open areas discovered. Resident #1 still had a wig on and EMS removed the wig to see goose egg which RN #400 had measured. Review of of RN #400's witness statement on 07/31/23 revealed the STNAs called out for a nurse. LPN #300 and RN #400 responded to Resident #1's room. RN #400 looked into the room and the mechanical (Hoyer) lift was there with three of four straps (loops) in place. Resident #1 was on the floor on her stomach. Resident #1 was turned onto her right side. RN #400 assessed the resident with Resident #1 stating the only pain was to her head. Upon looking under the resident's wig a 9.5 centimeter (cm) by 9.0 cm raised area was discovered. EMS arrived, assessed the resident, and transported her to the hospital. Interview on 09/07/23 at 2:12 P.M. via telephone with STNA #201 revealed on 07/30/23 she was transferring Resident #1 using the mechanical lift with assistance from STNA #200. Resident #1 was propelled in a tilt style wheelchair into her room. The mechanical lift sling was already in place under the resident. STNA#201 placed the lift over the resident from the direction of the resident's feet and was utilizing the controls. STNA #201 opened the legs of the lift to place the lift mechanism over the resident. STNA #200 hooked the sling to the lift with the black loops on the lift hooks which extended behind the residents shoulders. STNA #201 took the lower sling straps and placed the black loops to the lift hooks by criss crossing the sling under the residents thighs and hooking the left side to the right hook and right loop to the left hook. STNA #201 lifted the resident using the electronic control to the highest point. STNA #200 then pulled the chair out from under the resident. At that time the left or right upper loop disconnected from the lift and Resident #1 fell to the floor. STNA #201 pushed the lift to the side and called for help. STNA #200 went to the door and also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 2 of 5 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 09/11/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few called for help. RN #400 and LPN #300 responded and initiated an assessment of the resident, followed by calling 911. STNA #201 was unable to verbalize how the resident fell from the lift or verify all lift sling loops were in place. Review of the facility policy titled Mechanical Lift Transfer Policy, revised August 2023, revealed attaching the sling to lift. Attach the loops nearest the residents shoulders, to the hanger bar hooks of the lift nearest each shoulder using the same length and color of loop strap on each side. Take the sling leg lying over the left leg, cross it over and attach it on the hook of the hanger bar located on the right side of the resident. Next take the sling leg lying over the right leg, cross it over and attach it on the hook of the hanger bar located on the left side of the resident using the same length and color of loop strap on each sling leg. Make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook hanger bars. Resident is now ready to be lifted. Interview on 09/11/23 at 7:15 A.M. the Director of Nursing (DON) confirmed Resident #1 sustained a subdural hematoma due to falling from a Hoyer lift. STNA #200 and STNA #201 did not ensure the Hoyer lift sling remained in place with all sling straps affixed to the lift throughout the transfer. As a result of the incident the facility implemented corrective action to prevent further mechanical lift related occupancies. As a result of the deficient practice, the facility has implemented corrective action, which was completed as of 08/30/23, as follows: • On 07/30/23 the DON, Administrator, and Quality Assurance Nurse were notified of the incident. The lift and sling was pulled from service by RN #400. • On 07/30/23 starting at the next shift change, a review of safe transfer practice was initiated by RN #400 for current shift nursing staff and oncoming shift nursing staff. Staff Development Registered Nurse (SDRN) continued education with oncoming shifts. The education to all nursing staff was completed on 08/08/23. • On 07/31/23 SDRN and designee completed mechanical lift transfer education and return demonstration competency check off for all nursing and therapy staff. • On 07/31/23 the Interdisciplinary Team (IDT) fall and risk review was completed for Resident #1. • On 07/31/23 the mechanical lift slings were inspected and found to be free of rips, tears, or fraying by Central Supply Manager, State Tested Nurse Aide (STNA) #209. Maintenance Manager #1 inspected all lifts for proper function and found no lifts not working properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 3 of 5 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 09/11/2023 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 0689 • Level of Harm - Actual harm On 07/31/23 Quality Assurance (QA) Audits were established. Residents Affected - Few • On 08/08/23 fall information was introduced to monthly QA meetings, reviewed the incident and equipment reviewed the education of nursing and therapy staff regarding safe transfers with the mechanical lift. The facility continued random demonstration competencies with staff by SDRN and designee. • Random total lift audits by the nurse management staff continued on 08/09/23 twice, 08/11/23 twice, 08/21/23 twice, 08/24/23 twice, and 08/30/23 once. • On 09/06/23 at 9:05 A.M. observation of Resident #5 during a mechanical lift transfer by STNA #210 and LPN #315 noted appropriate and safe transfer provided in accordance with facility policy. • On 09/11/23 interview with STNA #205, STNA #206, LPN #301, and RN #401 confirmed education on 07/30/23 of the mechanical lift. This deficiency represents an episode of non-compliance investigated under Complaint Number OH00145861. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 4 of 5 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 09/11/2023 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 0760 Ensure that residents are free from significant medication errors. 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 the facility was free from significant medication errors when an antibiotic was not administered as ordered for one (#3) of five residents reviewed for medication administration in a facility census of 112. Residents Affected - Few Findings include: Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included hypotension, chronic kidney disease, atrial fibrillation, coronary artery disease, dementia, benign prostatic hyperplasia, congestive heart failure, and ischemic cardiomyopathy. Review of the physician order dated 07/12/23 revealed an order for the administration the antibiotic cephalexin 500 milligrams (mg) every morning and at bedtime for cellulitis to the toe for 10 days. Review of the medication administration record noted the cephalexin 500 mg to be documented as administered twice on 07/13/23 twice and once in the morning on 07/14/23. Beginning with the 07/14/23 evening dose through 07/18/23 the cephalexin was recorded as held. There was no documentation contained in the medical record the physician was informed of the medication being held. Interview on 09/06/23 at 1:40 P.M. interview with Certified Nurse Practitioner (CNP) #1 revealed she was not informed Resident #3 did not receive the antibiotic from 07/14/23 at 7:00 P.M. through 07/18/23 when he discharged . CNP#1 stated nursing was holding the medication due to a potential allergy. CNP #1 stated the resident was assess and no signs or symptoms of infection were noted and the medication was extended out until 07/22/23 to ensure the resident received the full antibiotic dose. Review of the facility policy titled Administering of Medications, approved February 2023, medications must be administered in accordance with orders, including any required time frames. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the residents attending physician or the facility's medical director to discuss the concerns. This deficiency represents non-compliance investigated under Complaint Number OH00145325. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366305 If continuation sheet Page 5 of 5