Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Sylvania during CMS and state inspections, most recent first.
The facility failed to provide palatable, visually appealing meals at safe and appetizing temperatures, as multiple residents reported that food was often cold, bland, overcooked, and visually unappealing, leading some to frequently request substitute meals such as soup. Surveyor observations and dietary staff interviews showed inconsistent and inadequate temperature control of beef brisket, including readings as low as 51°F before service and 125°F at the end of tray delivery, as well as delays and mishandling of a test tray during transport. The test tray review found the brisket only warm, not hot, and bland, with mixed vegetables cool and minimally seasoned, while residents described the lunch entrée as less than lukewarm, chewy, and lacking flavor, sometimes requiring substitutes or added seasonings to make the food acceptable.
Inaccurate documentation affected legionella prevention records and a resident’s MAR. Legionella weekly fixture exercise logs were copied and reused across multiple months, and a maintenance assistant said he copied the forms because writing took too long. For one resident with multiple chronic conditions and intact cognition, the physician order for Cozaar did not match the MAR, and an LPN charted morning meds as given even though the resident said she had not received them and the medication cup remained in the cart.
Staff failed to follow prescribed menu portions and diet orders, resulting in all residents on pureed diets receiving less than half of the required protein portion when a smaller scoop was used instead of the specified #6 scoop, and one resident on a pureed diet not receiving the required pureed bread item on the meal tray. A cognitively intact resident with DM II, cardiomegaly, morbid obesity, and high BMI, whose care plan addressed risk for impaired skin integrity and whose dietitian ordered double protein meals, was observed receiving double portions of various foods rather than the ordered double protein meat portion, and the diet order in the medical record was not updated to reflect the double protein requirement.
Failure to Obtain Informed Consent for Psychotropic Medications: Five residents received psychotropic meds without proper informed consent. Records showed missing, incomplete, or improperly signed consent forms for antipsychotic, antidepressant, and antianxiety meds, including cases where the resident was cognitively impaired, a representative should have signed, or the consent form did not list all ordered meds. Staff interviews confirmed the consent process was not completed as required.
Medication administration errors resulted in a 21.43% error rate. An LPN omitted a Depakote dose for a resident who received meds via feeding tube, another resident’s morning Bumetanide was delayed and Janumet was unavailable, and a third resident did not receive the full ordered antipsychotic regimen because Aripiprazole 20 mg and Risperdal were not located, leaving only 5 mg of Aripiprazole administered instead of 25 mg.
Medication administration did not follow accepted nursing practice for 12 residents when an LPN pulled meds from the cart, documented them as given, and then handed them to a MA-C to administer. The MA-C confirmed the process, and a regional RN stated this was not standard practice. The facility’s medication administration policy required the person giving the medication to initial the MAR after each dose.
Improper PPE use was observed during care of residents on droplet precautions and EBP. CNAs entered COVID isolation rooms wearing standard eyeglasses instead of the required eye protection, and one CNA used only a surgical mask rather than an N-95 with goggles. During wound care for a resident on EBP, an LPN, RN, and NP wore gloves and surgical masks but no gowns, despite the resident’s care plan and facility policy requiring gown and glove use for high-contact care.
Failure to provide a toilet raiser for a resident with intact cognition who was dependent for toileting hygiene, lower body dressing, and toilet transfers. OT documented a goal for toileting with a raised toilet seat/3-in-1 commode and grab bars, and the resident reported she had used a raised toilet seat at home and had asked multiple staff for one in the facility. At one point the bathroom had no toilet raiser present, though it was later observed in place; the DOR-PT noted the resident had multiple room changes and had previously used another resident’s toilet raiser.
Unsigned DNR Order in Medical Record: A resident with severe cognitive impairment and diagnoses including COPD, dementia, and respiratory failure had a DNR-CCA order documented in the chart and care plan, but the DNR form was not signed by the physician/NP when surveyed. The NP confirmed the form lacked her signature and stated the marks on the form were not hers; the facility policy stated a DNR order is a physician directive that the resident should not receive CPR.
Failure to Notify Resident of Room Change: A resident with intact cognition and a care plan noting that choices were important was moved from a second-floor room to a first-floor room without prior notification or choice. The chart lacked documentation of notification, and the LSW confirmed residents and families were normally notified before room moves per policy.
Failure to Monitor Psychotropic Meds for Insomnia: A cognitively intact resident with insomnia received routine bedtime trazodone and ramelteon as ordered, but the care plan did not address insomnia or include goals, interventions, or sleep monitoring. Nurse and CNA documentation also did not show monitoring of sleep patterns to support the ongoing use of the medications.
