Kingston Of Vermilion

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident did not receive showers as scheduled. CNA #203 verified Resident #37 had a large amount of an unknown substance under her fingernails. Observation on 12/22/25 at 11:47 A.M. of the lunch meal service revealed two CNAs were in the main dining room. Further observation revealed Resident #37 was sitting at

a table with one other resident and her lunch meal was sitting in front of her. Resident #37 was asking for her husband. Continuous observation revealed Resident #37 was not assisted with her lunch meal until 12:15 P.M., when CNA #213 began assisting her and another resident. Interview on 12/22/25 at 12:08 P.M. with CNA #213 revealed there were two CNAs in the dining room on most days to assist residents with eating. CNA #213 stated Resident #37 needed encouragement to eat and often required staff assistance with eating. CNA #213 verified Resident #37 was not assisted with eating in a timely manner. 3. Review of

the medical record for Resident #84 revealed an admission date of 08/20/25. Diagnoses included spastic quadriplegic cerebral palsy, Barrett's Esophagus with dysplasia, and dysphagia.Review of the quarterly MDS assessment, dated 11/26/25, revealed Resident #84 had intact cognition.Review of the care plan dated 08/20/25 revealed Resident #84 had potential for alteration in nutrition and hydration status related to

a mechanically altered diet and spastic quadriplegic cerebral palsy. Interventions included assisting with meals as needed. Further review of the care plan revealed Resident #84 required ADL assistance due to impaired mobility. Interventions included staff assistance with eating.Observation on 12/18/25 at 11:50 A.M. of the main dining room revealed seven residents who needed assistance or encouragement with eating and two CNAs were present to provide needed assistance. CNA #220 assisted Resident #84 with his lunch meal and then proceeded to assist another resident. Continuous observation revealed at 12:20 P.M., Resident #84's dessert was placed in from of him. CNA #220 did not return to assist Resident #84 with his dessert until 12:30 P.M. Interview on 12/18/25 at 12:20 P.M. with CNA #220 revealed they often had two CNAs to assist residents with eating in the dining room. CNA #220 verified residents were not assisted timely and frequently had to wait for assistance, adding some residents required more assistance than others. Interview on 12/22/25 at 10:40 A.M. with Resident #84 revealed the wait times to receive staff assistance with meals was long. Resident #84 stated there were usually two staff in the dining room to assist with eating, but he often had to wait long periods of time in between bites of food.4. Review of the medical record for Resident #65 revealed an admission date of 03/13/24. Diagnoses included active primary progressive Multiple Sclerosis (MS), major depressive disorder, and dysphagia.Review of the quarterly MDS assessment, dated 10/15/25, revealed Resident #65 had impaired cognition and was dependent on staff for ADLs.Review of the care plan dated 03/14/25 revealed Resident #65 had potential for alteration in nutrition and hydration status related to MS, depression, and neuromuscular dysfunction.

Interventions included assisting with meals as needed. Further review of the care plan revealed Resident #65 required ADL assistance related to MS and impaired cognition. Interventions included assisting with meals.Observation on 12/18/25 at 11:50 A.M. of the lunch meal service in the main dining room revealed seven residents who needed staff assistance or encouragement with eating. There were two CNAs present

in the dining room. Further observation revealed at 11:59 A.M., Resident #65's lunch meal was placed in front of him. Continuous observation revealed CNA #220 did not assist Resident #65 with eating until 12:15 P.M. Interview on 12/18/25 at 12:20 P.M. with CNA #220 verified Resident #65 waited approximately 16 minutes before she provided assistance with eating his lunch meal. CNA #220 revealed they had two CNAs to assist residents with eating in the dining room. CNA #220 confirmed residents were not assisted timely and frequently had to wait for assistance, adding some residents required more assistance than others.

This deficiency represents non-compliance investigated under Master Complaint Number 2695858 and Complaint Number 2672380.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kingston of Vermilion

4210 Telegraph Lane Vermilion, OH 44089

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of hospital records, and staff interview, the facility failed to ensure physician orders were in place to monitor medication levels. This affected one (#100) of three residents reviewed for medication monitoring. The facility census was 99.Findings include:Review of the closed medical record for Resident #100 revealed an admission date of 04/01/25. Diagnoses included encounter for orthopedic aftercare, streptococcal arthritis of the left elbow, and osteomyelitis of the left humerus.

Resident #100 discharged from the facility on 04/07/25.Review of the hospital discharge documents, dated 04/01/25, revealed Resident #100 was ordered intravenous (IV) vancomycin (antibiotic), 1,250 milligrams (mg) IV every 24 hours for 28 days and a vancomycin trough level (blood test to measure the level of vancomycin in the bloodstream to ensure the medication remains within a safe and effective range) weekly.

A Peripherally Inserted Central Catheter (PICC) line (a type of long catheter that is inserted through a peripheral vein and used when IV treatment is required over a long period) was placed in the right upper arm. Resident #100 was to be discharged to a skilled nursing facility (SNF) for IV antibiotic therapy and rehabilitation therapy. A vancomycin trough level was drawn at the hospital on [DATE REDACTED], prior to discharge.Review of the admission Minimum Data Set (MDS) assessment, dated 04/06/25, revealed Resident #100 had impaired cognition as evidence of a Brief Interview for Mental Status (BIMS) score of five. Resident #100 received antibiotic therapy.Review of the care plan dated 04/01/25 revealed Resident #100 received IV therapy via a PICC line for an infection in the left elbow. Interventions included inspecting

the IV site at least every day, document and notify the physician of any signs and symptoms of infiltration, extravasation, phlebitis, or other abnormality at the IV insertion site, obtain laboratory (lab) tests as ordered, and vital signs as indicated and as needed.Review of the physician orders dated 04/02/25 revealed Resident #100 was to have a complete blood count (CBC) and basic metabolic panel (BMP) laboratory (lab) test every Wednesday. Staff were to assess the PICC line site every shift for signs and symptoms of complications. Additionally, Resident #100 was ordered vancomycin IV solution, 1,250 mg per 250 milliliters (ml) IV every 24 hours for osteomyelitis of the left elbow for 28 days. Further review of the physician orders revealed no orders for a vancomycin trough level to be completed.Review of a physician progress note dated 04/07/25 revealed Resident #100 was seen by Medical Doctor (MD) #207. New orders were received for Ativan (antianxiety medication that is also used to treat seizure activity) and a neurological consult. No orders were given to complete a vancomycin trough.Interview on 12/17/25 at 1:44 P.M. with the Director of Nursing (DON) verified Resident #100 did not have a physician order to complete a vancomycin trough (due to have been drawn on 04/07/25) to monitor the medication. This deficiency represents noncompliance investigated under Complaint Number 2679714.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet