Kingston Health Center of Sylvania

Inspectors wroteBased on resident interview, review of a test tray, and staff interview, the facility failed to ensure resident meals were palatable and served at an appropriate temperature. This had the potential to affect all 122 residents in the facility.

Inspectors wroteBased on medical record review, observation, review of the legionella weekly fixture exercise logs for the year of 2025, staff interview, and policy review, the facility failed to ensure documentation for legionella prevention was accurate. This had the potential to affect all residents. Furthermore, the facility failed to ensure medications were accurately transcribed and the medical record was accurate regarding the receipt of medications for Resident #20. This affected one resident (#20) of four residents reviewed for accurate medical records. The facility census was 122.

Inspectors wroteBased on medical record review, staff interview, and review of the psychotropic consent forms, the facility failed to ensure residents and/or their representatives were informed of and consented to the use of psychotropic medications prior to administration. This affected five residents (#113, #3, #5, #4 and #49) of five residents reviewed for unnecessary medications. The facility census was 122.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to administer medications per physician orders. This affected three residents (#5, #20, and #125) of four residents reviewed for medication administration. The medication error rate was 21.43 percent with six errors for the 28 medication opportunities. The facility census was 122.

Inspectors wroteBased on observation, staff interview, review of the medical record, and review of the menu spreadsheet, the facility failed to ensure residents on a pureed diet received adequate protein portions. This affected all five residents (#5, #21, #72, #80, and #124) on a pureed diet. Additionally, the facility failed to ensure residents on a pureed diet received all menu items on their meal tray. This affected one (#80) of one resident observed for menu items. Further, the facility failed to ensure residents received double portions as ordered. This affected one (#77) of three residents reviewed for nutrition. The facility census was 122.

Inspectors wroteBased on staff interview and policy review, the facility failed to ensure nurses dispensed and administered medications within appropriate standards of practice. This affected 12 residents (#16, #34, #35, #36, #46, #62, #70, #72, #85, #111, #125, and #126). The facility census was 122.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of facility policy the facility failed to ensure the proper use of personal protective equipment (PPE) during care of residents on isolation and in enhanced barrier precautions (EBP). This affected six residents (#15, #9, #94, #119, #82, and #72) of eight residents reviewed for infection control practices. The facility census was 122.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to ensure a toilet raiser was provided for resident #130. This affected one (#130) of one resident reviewed for accommodation of needs. The facility census was 122.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure Do Not Resuscitate (DNR) orders were signed in the medical record. This affected one (#50) of 24 residents reviewed for advanced directives. The facility census was 122.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review the facility failed to inform a resident of an impending room change. This affected one resident (#77) who was unexpectedly moved to a new room. This had the ability to affect all residents. The facility census was 122.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to monitor the use of psychotropic medications to confirm they were necessary. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The census was 122.

Inspectors wroteBased on medical record review, staff interview, and review of policy for care planning, the facility failed to develop a care plan for a diagnosis of insomnia. This affected one resident (Resident #4) of 23 residents reviewed for care planning. The census was 122.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received adequate activities of daily living care. This affected one Resident (#77) for toenail care and one Resident #72 for fingernail care. This had the ability to affect all residents. The facility census was 122.

Inspectors wroteBased on record review, staff interview, resident review, and policy review, the facility failed to ensure nursing staff assessed wounds accurately. This affected Resident #123 and had the potential to affect 31 residents (#1, #6, #12, #15, #20, #27, #33, #36, #38, #49, #51, #57, #59, #68, #72, #87, #89, #95, #97, #99, #103, #104, #112, #120, #123, #124, #127, #129, #137, #140, and #141) identified with wounds. Additionally, the facility failed to ensure a resident did not receive food in preparation for a scheduled medical test. This affected one (#4) of one resident reviewed for medical testing. The facility census was 122.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure pressure-reducing devices were in place. This affected two (#28 and #123) of six residents reviewed for skin breakdown. The facility census was 122.

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure tube feedings were administered per the physician's orders and per professional nursing standards of practice. This affected one (#5) of one resident review for tube feeding. The facility census was 122.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure medications were administered per physician orders. This affected one (#3) of seven residents reviewed for medication administration. The facility census was 122.

Inspectors wroteBased on observation, medical record review, staff interview, and review of policy for medication storage, the facility failed to label insulin injector pens with open dates. This affected three residents (Residents #5, #20, and #148). The facility identified 22 residents with current orders for insulin injections. Further, the facility failed to properly store medications during the medication administration process. This affected one resident (Resident #20) of four residents observed during medication administration. The census was 122.