Failure to Include Insomnia in the Care Plan: A resident admitted with insomnia had ongoing sleep difficulty documented on MDS, and was receiving trazodone and ramelteon at HS as ordered for insomnia. However, the comprehensive care plan did not include the insomnia diagnosis or any related goals or interventions, and an RN confirmed the omission during interview.
Failure to Provide Adequate Nail Care: Two residents did not receive appropriate nail care. One resident with DM had extremely long, thick toenails and said staff would not trim them because of the DM diagnosis, while a CNA confirmed the nails needed podiatry care. Another resident with dementia and hospice care had very long fingernails with debris under them and nails pressing into the skin; CNAs noted the resident could not feed herself and nail cleaning appeared painful.
Nursing staff failed to accurately assess and measure a hospice resident's wound, with weekly skin records showing inconsistent measurements and one missed assessment. The facility also gave a resident breakfast despite an NPO order before an EGD, causing the procedure to be canceled and rescheduled.
Failure to use ordered heel offloading boots was identified for two residents at risk for impaired skin integrity. One resident with dementia and limited bed mobility had a care plan and MD order for heel lift boots while in bed, but the boots were found on a shelf while the resident lay in bed and a CNA said he thought they were only used at night. Another resident on hospice with impaired cognition and total dependence for bed mobility also had MD orders and a care plan for heel offloading as tolerated, but was observed in bed without the boots, which were also on a shelf in the room.
An LPN administered crushed meds via a resident's g-tube and stated she had not actually checked GRV, later saying to "pretend" she had done so. The resident, who had severe cognitive impairment and was dependent for eating, said he was hungry and had not been fed breakfast, while the untouched tray remained at the bedside. The LPN also said she was unaware of the ordered bolus tube feeding until later and attributed the missed feeding and rushed care to being behind with her assignment.
A resident with hypertensive heart disease, CKD, dementia, and HF received Lisinopril 40 mg daily even when the physician order required the medication to be held for SBP less than 100 mmHg. The MAR showed the drug was administered on four occasions when the resident’s BP was below the ordered threshold, and a regional RN confirmed the administrations were inconsistent with the order.
Insulin pen injectors for three residents with type II DM were found on the med cart without open dates, including Lantus, Humalog, and Novolog pens with remaining insulin in each device. An RN confirmed the pens were not labeled, and the facility policy stated outdated or deteriorated drugs or biologicals shall not be used. In a separate med pass observation, a resident said she had not received her morning meds, yet the MAR showed them as given; an LPN later confirmed the meds were pulled but left in the med cart drawer, with seven meds in an unlabeled cup and the resident's bumetanide among the medications charted as administered.
A resident with severe cognitive impairment and multiple health issues was found with bruising after an aggressive transfer by a CNA, as reported by another CNA in orientation. The resident reported being hit, and witnesses described the care as rough, with the resident expressing pain during the incident. The facility's investigation confirmed that the CNA's actions violated work rules and resulted in physical injury, leading to the CNA's termination.
A resident with severe cognitive impairment and multiple health issues was found with bruising after care was provided by two CNAs, one of whom was reported by a colleague to have acted aggressively during a transfer. The colleague, new to healthcare, did not immediately report the incident as required by facility policy, resulting in a delay in the reporting of suspected abuse.
The facility failed to maintain a sanitary and comfortable environment, affecting multiple residents. A resident reported sticky spots and debris on her room floor, confirmed by an RN, which interfered with her mobility. Additionally, a medication cart used for several residents had hair and debris on its castors, and a brown substance was splattered on a wall, verified by an LPN. These issues indicate non-compliance with the facility's policy for a clean environment.
The facility experienced a deficiency in maintaining a functional call light system, affecting several residents. Observations showed that a green light was incorrectly illuminated, and call lights were alarming without being deactivated due to a shortage of Versus badges. Staff interviews revealed that the badge shortage was due to agency staff not returning them, and maintenance records indicated multiple instances of malfunctioning call lights. The facility did not maintain a call light log, relying on the Versus System for monitoring.
A resident with quadriplegia and a left lower leg amputation fell out of bed due to inadequate supervision during morning care. The resident, who was at high risk for falls, was left on his side by an STNA who stepped away to retrieve items. The facility's policy on fall risk management was not effectively implemented, resulting in the resident rolling off the bed and sustaining minor injuries.
