Inspection·March 11, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure a sanitary and comfortable environment. This affected 18 (Residents #75, #1, #7, #47, #53, #54, #55, #60, #65, #66, #69, #74, #78, #102, #104, #109, #114, and #115) of 18 residents reviewed. The facility census was 126. Findings include: 1. Review of the medical record for Resident #75 revealed an admission date of 02/12/25 with diagnoses including displaced fracture of neck of right radius, fracture of left pubis, fracture of right pubis, Parkinson's disease, depression, osteoporosis, and urge incontinence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #75 was cognitively intact. Observation on 03/10/25 at 9:57 A.M. of Resident #75's room revealed there were three spots on the floor that were sticky and scattered debris on the floor. Interview on 03/10/25 at 10:00 A.M. with Resident #75 revealed there were three spots on the floor that were sticky and the unidentified sticky substance gets caught in the sleds of her walker. Resident #75 revealed the facility was aware. Further interview with Resident #75 revealed scattered debris on the floor in her room. She stated she did not feel the facility does an adequate job keeping the floor in her room clean. Interview on 03/10/25 at 10:12 A.M. with Registered Nurse (RN) #336 verified the sticky spots, as well as the scattered debris on the floor in Resident #75's room. 2. Observation on 03/10/25 at 7:15 A.M. of a medication cart revealed all four castors contained large amounts of hair and various debris wrapped throughout them. Observation on 03/10/25 at 7:16 A.M. of the wall outside of Resident #60's room revealed a splatter of an unidentified brown substance. Interview on 03/10/25 with Licensed Practical Nurse (LPN) #415 verified all four castors on the medication cart used for 17 residents (#1, #7, #47, #53, #54, #55, #60, #65, #66, #69, #74, #78, #102, #104, #109, #114, and #115) contained large amounts of hair and various debris wrapped throughout them as well as the unidentified brown substance splattered on the wall outside Resident #60's room. (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 03/11/2025 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)