Inspection·October 8, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA #300 threw Resident #108 on the bed and when doing so the bed bounced a little. CNA #275 assisted by taking Resident #108's feet and gently placed them on the bed. CNA #275 stated she does not know when the bruising could have occurred especially to the face as she never saw any contact with the resident's face. Review of Self-Reported Incident (SRI) #265552, dated 09/23/25, revealed an allegation of physical abuse of Resident #108 with the perpetrator identified as CNA #300. Resident #108 was found to have a bruise under her left eye and a bruise on her wrist. Once identified, Resident #108 received a head-to-toe assessment. CNA #300 was identified as the caretaker who provided care to Resident #108 and CNA #300 was suspended pending investigation. Resident #108 indicated she was hit in the eye but could not recall who did it. A CNA who was working with CNA #300 stated she thought the aide was being aggressive in that she had grabbed the resident's arms and the resident said ow. Resident #108's roommate indicated the nurse was rough with the resident. Neither witness observed Resident #108 being struck in the face or indicated that it appeared the aide intended to hurt Resident #108. It was reported the resident was combative during care and the resident was agitated and aggressive when she was put to bed. The allegation was unsubstantiated due to inconclusive evidence. As a result of the investigation, the facility dismissed CNA #300 from employment. The police were notified and the family opted not to press charges. Review of witness statement, dated 09/23/25, with CNA #275 verified she had assisted CNA #300 get Resident #108 to bed. CNA #275 stated CNA #300 was aggressive stating she picked the resident up and threw her into bed. CNA #275 lifted the resident's legs into bed. CNA #275 states at one point CNA #300 had grabbed the resident's arms and the resident said ow. Review of the personnel file revealed CNA #300 had been hired on 08/15/15. Review of corrective action form dated 09/24/25 revealed CNA #300 was terminated due to violent behavior or use of force towards residents. On the evening shift of 09/22/25 a serious incident occurred involving an employee toward a resident. Following a thorough investigation, it was confirmed the employee engaged in behavior that violated multiple facility work rules, including harassment in the form of verbal or physical mistreatment, actions that placed a resident at risk of harm, and conduct that demeaned the resident's dignity and showed a lack of courtesy and respect. The incident was reported by the resident involved and corroborated by multiple witnesses. The outcome of this behavior included physical bruising and identifying marks on the resident, which is deeply concerning and unacceptable. This conduct is in direct conflict with the facility's commitment to providing compassionate, respectful, and safe care to all residents. Review of policy, Abuse and Neglect- Staff Treatment of Residents, dated 03/03/20, verified residents have the right to be free from abuse, neglect, and exploitation. Every employee has a responsibility to report immediately any and all known instances of abuse, neglect or misappropriation of property, which may be self-inflicted or caused by employees, other residents, or visitors. The deficiency was corrected on 10/06/25 when the facility implemented the following corrective actions: On 09/23/25, Resident #108 was assessed for injuries and psychosocial wellbeing. On 09/23/25, Resident #97 was assessed for injuries and psychosocial wellbeing. On 09/23/25, all staff were educated on the abuse policy and reporting allegations of abuse timely. On 09/23/25, CNA #300 was suspended pending investigation. On 09/23/25, CNA #275 received one on one education on reporting timely. On 09/23/25, all residents were interviewed to ensure they felt safe and there were no further concerns of abuse. On 09/23/25, head to toe assessments were completed on memory impaired residents who were unable to answer questions. On 09/25/25, AD-HOC Quality Assurance meeting conducted. The Director of Nursing or designee will interview five residents weekly for four weeks and then five residents monthly for two months to ensure residents feel safe and there are no concerns of allegations of abuse in the facility. All audits will be taken to Quality Assurance (QA). The (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 10/08/2025 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)