Failure to Provide Palatable, Properly Seasoned Meals at Safe Serving Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were palatable, visually appealing, properly seasoned, and maintained at safe and appetizing temperatures. Multiple resident interviews revealed consistent concerns: vegetables were described as overcooked and portions as smaller; food was reported as visually unappealing, unseasoned, bland, and often cold; and several residents stated they frequently requested substitute meals, such as chicken noodle soup, because the main entrees were unsatisfactory. One resident reported that the food was “always cold” and did not taste good, and another stated that the main meal was always cold and unseasoned, leading to frequent requests for alternatives. Surveyor observations and staff interviews further documented problems with food preparation and temperature control. A staff member stated that beef brisket needed to be cooked to at least 165°F before serving, yet an observation showed the brisket at 51°F upon removal from the steamer oven, with the cook acknowledging it needed to reach appropriate temperature before service. Despite this, the cook reported beginning to serve trays and later claimed the brisket had reached 202°F, while a subsequent temperature check by the Interim Dietary Manager showed 160°F after gravy had been added. A test tray plated and sent from the kitchen experienced delays and handling issues before service, and when checked at the end of the pass, the brisket measured 125°F and was described as warm but not hot, bland, and not very flavorful; the mixed vegetables were cool and very bland, with only black pepper noted as seasoning. Residents later confirmed that the lunch food was less than lukewarm, inferior in taste, and in one case too chewy and without flavor, requiring a substitute entrée or added seasonings and butter to make the vegetables palatable.
Inaccurate Documentation of Legionella Logs and Medication Administration
Penalty
Summary
The facility failed to ensure documentation for legionella prevention was accurate. Review of the 2025 legionella weekly fixture exercise logs showed that the documents for July, August, and September were copied and reused for October, November, and December. A Regional RN verified the documents had been photocopied, and a Maintenance Assistant stated he made copies because he did not like to write and it would take more time. The facility did not have a policy regarding accurate documentation. The facility also failed to ensure medications were accurately transcribed and the medical record was accurate for one resident. The resident was admitted with diagnoses including acute kidney failure, cellulitis of the right lower limb, hypertensive heart disease, CHF, metabolic syndrome, COPD, type 2 diabetes mellitus, and GERD, and had a BIMS score of 15 indicating intact cognition. The physician order for Cozaar 25 mg daily for hypertension did not match the MAR, which listed Cozaar 25 mg with instructions to give one mg daily. In addition, the resident stated she had not yet received her morning medications, including a water pill for swelling, even though the MAR had been checked off as administered; the LPN confirmed she had charted the medications as given before realizing the resident was not in the room and the cup of medications remained in the medication cart.
Failure to Provide Ordered Protein Portions and Menu Items for Pureed and Special Diets
Penalty
Summary
Menus failed to meet residents’ nutritional needs when staff did not follow prescribed portion sizes and menu items for pureed diets and special diet orders. During a noon meal service, staff used a blue scoop that provided a 2‑oz portion to plate pureed beef brisket for residents on pureed diets, despite the menu spreadsheet specifying a #6 scoop (5⅓‑oz portion) for protein. The dietary manager confirmed that residents on pureed diets received less than half of the required protein portion. For a resident with dysphagia and dementia on a regular diet with blenderized (pureed) texture and thin liquids, observation of tray plating showed no pureed bread being placed on the tray, and subsequent inspection of the resident’s plate confirmed there was no bread present, even though the menu spreadsheet required a pureed bread serving for that meal. A resident with diabetes mellitus type II, cardiomegaly, morbid obesity, and intact cognition had a care plan identifying risk for impaired skin integrity and a dietary note recommending double protein meals at lunch and dinner due to a high BMI. The physician’s diet order in the record listed a no concentrated sweets diet with regular texture and thin consistency, and the dietitian ordered double protein meals, which were correctly printed as “double protein” on the meal tickets. However, the resident reported not receiving the proper diet, and observation of a lunch tray showed two sweet potatoes, two dinner rolls, approximately one cup of shredded meat, mixed vegetables, cranberry juice, a cookie, and brown sugar, rather than the 16‑oz meat portion that would constitute double protein based on the 8‑oz single meat portion listed on the portion size spreadsheet. The dietary manager and dietitian confirmed that staff had been providing double portions instead of double protein and that the medical record diet order had not been updated to reflect the double protein order.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents and/or their representatives were informed of and consented to psychotropic medications before those medications were administered. This deficiency involved five residents reviewed for unnecessary medications, and the report states the facility census was 122. The issue was identified through medical record review, staff interviews, and review of psychotropic consent forms. Resident #113 had diagnoses including adjustment disorder, Parkinson’s disease, type II diabetes, dementia with mood disorder, major depressive disorder, and general anxiety disorder. The resident’s MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Physician orders included duloxetine 60 mg in the morning for mood and olanzapine 7.5 mg at bedtime for anxiety and major depression related to Parkinson’s disease. The psychotropic consent form listed olanzapine, but it was not signed by the resident or a representative; only an RN signed it. No consent form was found for duloxetine. Staff interviews confirmed consent had not been