Kingston Health Center of Perrysburg

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect all residents who were identified to receive food from the kitchen. The facility census was 57. Findings Include:Observation on 07/13/26 at 7:40 A.M. of refrigerator in the first-floor kitchen revealed a container of [NAME] salad dressing with an expiration date of 04/26/26 and a container of Italian salad dressing with an expiration of 06/28/26. Interview on 07/13/26 at 7:40 A.M. with [NAME] #247 verified the container of [NAME] salad dressing had an expiration date of 04/26/26. [NAME] #247 also verified the container of Italian salad dressing had an expiration date of 06/28/26. Both containers were removed from the refrigerator by [NAME] #247 and discarded. Observation on 07/13/26 at 8:00 A.M. [...]

Inspectors wroteBased on observation, medical record review, staff and resident interview, the facility failed to ensure residents were informed of daily therapy schedules. This affected four (#85, #53, #98, and #108) of 54 resident identified by the facility to be receiving therapy services in a facility census of 57.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to develop a plan of care to address the administration and monitoring of an anticoagulant medication. This affected one resident (#20) out of 21 residents whose care plans were reviewed. The facility census was 57. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included fracture of left ischium, Type II Diabetes Mellitus, chronic pulmonary embolism, congestive heart failure and atrial fibrillation. Review of the Minimum Data Set (MDS) for Resident #20 dated 06/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Resident #20 had no behaviors documented. Functional abilities included dependent on others for sit to stand, chair to bed transfer, toilet transfers and car transfers. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure Resident #112's call light was timely answered. This affected one resident (#112) reviewed for call light response time. The facility census was 57. Findings Include: Review of the medical record for Resident #112 revealed an admission date of 07/13/26, with diagnoses including: right achilles tendinitis, syncope and collapse, type two Diabetes Mellitus, hyperlipidemia, hypertension, morbid obesity, generalized anxiety disorder, orthostatic hypotension, hypothyroidism, neuralgia and neuritis, other cervical disc degeneration, history of falling, allergic rhinitis, body mass index 39.0 - 39.9, elevation of levels of liver transaminase, generalized muscle weakness, difficulty in walking, depression, and insomnia. [...]

Inspectors wroteBased on observation, resident interview, medical record review, staff interview and facility policy review, the facility failed to change the dressing of a Vascular Access Device (VAD) according to physicians' orders and the facility policy. This affected one resident (#38) out of one reviewed for intravenous medications. The facility census was 57. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included orthopedic surgery and infection/inflammatory reaction due to right hip prosthesis. Review of the admission Minimum Data Set (MDS) assessment for Resident #38 dated 07/11/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No behaviors documented. Functional abilities included partial assistance with showering and substantial assistance with lower body dressing. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure interventions to promote range of motion were implemented as prescribed by the physician. This affected one resident (#56) of three residents reviewed for range of motion services. The facility census was 57.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure care-planned fall interventions were in place for Resident #108. This affected one resident (#108) of two residents (#56 and #108) reviewed for falls. The facility identified 10 residents (#2, #14, #50, #65, #69, #88, #106, #107, #108, and #111) as high-risk for falls. The facility census was 57. Findings Include:Review of the medical record for Resident #108 revealed an admission date of 07/09/26, with diagnoses including: [...]

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to timely address Resident #48's significant weight loss. This affected one resident (#48) of one resident reviewed for significant weight loss. This had the potential to affect five residents (#1, #42, #48, #56, and #68) identified by the facility has having significant weight loss. Additionally, the failed to ensure Resident #42's request for a protein snack after hemodialysis (HD) was honored. This affected one of one resident (#42) reviewed for post HD nutrition. The facility identified one resident (#42) who was on HD. The facility census was 57. Findings Include: 1. Review of the medical record for Resident #48 revealed an admission date of 05/22/26 with diagnoses including: [...]

Inspectors wroteBased on observation, staff interview, medical record review, review of manufacturer's instructions for use, and review of facility policy, the facility failed to ensure a significant medication error did not occur for Resident #65. This affected one resident (#65) of four residents (#33, #65, #97, and #109) reviewed for medication administration. The facility identified two residents (#65 and #111) prescribed Carbidopa-Levodopa (the primary medication used to treat Parkinson's disease and related symptoms such as tremors, stiffness, and slow movement). The facility census was 57. [...]

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy. The facility failed to ensure medications were appropriately and safely stored. This affected one resident (#108) of one resident reviewed for medication storage. The facility census was 57. [...]

Inspectors wroteBased on observation, medical record review, staff interview and policy review, the facility failed to ensure a resident was placed in Enhanced Barrier Precautions (EBP) according to the facility policy. This affected one resident (#42) out of six reviewed for EBP. Total number of residents in the facility with EBP was 25. The facility census was 57. Findings Include:Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included orthopedic surgery post fracture of left tibia, fracture of left fibula, end stage renal disease, kidney transplant and congestive heart failure. Review of the incomplete admission Minimum Data Set (MDS) dated [DATE] for Resident #42 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No behaviors documented. [...]

Inspectors wroteBased on observation, staff interview, medical record review, review of maintenance documents, and review of the facility's policies, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing care for residents who were infected with COVID-19. This affected one (Resident #114) of one resident observed for droplet precautions. Additionally, the facility failed to complete weekly water flushes of equipment at risk for developing Legionella pneumophila (the cause of Legionnaire's Disease). This had the potential to affect all 55 residents in the facility.

Inspectors wroteBased on observation, record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents were provided a bed long enough to accommodate their height. This affected one (#107) of one resident reviewed for bed length. The facility census was 55.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of policy, the facility failed to ensure care conferences were offered quarterly. This affected two (#13 and #41) of three residents reviewed for care plan conferences. The facility census was 55.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review, the facility failed to assist dependent male residents with shaving. This affected two (Residents #22 and #157) of two reviewed for activities of daily living. The facility census was 55.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of policy, the facility failed to ensure pressure ulcer reducing interventions were implemented as ordered. This affected one (#41) of one residents reviewed for pressure ulcers. The facility census was 55.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the gap between mattresses and bed rails were safe and appropriate. This affected one (#32) of two residents reviewed for bed rails. The facility census was 55.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents had access to a call light. This affected one (#32) of one resident reviewed for call light accessibility. The facility census was 55.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure medications were not left at bedside and were administered appropriately. This affected one (Resident #30) out of 24 residents on the third floor. The facility census was 52.

Inspectors wroteBased 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.