Inspectors wroteTHE 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 facility submitted Self-Reported Incidents (SRI), review of personnel records, and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident abuse. This affected one (#108) of three residents reviewed for abuse. The facility census was 117.

Inspectors wroteTHE 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff interview, review of maintenance work orders, review of call light logs and review of policy, the facility failed to maintain a functional call light system. This affected six (#37, #38, #44, #59, #78, and #108) with the potential to affect all 105 residents in a facility. The total facility census was 105.

Inspectors wroteBased 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.

Inspectors wroteTHIS DEFICIENCY REPRESENTS AN EXAMPLE OF PAST NON-COMPLIANCE. Based on medical record review, staff interview, review of facility policy, review of facility investigation documentation, and review of facility corrective action documentation, the facility failed to ensure staff utilized a mechanical lift safely during transfer of Resident #1. Actual harm occurred when two state tested nurse aides lifted Resident #1 with a mechanical lift from a wheelchair and one lift sling strap became dislodged causing Resident #1 to fall to the floor. As a result of the fall Resident #1 sustained subdural hematoma and required hospitalization. This affected one (#1) of three residents reviewed for mechanical lift transfers in a facility census of 112.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure the facility was free from significant medication errors when an antibiotic was not administered as ordered for one (#3) of five residents reviewed for medication administration in a facility census of 112.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents were provided with clean linen. This affected one (Resident #70) of three residents reviewed for a clean and sanitary environment. The facility census was 113.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure a resident's personal hygiene needs were met. This affected one (Resident #58) of one resident reviewed for activities of daily living. The facility census was 113.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure auto-lock brakes were applied to a resident's wheelchair as ordered to potentially prevent falls. This affected one (Resident #41) of three residents reviewed for falls. The facility census was 113.

Inspectors wroteBased on observation, medical record review, staff interview, facility pain clinical protocol and manufacture owners manual, the facility failed to ensure pain control interventions were monitored for effectiveness. This affected one resident (#52) reviewed for pain control interventions. Facility census 113.

Inspectors wrote2. Observation on 02/26/20 at 5:18 P.M. revealed DM #500 was in the kitchen cooking at the stove, and plating food for hall trays. DM #500 had a hair net on, however did not have her bangs and approximately two inches of the front of her hair covered. Interview with DM #500 at the time of the observation verified the hair nets were required in the kitchen and her hair was not fully covered. Review of the facility policy titled Dietary Infection Control approval date April 2014 revealed hair restraints are required and should cover all hair. 3. Observation on 02/24/20 at 12:29 P.M. of hall trays being served by State Tested Nursing Assistant (STNA) #587 to room [ROOM NUMBER] revealed she assisted the resident with set up of her food tray with bare hands touching several surfaces on, and around the tray. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure an allegation of staff to resident verbal abuse was reported to the State Agency. This affected one Resident (#39) of one reviewed for abuse. The facility census was 123.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure an allegation of staff to resident verbal abuse was thoroughly investigated. This affected one Resident (#39) of one reviewed for abuse. The facility census was 123.

Inspectors wrote3. Medical record review revealed Resident #78 was admitted to the facility on [DATE]. Review of Resident #78's MDS assessment dated [DATE] revealed the resident was cognitively intact. Continued review of Resident #78's medical record revealed the resident was transferred to the local hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence the resident received a copy of the facility's bed hold policy. Interview on 02/27/20 at 8:32 A.M. with the Director of Nursing (DON) verified there was no evidence Resident #78 was provided a copy of the facility's bed hold policy. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to develop a plan of care for the use of a Foley catheter for one Resident (#105) of 24 reviewed for care plans. The facility census was 123.

Inspectors wroteBased on medical record review, observation and staff interview, resident interview, and facility policy review, the facility failed to provide an individualized activity program designed to meet the interests and social needs of nonverbal residents. This affected one Resident (#63) of one reviewed for activities. The facility census was 123.

Inspectors wroteBased on test tray tasting, staff interview, resident interview, and review of facility policy, the facility failed to serve food that was palatable and appealing. This affected one Resident (#215) of six reviewed for food quality. The facility census was 123.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to maintain infection control practices during a dressing change. This affected one Resident (#214) of three reviewed for pressure ulcers. The facility census was 123.