obtained from the resident or representative for these psychotropic medications. Resident #3 had diagnoses including left femur fracture, hypertensive heart disease, chronic kidney disease, dementia, heart failure, Alzheimer’s disease, hyperparathyroidism, osteoporosis, and dependence on supplemental oxygen. The admission MDS showed impaired cognition and indicated use of antipsychotic, antianxiety, and antidepressant medications. Orders showed trazodone, buspirone, and quetiapine were administered. The psychotropic consent form only referenced quetiapine 50 mg twice daily, did not list diagnoses or indications, and did not include trazodone or buspirone. Staff confirmed the consent form did not include all psychotropic medications the resident received. Resident #5 had severely impaired cognition with a BIMS score of 01 and had two resident representatives listed on the face sheet. The resident was receiving Seroquel 25 mg in the morning and 12.5 mg at bedtime. The psychotropic consent form was electronically signed by the resident, even though the resident was not his own responsible party. Resident #4 was cognitively intact and received multiple psychotropic medications, including quetiapine, aripiprazole, sertraline, ramelteon, and trazodone. The record contained one consent form listing only aripiprazole and another blank consent form signed by the resident, and staff confirmed consent had not been obtained for the resident’s psychotropic medications. Resident #49 had intact cognition and was receiving fluoxetine 20 mg daily. The psychotropic consent form was left blank for medication information, consent, and resident/representative information, but was signed by a staff nurse. The resident stated he did not recall signing the form, and corporate nursing confirmed the consent form had not been completed before the antidepressant was administered.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications per physician orders, resulting in a medication error rate of 21.43 percent with six errors out of 28 medication opportunities. This affected three of four residents reviewed for medication administration. The report states the facility census was 122. For one resident with hypertensive chronic kidney disease stage 3B, anxiety, non-ischemic myocardial injury, gout, and type II diabetes mellitus, the physician ordered Depakote 125 mg twice daily for agitation. During observation, an LPN did not prepare the Depakote and stated it was omitted because she could not crush the tablet, even though the resident took pills through a feeding tube. The MAR was marked with a 9 for other, but no nursing note was entered to explain the omission. For another resident with acute kidney failure, cellulitis, hypertensive heart disease, CHF, metabolic syndrome, COPD, type II diabetes mellitus, and GERD, morning Bumetanide was not given until 11:43 A.M., and Janumet was not administered because it was unavailable after the previous nurse did not reorder it in time. For a third resident with schizoaffective disorder and other psychiatric diagnoses, ordered Aripiprazole 20 mg, Aripiprazole 5 mg, and Risperdal 1 mg were not fully administered because the 20 mg Aripiprazole and Risperdal were not located during medication preparation, resulting in only 5 mg of Aripiprazole being given instead of the ordered 25 mg dose.
Medication Administration Not Performed by One Staff Member
Penalty
Summary
Nurses failed to dispense and administer medications within accepted standards of practice for 12 residents. During an interview, an agency LPN stated she arrived late for the shift and completed a medication pass in coordination with a MA-C. She said she pulled the medications from the cart, charted them as administered, and handed the medications to the MA-C to give to residents. The MA-C confirmed she assisted with the medication pass and stated the LPN pulled the medications from the cart while the MA-C administered them to the residents. The MA-C identified that this occurred for residents #16, #34, #35, #36, #46, #62, #70, #72, #85, #111, #125, and #126. A regional RN stated it was not nursing standard of practice for one staff member to pull medications from the cart and another staff member to administer them. The facility policy on Medication Administration, approved 04/2024, stated the individual administering the medication must initial the MAR after giving each medication and before administering the next ones.
Improper PPE Use During Isolation and EBP Care
Penalty
Summary
The facility failed to ensure proper use of PPE during care of residents on droplet precautions and residents on enhanced barrier precautions (EBP). During observations, CNA #655 entered the rooms of residents on droplet isolation for COVID-19 wearing standard glasses, a gown, gloves, and an N-95 mask, but did not apply goggles or other eye protection as posted on the door. After exiting those rooms, no disinfection of the glasses was observed. CNA #655 also stated that wearing standard glasses was sufficient eye protection for residents on droplet precautions. Additional observations showed CNA #647 entering rooms of residents on droplet precautions wearing a surgical mask and standard eyeglasses, with a gown and gloves, but without an N-95 mask or goggles. CNA #647 entered a room with two COVID-positive residents and later entered another droplet isolation room to respond to a call light while still wearing only a surgical mask and standard eyeglasses. Resident #9, who was alert and aware, stated that staff were not always wearing the necessary PPE when helping with care. In contrast, the Administrator in Training was observed entering a COVID isolation room with an N-95, gown, gloves, and goggles and verified the required PPE for that room. For Resident #72, the medical record showed diagnoses including dementia, depression, Alzheimer's disease, and long-term anticoagulant use, with intact cognition on the most recent MDS and dependence for personal hygiene. The resident had an order for EBP related to wounds, and the care plan directed staff to wear appropriate PPE during care. During wound measurements, an LPN unit supervisor, an RN unit supervisor, and a nurse practitioner were present in the room wearing gloves and surgical masks but not gowns. All three verified they were not wearing the appropriate PPE for EBP when caring for the resident. The facility policy for EBP required gowns and gloves for high-contact care activities such as wound care.
