Health inspection·June 9, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (Resident #34 and #152) out of 28 resident bedrooms observed on the second floor of the facility. The census was 52. Findings include: 1. Review of Resident #34's medical record revealed an admission date of 05/03/22. Diagnoses included orthopedic aftercare following surgical amputation, chronic respiratory failure with hypoxia, end stage renal disease, diabetes mellitus type two, and peripheral vascular disease. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was assessed with moderately impaired cognition. Review of physician orders dated between 05/03/22 and 06/07/22 revealed Resident #34 had no physician order for artificial tears. Review of medication administration records (MARs) from May 2022 and June 2022 revealed no documentation of Resident #34 ever having received artificial tears while in the facility. Review of progress notes between 05/03/22 and 06/07/22 revealed no documentation of Resident #34 having received artificial tears while in the facility. Observation on 06/06/22 at 11:17 A.M. revealed Resident #34 had a bottle of artificial tears eye drops, a medication for dry eyes, inside of its box located on a shelf in Resident #34's bedroom among other personal items. Observation inside the box revealed the plastic seal on the eye drops bottle was removed. Observation on 06/07/22 at 1:17 P.M. revealed the box with the bottle of artificial tears medication remained in Resident #34's bedroom. Interview on 06/07/22 at 1:17 P.M. with Resident #34 revealed an unidentified nurse gave him the bottle of artificial tears because he complained about having an itchy left eye. Resident #34 stated he could not remember the nurses name, what she looked like, or the day the bottle was given to him, and stated he only used the eye drops once. Resident #34 stated he did not know the eye drops were still in his bedroom and stated the nurse must have left them in the room in case he needed to use them again. Observation on 06/08/22 at 2:12 P.M. revealed the box with the bottle of artificial tears medication still remained in Resident #34's bedroom. Interview on 06/08/22 at 2:46 P.M. with Licensed Practical Nurse (LPN) #464 verified there was a bottle of artificial tears medication in Resident #34's bedroom and LPN #464 removed it. LPN #464 stated she was not aware of anytime Resident #34 received the medication and verified it should not be stored in his bedroom. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366409 If continuation sheet Page 2 of 3 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 366409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston Rehabilitation of Perrysburg 345 East Boundary Street Perrysburg, OH 43551 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 0761 Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #152's medical record revealed an admission date of 05/19/22. Diagnoses included old myocardial infarction, acute kidney failure, insomnia, restless leg syndrome, anxiety, and heart failure. Review of an admission MDS assessment dated [DATE] revealed Resident #152 was assessed with moderately impaired cognition. Residents Affected - Few Review of physician orders dated between 05/19/22 and 06/08/22 revealed Resident #152 had no physician order for calcium carbonate. Review of MARs from May 2022 and June 2022 revealed no documentation of Resident #152 having received calcium carbonate in the facility. Review of progress notes between 05/19/22 and 06/08/22 revealed no documentation of Resident #152 having received calcium carbonate while in the facility. Observation on 06/06/22 at 11:10 A.M. revealed a partial bottle of calcium carbonate, a antacid medication, tablets on a shelf under the television in Resident #152's bedroom. Observation on 06/07/22 at 1:15 P.M. and on 06/08/22 at 8:32 A.M. revealed the partial bottle of calcium carbonate tablets remained in Resident #152's bedroom. Observation on 06/08/22 at 2:14 P.M. revealed the partial bottle of calcium carbonate remained in Resident #152's bedroom. Interview with Resident #152 at that time revealed she brought the medication with her from home because she sometimes had acid reflux but had not taken any of the calcium carbonate since she was in the facility. Interview on 06/08/22 at 2:40 P.M. with LPN #464 verified the partial bottle of calcium carbonate in Resident #152's bedroom and LPN #464 told Resident #152 she was going to secure the medication. At that time, Resident #152 told LPN #464 she had not taken any of the medication since she was admitted to the facility. LPN #464 stated she was not aware of anytime Resident #152 received the medication and verified it should not be stored in her bedroom. Review of a facility policy titled Storage of Medications, dated 01/07/21, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems and each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366409 If continuation sheet Page 3 of 3