Inspection·June 20, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and review of the facility policy, the facility failed to provide adequate supervision and assistance during resident care, resulting in the resident falling out of bed. This affected one (Resident #87) of three residents reviewed for falls. The facility census was 112. Findings include: Review of the medical record for Resident #87 revealed an admission date of 11/13/23. Diagnoses included quadriplegia and left lower leg amputation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intake and dependent on staff for all care. The resident suffered impairment to bilateral sides of his upper and lower body. Review of Resident #87's most recent care plan revealed the resident was at risk for falls due to quadriplegia. Review of Resident #87's Fall Risk Evaluation dated 06/01/24 revealed he was at a high risk for falls. Review of the nurse's note dated 06/01/24 revealed Resident #87 fell out of bed and hit his head. He had a raised area to the forehead and skin tear to the right upper arm. The resident complained of a headache and raised area was noted on his forehead. The physician was notified and ordered the resident be transferred to a local hospital. The wife, clinical director and the Director of Nursing (DON) were notified. State Tested Nursing Aide (STNA) #229 stated she left the resident on his side and went into the bathroom. When she returned, Resident #87 was on the floor. Review of Resident #87's emergency room report dated 06/01/24 revealed he was a bed-bound male, left above the knee amputation, indwelling catheter, chronic sacral decubitus ulcers, residing in the nursing home over over one year. He was status post fall from his bed while getting changed and onto the floor. He felt diffusely achy but nothing tender, but wife stated he had diminished sensation globally. X-rays and testing found no new fractures or further injuries. Review of Resident #87's Fall Review/Investigation dated 06/01/24 revealed during morning care while in bed, Resident #87 requested STNA #229 to roll him on his left side to facilitate a bowel movement. STNA #229 stepped away from the bed to retrieve items from the bathroom and the resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366305 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 06/20/2024 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)