Failure to Provide Requested Toilet Raiser
Penalty
Summary
The facility failed to ensure a toilet raiser was provided for Resident #130, who was admitted with diagnoses including hypertensive heart disease, acute pulmonary edema, unspecified atrial fibrillation, anxiety, depression, and chronic ulcers of the right foot and left thigh. The resident’s MDS showed a BIMS score of 15, indicating intact cognition, and she was dependent for toileting hygiene and lower body dressing, with substantial to maximal assistance needed for sit-to-stand and toilet transfers. The resident’s care plan identified a need for ADL assistance due to weakness related to heart failure and included use of assistive devices to improve mobility and ADL independence. OT documentation showed a goal for the resident to safely perform toileting tasks using a raised toilet seat/three-in-one commode and grab bars, and the resident reported she had used a raised toilet seat with grab bars in her prior home. During interview, the resident stated she had asked multiple nurses, nurse aides, PTs, and OTs for a toilet raiser but did not receive one. Observation of her bathroom showed no toilet raiser present at one point, and later observation showed one in place. The DOR-PT stated the resident had multiple room changes and had previously used another resident’s toilet raiser when upstairs.
Unsigned DNR Order in Medical Record
Penalty
Summary
The facility failed to ensure that Do Not Resuscitate (DNR) orders were signed in the medical record for one resident reviewed for advance directives. Resident #50 was admitted with diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness, acute and chronic respiratory failure with hypoxia, COPD, dementia, and depression. The resident’s Medicare five-day MDS assessment showed a BIMS score of 05, indicating severely impaired cognition. Review of the resident’s physician orders showed a code status order for Do Not Resuscitate - Comfort Care Arrest (DNR-CCA) initiated on [DATE], and the care plan documented that the resident and family had chosen DNR-CCA with interventions including not initiating CPR in the event of cardiac or respiratory arrest and obtaining the appropriate DNR order. However, observation on [DATE] at 2:50 P.M. found the DNR-CCA form was not signed by the physician/NP. During interview, NP #501 stated it was her responsibility to sign DNR orders for residents she saw and verified there was no signature on the resident’s DNR form; she also stated the pen marks at the bottom of the form were not her signature. The facility policy stated that a DNR order is a directive issued by a physician stating that a resident should not receive CPR.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to inform a resident of an impending room change. Resident #77, who was admitted with diagnoses including osteoarthritis, diabetes mellitus, hepatomegaly, splenomegaly, and cardiomegaly, had intact cognition on the 5-day admission MDS and had a care plan noting that choices were important to her while in the facility. The resident was moved from a second-floor room to a first-floor room without prior notification or choice, and the progress note documented that she was moved with report, medications, and chart given to the receiving nurse. During interview, the resident stated she was moved without proper notification and denied that the move was COVID related. The LSW verified that the chart lacked documentation of notification regarding the room move and stated that residents and families were normally notified prior to a room move. The facility policy stated that after a room move decision, the social worker or designee would follow up with the resident and resident representative to ensure agreement with the plan.
Failure to Monitor Psychotropic Medications for Insomnia
Penalty
Summary
The facility failed to monitor the use of psychotropic medications to confirm they were necessary for one resident. Resident #4 was admitted with a diagnosis that included insomnia and was cognitively intact on the quarterly MDS assessment dated 11/08/25. The assessment also showed the resident reported trouble falling asleep, staying asleep, or sleeping too much on 12 to 14 days of the two-week assessment period. Physician orders dated 11/02/25 included trazodone hydrochloride 50 mg at bedtime and ramelteon 8 mg at bedtime, both ordered to treat insomnia. The MAR for 11/01/25 through 01/12/26 confirmed both medications were administered every night as ordered. However, the comprehensive care plan did not include insomnia, goals or interventions related to the routine use of the two medications, or monitoring of the resident’s sleep patterns. Review of nurse and CNA documentation also confirmed the facility was not monitoring the resident’s sleep patterns, and a Regional RN confirmed the record did not include documented monitoring to support the use of the two routine psychotropic medications for insomnia.