F 0600 DON is responsible for ongoing compliance. This deficiency represents non-compliance investigated under Complaint Number 2630679. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 10/08/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of a facility submitted Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure staff timely reported allegations of abuse. This affected one (#108) of three residents reviewed for abuse. The facility census was 117.Findings include:Review of the medical record revealed Resident #108 was admitted on [DATE]. Diagnoses included unspecified dementia moderate with other behavioral disturbances, chronic kidney disease stage two, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and dysphagia oropharyngeal phase.Review of the Minimum Data Set (MDS) assessment, dated 08/19/25, revealed the resident was severely cognitively impaired and required substantial assistance with chair to bed transfers. Review of a nursing progress note dated 09/23/25 at 7:15 A.M. revealed a bruise was noted under Resident #108's left eye. Another nurse asked what happened to her eye and the resident stated, someone hit me in the eye. The bruise was noted to be 0.5 centimeters (cm) x 1.5 cm red and blue. The resident reported a lady hit her in the eye last night but could not provide any additional details. Review of Non-Pressure Injury Review, dated 09/23/25, revealed a wound was located below the left eye measuring 0.5 cm x 1.5 cm and left wrist out aspect 4 cm x 3 cm. Review of the facility submitted SRI, dated 09/23/25, revealed an allegation of physical abuse of Resident #108 with the perpetrator identified as CNA #300. Resident #108 was found to have a bruise under her left eye and a bruise on her wrist. Once identified, Resident #108 received a head-to-toe assessment. CNA #300 was identified as the caretaker who provided care to Resident #108 and CNA #300 was suspended pending investigation. Resident #108 indicated she was hit in the eye but could not recall who did it. A CNA who was working with CNA #300 stated she thought the aide was being aggressive in that she had grabbed the resident's arms and the resident said ow. Resident #108's roommate indicated the nurse was rough with the resident. Neither witness observed Resident #108 being struck in the face or indicated that it appeared the aide intended to hurt Resident #108. It was reported the resident was combative during care and the resident was agitated and aggressive when she was put to bed. The allegation was unsubstantiated due to inconclusive evidence. As a result of the investigation, the facility dismissed CNA #300 from employment. The police were notified, and the family opted not to press charges. Interview on 10/09/25 at 2:19 P.M. with Certified Nursing Assistant (CNA) #275 verified she had worked on 09/22/25 from 2:00 P.M. to 10:00 P.M. and provided care to Resident #108 with CNA #300. CNA #275 stated she was new to healthcare and it was her third day in orientation. CNA #275 stated while providing care to Resident #108, CNA #300 was being aggressive. CNA #300 was attempting to assist the resident in transferring to bed, and the resident was grabbing CNA #300's wrists. In return, CNA #300 grabbed onto Resident #108's wrists. CNA #275 stated CNA #300 threw Resident #108 on the bed and when doing so the bed bounced a little. CNA #275 assisted by taking Resident #108's feet and gently placed them on the bed. CNA #275 stated she did not know when the bruising could have occurred, especially to the face, as she never saw any contact with the resident's face. CNA #275 verified not reporting the incident immediately, stating she was new and did not know who to tell. Review of policy, Abuse and Neglect- Staff Treatment of Residents, dated 03/03/20, verified residents have the right to be free from abuse, neglect, and exploitation. Every employee has a responsibility to report immediately any and all known instances of abuse, neglect or misappropriation of property, which may be self-inflicted or caused by employees, other residents, or visitors. The deficiency was corrected on 10/06/25 when the facility implemented the following corrective actions: On (continued on next page) 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 10/08/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 09/23/25, LPN #277 assessed Resident #108 for injuries and psychosocial wellbeing. On 09/23/25, the DON or designee initiated re-educated for all facility staff on the abuse policy and reporting of allegations of abuse timely. Evidence was received to verify education was completed on 09/30/25. On 09/23/25, CNA #300 was suspended pending investigation and terminated on 09/24/25. On 09/23/25, the DON provided CNA #275 one-on-one education on timely reporting of potential abuse allegations or concerns. On 09/23/25, the DON or designee interviewed all interviewable residents to ensure they felt safe and there were no further concerns of abuse. On 09/23/25, the DON or designee completed head-to-toe assessments on all residents who were not interviewable. No concerns were identified. On 09/25/25, an AD-HOC Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review the incident and the corrective action implemented. Beginning on 10/01/25, the DON or designee will interview five residents weekly for four weeks and then five residents monthly for two months to ensure residents feel safe and there were no abuse concerns. All audits will be reviewed by QAPI to ensure on-going compliance. The DON is responsible for ongoing compliance. Evidence was received to verify audits were completed on 10/01/25 and 10/06/25, with no concerns identified.This deficiency represents non-compliance investigated under Complaint Number 2630679. Event ID: Facility ID: 366305 If continuation sheet Page 5 of 5