Kingston Health Center of Sylvania

In the surveyor’s words

From the most serious findings on record at Kingston Health Center of Sylvania, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 11, 2023

  THIS 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. […]

• No harm, potential for more than minimal, widespreadF804Jan 12, 2026

  Based 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.Findings include:Interview on 01/05/26 at 9:53 A.M. with Resident #112 revealed the vegetables were overcooked and the portions seemed to be getting smaller. Interview on 01/05/26 at 10:22 A.M. with Resident #36 revealed the food was visually unappealing, was not seasoned, and was cold. Interview on 01/05/26 at 10:55 A.M. with Resident #77 revealed the food was cold and bland. Interview on 01/05/26 at 12:00 P.M. with Resident #20 revealed the food was always cold and did not taste good. Interview on 01/05/26 at 2:48 P.M. […]

• No harm, potential for more than minimal, widespreadF842Jan 12, 2026

  Based 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.Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF919Oct 24, 2024

  Based 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. Findings include: Observation on 10/24/24 at 4:20 A.M., revealed the green light above Resident #38's room was illuminated. Interview on 10/24/24 at 4:20 A.M., with Licensed Practical Nurse (LPN) #207 revealed the green light above each resident room is intended to illuminate when a member of therapy staff is in the room with the resident. Observation on 10/24/24 at 4:22 A.M., revealed Resident #38 was asleep in her room with no therapy staff present. […]

• No harm, potential for more than minimal, patternF552Jan 12, 2026

  Based 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. Findings include:1. Review of Resident #113's medical record revealed an admission date of 09/21/25 and a discharge date of 01/08/26. Diagnoses included adjustment disorder, Parkinson's disease, type II diabetes, dementia with mood disorder, immunodeficiency due to medications (cancer medications), major depressive disorder, and general anxiety disorder. […]