Failure to Include Insomnia in the Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a diagnosis of insomnia. Resident #4 was admitted with insomnia, and the quarterly MDS dated 11/08/25 showed the resident was cognitively intact and reported trouble falling asleep, staying asleep, or sleeping too much on 12 to 14 days during the two-week assessment period. Physician orders dated 11/02/25 included trazodone hydrochloride 50 mg at bedtime and ramelteon 8 mg at bedtime, both ordered to treat insomnia, and the MAR confirmed both medications were administered nightly as ordered from 11/01/25 through 01/12/26. Review of the resident’s comprehensive care plan showed no diagnosis of insomnia and no goals or interventions related to the condition, including the routine administration of the two medications ordered specifically for insomnia. During interview on 01/12/26 at 9:35 A.M., Regional RN #800 confirmed the care plan did not include the diagnosed insomnia or any related goals or interventions despite the resident receiving trazodone and ramelteon routinely. The facility policy for Care Planning - Interdisciplinary Team stated that a comprehensive care plan shall be developed within seven days of the comprehensive assessment.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure dependent residents received adequate assistance with activities of daily living, specifically nail care, for two residents. Resident #77 had diagnoses including osteoarthritis, type II diabetes mellitus, and a history of lower leg cellulitis, and required substantial assistance with some activities of daily living. Observation showed the resident’s toenails were extremely thick and long, with the right great toenail grown about one inch past the toe and curled inward, and the second toe on the left foot similarly affected. The resident stated she had asked to see podiatry on admission but had not, and said staff refused to trim her toenails because of her diabetes. A CNA confirmed the toenails were very long, thick, and flaky and in need of podiatry care, and stated staff do not trim toenails for residents with diabetes. Resident #72 had diagnoses including dementia, depression, Alzheimer’s disease, and long-term use of anticoagulants, and was dependent for personal hygiene with care plan interventions for assistance with activities of daily living. Observation and staff interviews showed the resident’s fingernails were very long, extended well beyond the fingertips, had debris under most of them, and several nails were curving and pressing into the skin at the sides of the fingertips. One CNA stated the resident was unable to feed herself and that attempts to clean the nails had appeared painful to the resident. Another CNA confirmed the long nails and debris under them, and noted the skin appeared bunched up under the nails. The facility policy stated nail care includes regular cleaning and trimming, and that nails should be trimmed and smooth unless otherwise permitted for diabetic residents or residents with circulatory impairments.
Inaccurate wound measurements and failure to keep resident NPO before EGD
Penalty
Summary
Nursing staff failed to accurately assess and measure wounds for a resident receiving hospice services. The resident had diagnoses including anxiety, chronic respiratory therapy, depression, and embolism and thrombosis, and the quarterly MDS showed impaired cognition, dependence for bed mobility, and risk for pressure ulcers. Weekly Non-Pressure Injury Reviews documented a right buttock wound with varying measurements over several weeks, including 8 cm by 5 cm by 2 cm, 10 cm by 6 cm by 0.1 cm, 9 cm by 5.2 cm, 8 cm by 5 cm, 8 cm by 5 cm by less than 0.1 cm, and later 1.4 cm by 4 cm by 0.1 cm, with one week showing no assessment completed. The wound nurse stated the resident's wound was not considered a pressure ulcer and that floor nurses were assigned to measure and assess it. She also stated the nurses may have measured the whole darkened area instead of only the open area, may not have oriented measurements head-to-toe, and that she had found discrepancies in wound measuring since starting the position. The facility also failed to ensure a resident did not receive food before a scheduled EGD. The resident had diagnoses including type II diabetes mellitus and dysphagia, and the care plan identified a potential for altered nutrition and/or hydration status related in part to dysphagia. Physician orders included an NDD Level 3 diet with nectar-thick liquids and an order for nothing by mouth after midnight before the EGD. Despite this, the resident was given a breakfast tray and ate the meal on the morning of the procedure, and the procedure was canceled and rescheduled. A regional RN confirmed the breakfast was provided and stated the kitchen is typically made aware of such orders and will hold the meal, which did not happen in this case.
Failure to Use Ordered Heel Offloading Boots
Penalty
Summary
Failure to provide pressure-reducing devices was identified for two residents reviewed for skin breakdown. Resident #28 was admitted with atrial fibrillation, dementia, and Raynaud syndrome, had impaired cognition, required substantial to maximal assistance for bed mobility, and was identified as being at risk for pressure injuries. The care plan directed staff to off-load the resident’s heels while in bed, and a physician order required heel lift boots to both lower extremities when in bed. During observation, the resident was lying in bed while the offloading boots were found sitting on a shelf opposite the bed. A CNA confirmed the resident was not wearing the boots and stated he believed they were only used at night, not when the resident was placed in bed for a nap. Resident #123, who was under hospice care, had diagnoses including anxiety, chronic respiratory therapy, depression, embolism, and thrombosis. The quarterly MDS showed impaired cognition, dependence on staff for bed mobility, and risk for pressure ulcers, with no pressure ulcers present at the time of assessment. Physician orders required heel lift boots on as tolerated while in bed for skin integrity and to offload heels when in bed if the resident tolerated it. The care plan also included off-loading heel boots as tolerated. During observation, the resident was lying in bed with the boots on a shelf in the room, and the Unit Supervisor confirmed the resident was not wearing them. The supervisor then asked the resident if the boots could be placed on her heels, and the resident agreed. The facility policy stated preventative interventions to protect skin integrity would be implemented immediately upon admission.
