Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kingston Health Center Of Perrysburg during CMS and state inspections, most recent first.
A facility failed to ensure staff wore appropriate PPE for a COVID-19 positive resident, with an occupational therapist observed without a gown, eye protection, or gloves. Additionally, the facility did not complete required weekly water flushes to prevent Legionella pneumophila, with maintenance logs showing incomplete records and no evidence of flushing from June to August 2024.
The facility failed to provide adequate window coverings in the dining rooms, leading to discomfort for residents due to bright sunlight. Observations showed only sheer curtains were present, insufficient to block the glare. Residents expressed concerns about the brightness, but staff were unaware of these complaints. The facility's policy on comfortable lighting was not followed.
A resident, who is six feet, six inches tall, was provided with a bed that was too short, causing discomfort and difficulty sleeping. Despite a tall bed being ordered upon admission, observations showed the resident's head at the top of the mattress and legs bent with pillows. Staff interviews revealed awareness of the issue, but the facility's policy on accommodating residents' needs was not effectively implemented.
The facility failed to conduct quarterly care conferences for two residents, as required by policy. One resident, with cognitive impairment and multiple diagnoses, had no documented care conference since November 2023. The LSW confirmed the resident's representative declined meetings over the summer, and the interdisciplinary team did not document their meetings as care conferences. Another resident, cognitively intact with severe medical conditions, had no care conference documented since April 2024, and the resident could not recall attending one. The facility's policy requires care update meetings every 90 days.
The facility failed to assist two male residents with shaving due to a lack of proper equipment and staff availability. One resident, with hemiplegia and diabetes, had an uneven beard and was unable to shave due to his condition. Another resident, with hemiplegia and dysphasia, also could not receive assistance for shaving. The facility's policy on shaving was not effectively implemented, leading to this deficiency.
A facility failed to implement ordered pressure ulcer interventions for a resident with multiple pressure ulcers. Despite physician orders to off-load heels and use a pressure-relieving air cushion, observations showed the resident's heels were not elevated, and the cushion was turned off. The facility's policy emphasized these interventions, but they were not consistently applied.
A resident with quadriplegia was found to have unsafe gaps between their mattress and bed rails, with measurements of 5.25 inches on the left and 3.25 inches on the right. The DON confirmed these gaps were too large and potentially unsafe, and the facility could not provide manufacturer guidelines for acceptable distances.
A resident with quadriplegia and communication difficulties was unable to use the standard call light system due to his condition. His electronic communication board, which was not connected to the call light system, was placed out of his visual range, preventing him from requesting assistance. Staff interviews confirmed the resident's inability to use the call light and the improper placement of his communication board.
The facility did not complete reference checks for new hires, including STNAs, an RN, an Environmental Services Manager, an Activity Director, and a Maintenance Manager. The HR Manager indicated that the corporate office advised that reference checks were no longer legally required, resulting in the omission.
Inadequate PPE Use and Water Management in LTC Facility
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when providing care for a resident infected with COVID-19. The resident, who had intact cognition, was placed in droplet precautions in single room isolation. Despite the facility's policy requiring full PPE, including an N95 mask, gloves, eye protection, and a gown, an occupational therapist was observed not wearing a gown, eye protection, or gloves while in the resident's room. This was confirmed during an interview with the occupational therapist, who admitted to not wearing the required PPE while setting his things down in the resident's room. Additionally, the facility failed to complete weekly water flushes of equipment at risk for developing Legionella pneumophila, which could potentially affect all 55 residents. The maintenance logs indicated that the required weekly flushing of fixtures was only performed during the first week of each month from January to May 2024, with no logs available for June through August 2024. The Maintenance Manager, who had recently started working at the facility, confirmed the lack of evidence for weekly flushing as required by the facility's Water Management Protocol.
Inadequate Window Coverings in Dining Rooms
Penalty
Summary
The facility failed to provide adequate window coverings in the dining rooms to prevent glare, affecting three residents and potentially impacting eleven others who dined on the second floor. Observations revealed that the dining rooms on both the second and third floors had only sheer curtains, which were insufficient to block the bright sunlight coming through the windows. This issue was highlighted by Resident #108, who expressed discomfort due to the brightness and preferred to sit with her back to the windows. Similar concerns were echoed by Resident #41, who described the sunlight during dinner as blinding and uncomfortable. Interviews with staff, including the Director of Nursing and a Licensed Practical Nurse, indicated they were unaware of any resident complaints regarding the brightness. However, a State tested Nurse Aide reported that residents had voiced concerns, and a concern form was supposedly submitted to Human Resources. The Human Resources Manager, however, stated that she did not receive any such forms, and the Administrator did not recall receiving any complaints about the dining room's brightness. The facility's policy on providing a homelike environment, which includes comfortable lighting and glare reduction, was not adhered to, as confirmed by the observations and resident feedback.
Inadequate Bed Length for Tall Resident
Penalty
Summary
The facility failed to provide a bed long enough to accommodate the height of Resident #107, who is six feet, six inches tall. Upon admission, a tall bed was ordered for the resident, but observations and interviews revealed that the bed was still too short, causing discomfort. The resident was observed with his head at the top of the mattress and his legs bent at the knees with pillows, indicating the bed's inadequacy. The resident expressed discomfort and difficulty sleeping due to the bed's length. Interviews with staff, including the Assistant Director of Nursing (ADON) and a State Tested Nurse Aide (STNA), revealed awareness of the bed's inadequacy. The STNA had reported the issue to a nurse, but the ADON was not initially aware of the problem. Upon further investigation, the ADON discovered the bed was 80 inches long and ordered a longer bed. The facility's policy on accommodating residents' needs was not effectively implemented, as the resident's height was not adequately considered when ordering the bed.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were offered quarterly for two residents, as required by their policy. Resident #13, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease, major depressive disorder, and mixed hyperlipidemia, had not been assessed for cognition in the most recent MDS assessment. The last documented care conference for this resident was held on 11/02/23, and no further conferences were documented. The Licensed Social Worker (LSW) confirmed that the resident's representative did not want to meet over the summer, and although the interdisciplinary team met, they did not attempt to include the resident or document the meeting as a care conference. Similarly, Resident #41, admitted with diagnoses such as incomplete lesion at cervical spinal cord levels, acute and chronic respiratory failure, type two diabetes mellitus, and stage four pressure ulcers, was found to be cognitively intact in the MDS assessment. The last care conference documented for this resident was on 04/10/24, and no subsequent conferences were recorded. The resident could not recall having a care conference, and the LSW verified the absence of documentation for any care conference since April 2024. The facility's policy mandates care update meetings every 90 days, and the medical record should reflect if a meeting is canceled or not attended by the resident or representative.
Failure to Assist Residents with Shaving
Penalty
Summary
The facility failed to assist two male residents with shaving, despite their dependence on staff for this activity of daily living. Resident #22, who was admitted with diagnoses including hemiplegia, hemiparesis, and diabetes mellitus, required substantial assistance for personal grooming due to weakness and the inability to lift his left arm. Observations revealed that he had an uneven beard approximately 1.5 inches long, which he wanted shaved off. However, staff were unable to assist him due to a lack of proper equipment. Although the resident expressed his desire to have his beard shaved, staff informed him that they did not have time and suggested he wait until he returned home where he had the necessary equipment. Similarly, Resident #157, who was admitted with conditions such as hemiplegia, hemiparesis, dysphasia, and congestive heart failure, required setup assistance for personal hygiene, including shaving. Observations showed that he had about 1/2 inch of beard growth and was unable to receive assistance from staff. Interviews with nursing aides revealed that while residents typically brought their electric razors upon admission, the facility only provided disposable razors, which were ineffective for longer beards. The facility's policy on shaving emphasized promoting cleanliness and skin care, yet the lack of appropriate equipment and staff availability led to the deficiency in care for these residents.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement pressure ulcer reducing interventions as ordered for a resident with multiple pressure ulcers. The resident, who was cognitively intact and required substantial assistance with daily activities, had a history of pressure ulcers, including a stage four ulcer on the sacral region and other sites. Physician orders included off-loading heels when in bed and using a pressure-relieving air cushion in the wheelchair. However, observations revealed that the resident was not wearing heel boots, and their heels were not elevated while in bed, contrary to the care plan. Further observations showed that the alternating pressure wheelchair seat cushion was turned off, which was confirmed by an LPN who stated it needed to be plugged in and turned on. The facility's policy on pressure injury assessment and prevention emphasized the importance of offloading heels and using devices for repositioning to prevent pressure injuries. Despite these guidelines, the facility did not ensure the interventions were consistently implemented, as evidenced by the resident's statements and staff verification.
Unsafe Bed Rail and Mattress Configuration
Penalty
Summary
The facility failed to ensure the safety of bed rails and mattresses for a resident with quadriplegia and acute and chronic respiratory failure. The resident, who was dependent on staff for all Activities of Daily Living (ADLs) and rarely/never understood, was observed lying on an air mattress with significant gaps between the mattress and bed rails. These gaps were measured at 5.25 inches on the left side and 3.25 inches on the right side, which were confirmed by the Director of Nursing (DON) to be potentially unsafe. The deficiency was identified during an observation and confirmed through interviews with staff, including a Licensed Practical Nurse (LPN) and the DON. The facility was unable to provide manufacturer guidelines for the acceptable distance between the mattress and bed rails, but the DON acknowledged that the existing gaps were too large and posed a safety risk. This issue affected one of the two residents reviewed for bed rails, highlighting a lapse in ensuring the safety and appropriateness of bed rail and mattress configurations.
Failure to Provide Accessible Call Light System for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a resident with quadriplegia and communication difficulties had access to a functional call light system. Resident #32, who was dependent on staff for all Activities of Daily Living (ADLs) and had been working with speech language pathology therapy to use an eye gaze device, was observed with a standard push-call light button clipped to his bed, which he could not use due to his condition. The resident's electronic communication board, which he used to communicate, was not connected to the call light system, and staff frequently checked on him instead. Further observations revealed that the electronic communication board was placed out of the resident's visual range, rendering it unusable for him to request assistance. Staff interviews confirmed that the resident was unable to use the standard call light and that the communication board was not within reach. Despite the facility's policy requiring staff to ensure residents can use the call system, the resident's needs were not adequately met, as evidenced by the lack of a suitable call light system for his condition.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to complete reference checks for new hires, which could potentially affect all residents. Personnel file reviews revealed that several staff members, including State tested Nursing Aides, a Registered Nurse, an Environmental Services Manager, an Activity Director, and a Maintenance Manager, were hired without completed reference checks. The Human Resource Manager stated that the corporate office had informed the facility that reference checks were no longer required by law, leading to the omission of these checks.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 538 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Perrysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor At Perrysburg | 1 mi | ★★★★★ | 29 | 0 |
| Three Meadows Post Acute | 1.7 mi | ★★★★★ | 13 | 1 |
| Avalon By Otterbein At Perrysburg | 1.7 mi | ★★★★★ | 23 | 0 |
| Concord Care Center Of Toledo | 2.7 mi | ★★★★★ | 31 | 0 |
| Heatherdowns Rehab & Residential Care Center | 3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.