Federal inspectors documented the infection control failures during a complaint investigation in late October, finding that staff had violated the facility's own policies designed to prevent catheter-related infections.
The violations affected two residents among three reviewed for urinary catheter care. Both had serious underlying health conditions that made infection risks particularly dangerous.
Resident #23, a woman admitted in April 2021, lived with chronic respiratory failure, diabetes, heart disease, and multiple other conditions including COVID-19. Inspectors found her catheter drainage bag laying directly on her room floor at 7:45 a.m. on October 28.
Licensed Practical Nurse #407 confirmed what inspectors observed. The drainage bag was indeed on the floor.
The next day, inspectors found an identical violation in another resident's room. Resident #69, a man admitted in June 2023 with stroke-related speech problems, heart disease, and prostate cancer, also had his catheter drainage bag lying directly on the floor.
Certified Nurse Aide #210 verified the bag's placement when questioned at 1:20 p.m. on October 29.
Both discoveries violated Kingston of Ashland's own written policy on urinary catheter care, dated November 2023. The facility's guidelines specifically require staff to keep catheter tubing and drainage bags off the floor.
The policy exists for good reason. Floors harbor bacteria and other pathogens that can travel up catheter tubing and cause urinary tract infections, particularly dangerous for elderly residents with compromised immune systems.
Resident #23's medical complexity made infection risks especially concerning. Her conditions included chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, morbid obesity, and moderately impaired cognition. An infection could have triggered serious complications given her already fragile respiratory and cardiac status.
Resident #69 faced his own vulnerabilities. Though his cognition remained intact, his history of stroke, heart disease, and cancer created multiple pathways for infection to cause severe illness.
The failures occurred despite clear facility protocols. Staff members responsible for both residents' care acknowledged the violations when confronted by inspectors, suggesting the problems weren't isolated oversights but potentially systemic lapses in basic infection prevention.
Kingston of Ashland operates with a census of 90 residents, many of whom likely face similar infection risks. The facility's inability to maintain basic catheter care standards for even a small sample of residents raises questions about broader infection control practices.
Catheter-associated urinary tract infections rank among the most common healthcare-associated infections in nursing homes. They can lead to sepsis, hospitalization, and death in frail elderly populations. Proper drainage bag positioning represents one of the most basic preventive measures.
The inspection occurred as part of a complaint investigation, suggesting someone reported concerns about care quality at the facility. Federal regulators classified the violations as causing "minimal harm or potential for actual harm," though infection risks for medically complex residents like #23 and #69 could escalate quickly.
Both residents discovered with floor-placed drainage bags required ongoing catheter care for underlying urological conditions. Resident #23 had obstructive and reflux uropathy, while Resident #69 suffered from neuromuscular bladder dysfunction. Their conditions made proper catheter maintenance critical for preventing complications.
The facility's November 2023 catheter care policy indicated management understood infection prevention requirements. Staff training should have covered these basic procedures. Yet when inspectors arrived nearly a year later, they found fundamental violations affecting two-thirds of residents reviewed.
Neither LPN #407 nor CNA #210 offered explanations for why drainage bags were on floors despite clear policy requirements. The violations suggest either inadequate training, insufficient supervision, or staff disregard for established infection control protocols.
For residents like #23 and #69, already managing multiple serious health conditions, preventable infections could prove devastating. Their families trusted Kingston of Ashland to provide basic infection prevention measures that protect vulnerable residents from additional health risks.
The inspection findings emerged from complaint number 2644890, indicating someone felt compelled to report concerns about facility operations to federal regulators. The catheter care violations were discovered incidentally during that broader investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kingston of Ashland from 2025-10-30 including all violations, facility responses, and corrective action plans.