Tube Feeding and Medication Administration via G-Tube Not Performed per Orders
Penalty
Summary
The facility failed to ensure tube feedings were administered according to the physician's orders and professional nursing standards of practice for a resident with a gastrostomy tube. Resident #5 was admitted with diagnoses including hypertensive chronic kidney disease stage 3B, anxiety, non-ischemic myocardial injury, gout, and type 2 diabetes mellitus. The resident's MDS showed a BIMS score of 01, indicating severely impaired cognition, and he was dependent for eating and all mobility. His care plan required tube feeding to maintain adequate nutrition and hydration, with interventions to check residual every shift and as needed, follow the ordered formula/rate, and keep the head of the bed elevated over 30 degrees. During observation, an LPN administered crushed medications through the g-tube by verifying placement with an air bolus and stethoscope, then pushing the medications through with a syringe. The LPN stated, "I know to check for gastric residual volume (GRV), just pretend I did that," and later said she was not aware the resident received bolus tube feeding and was preparing to administer it after the scheduled time had passed. The resident stated he was very hungry and said no one had fed him breakfast, while the breakfast tray remained untouched. The LPN acknowledged she was behind due to the patient load, said she normally checks residuals but was rushed, and stated she would not normally pull back the plunger when the syringe is in the tube. The facility policy titled Enteral Tube Feeding via Continuous Pump required checking GRV and, if stomach contents could not be aspirated, repositioning the tube and withholding medication if the tube was still not patent.
Medication Given Despite Hold Parameter
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for one resident reviewed for medication administration. The resident was admitted with hypertensive heart disease and chronic kidney disease, dementia, and heart failure, and the admission MDS showed impaired cognition and use of antipsychotic, antianxiety, and antidepressant medications. The physician order for Lisinopril 40 mg daily for hypertension included a hold parameter for systolic blood pressure less than 100 mmHg, but the resident’s blood pressures were documented as 90/62, 94/52, 99/70, and 91/57 on multiple dates, and the MAR showed Lisinopril was still administered on each of those occasions. A regional RN confirmed the medication was given when the resident’s SBP was below 100 on four occasions, and the facility policy stated medications must be administered in accordance with orders.
Unlabeled insulin pens and inaccurate medication administration storage/documentation
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when insulin pen injectors for three residents were found on the medication cart without open dates. Resident #5 had type II diabetes mellitus and an order for insulin Glargine (Lantus) via pen injector, 35 units every 12 hours. On observation of the C-2 Hall medication cart, the pen injector had approximately 70 units remaining and was not marked with an open date. Resident #20 had type II diabetes mellitus and an order for insulin Lispro (Humalog) via pen injector per sliding scale. The pen injector on the cart had approximately 230 units remaining and was also not marked with an open date. Resident #148 had type II diabetes mellitus and an order for insulin aspart (Novolog) via pen injector, 3 units before meals plus sliding scale. The pen injector on the cart had approximately 75 units remaining and was not marked with an open date. The RN confirmed the insulin pen injectors were not marked with open dates, and the facility policy stated nursing staff shall not use outdated or deteriorated drugs or biologicals. During medication administration, Resident #20 stated she had not yet received her morning medications, including a water pill for swelling in both lower legs. However, the January 2026 MAR showed the morning medications were checked off as administered, including bumetanide 2 mg ordered for congestive heart failure/lymphedema. The LPN who completed the medication pass with assistance from a medication aide initially could not verify whether the medications had been given, then confirmed she had pulled Resident #20's medications but was unable to administer them because the resident was not in her room. The LPN confirmed the charting indicated the medications had been received, while the cup of medications remained in the top drawer of the medication cart awaiting administration, and seven medications were in an unlabeled medication cup. The facility policy stated each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent mixing medications of several residents.
