Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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.
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.
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.
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 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 431 citations issued within 25 miles in the last 12 months — including the 2 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 | — | 3 | 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 August 2026) and official state health department websites.