Failure to Protect Resident from Staff-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia and chronic kidney disease, was found with bruising under the left eye and on the left wrist. The resident reported being hit in the eye, but could not provide further details. Nursing staff documented the injuries and conducted assessments, noting the new bruises and monitoring the resident's condition. The incident was further corroborated by a nurse who observed the bruising and by another nurse who completed follow-up skin assessments. A Certified Nursing Assistant (CNA) who was new to healthcare and in orientation reported that while assisting with care, another CNA was aggressive during a transfer, grabbing the resident's wrists and throwing the resident onto the bed. The resident was noted to have said "ow" during the interaction. Although neither the reporting CNA nor the resident's roommate witnessed the resident being struck in the face, both described the care as rough and aggressive. The resident was described as combative and agitated during the incident. The facility's investigation, which included review of witness statements and personnel records, determined that the CNA involved had engaged in behavior that violated facility work rules, including physical mistreatment and actions that placed the resident at risk of harm. The incident resulted in physical bruising and was reported by both the resident and witnesses. The CNA was subsequently terminated for violent behavior and use of force towards residents, as documented in the personnel file and corrective action form.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that staff timely reported allegations of abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and chronic kidney disease. The incident involved a bruise found under the resident's left eye and on the left wrist, with the resident stating that someone had hit her, though she could not provide further details. A CNA who was present during care reported that another CNA was aggressive while assisting the resident with a transfer, including grabbing the resident's wrists and throwing her onto the bed, but did not witness any direct contact with the resident's face. The CNA who witnessed the aggressive behavior did not immediately report the incident, stating she was new to healthcare and unsure of the reporting process. Facility policy requires all employees to immediately report any known instances of abuse, neglect, or misappropriation of property. Despite this, the incident was not reported in a timely manner. The investigation into the allegation was ultimately unsubstantiated due to inconclusive evidence, but the delay in reporting constituted a failure to follow established procedures for the timely reporting of suspected abuse.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for its residents, as evidenced by multiple observations and interviews. Resident #75, who is cognitively intact with a BIMS score of 14, reported sticky spots and scattered debris on the floor of her room, which interfered with her mobility as the substance got caught in her walker. This was confirmed by a Registered Nurse who verified the presence of sticky spots and debris. The resident expressed dissatisfaction with the cleanliness of her room, indicating that the facility was aware of the issue but had not adequately addressed it. Additionally, a medication cart used for 17 residents was observed to have large amounts of hair and debris wrapped around its castors. A splatter of an unidentified brown substance was also noted on the wall outside another resident's room. These observations were verified by an LPN, highlighting a broader issue of cleanliness and maintenance within the facility. The facility's policy on providing a safe, clean, and homelike environment was not adhered to, as evidenced by these findings, which were part of a complaint investigation.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to maintain a functional call light system, affecting six residents and potentially impacting all 105 residents. Observations revealed that the green light above a resident's room was illuminated without any therapy staff present, indicating a malfunction. Interviews with staff confirmed that the green light should only be on when therapy staff are in the room, but it remained on despite the absence of staff. Additionally, several residents' call lights were alarming, and staff were unable to turn them off due to a shortage of Versus badges, which are required to deactivate the call lights. The shortage of Versus badges was attributed to agency staff not returning them after their shifts. Staff members without badges had to borrow from others, complicating the response to call lights. Interviews with the DON and other staff revealed that the facility was aware of the badge shortage and its impact on the call light system. Furthermore, a malfunction was noted in one resident's room where the call light would not function properly if pulled too hard, requiring manual adjustment to the wall unit. Maintenance records showed multiple instances of malfunctioning call lights, with work orders placed and resolved over the previous month. However, the facility did not maintain a call light log, relying instead on the Versus System for monitoring. The Administrator acknowledged the issue and mentioned that residents were provided with bells as an alternative when the call light system was not functioning. The facility had 189 badges and was planning to implement a process to prevent agency staff from removing them from the facility.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance during resident care, resulting in a fall incident involving a resident with quadriplegia and a left lower leg amputation. The resident, who was cognitively intact but dependent on staff for all care, was identified as being at high risk for falls. During morning care, the resident requested to be positioned on his left side to facilitate a bowel movement. The State Tested Nursing Aide (STNA) #229 positioned the resident on his side and left the bedside to retrieve items from the bathroom. Upon returning, the STNA found the resident had rolled off the bed and onto the floor, resulting in a raised area on the forehead and a skin tear on the right upper arm. The facility's policy on managing falls and fall risks emphasized the need for staff to identify interventions based on assessments and evaluations to prevent falls and minimize complications. However, in this instance, the policy was not effectively implemented, as the resident was left unsupervised, leading to the fall. The incident was documented in the nurse's notes, and the resident was transferred to a local hospital for evaluation. The emergency room report confirmed no new fractures or further injuries, although the resident experienced diffuse aches and diminished sensation globally.
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 582 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 Sylvania
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Sylvania | 1.2 mi | ★★★★★ | 1 | 0 |
| Rosary Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Franciscan Care Ctr Sylvania | 1.9 mi | ★★★★★ | 27 | 1 |
| Lakes Of Sylvania, The | 2.3 mi | ★★★★★ | 9 | 0 |
| Otterbein Sunset Village | 3.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Kingston Health Center Of Sylvania.
100% money-back within 48 hours.
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.