The fall occurred at approximately 5:57 p.m. on October 9, according to interviews with the facility's Director of Nursing. The resident's son told federal inspectors he observed his father walking between his bed and wheelchair when he fell during the transfer attempt.
Resident 91 had been admitted to the facility on October 6 with a complex array of serious medical conditions including metabolic encephalopathy, bone infection in his left arm, heart infection, diabetes, pneumonia, heart failure, and anxiety. Medical assessments showed he had moderately impaired cognition. He was discharged on October 11.
Despite the witnessed fall and the resident's fragile health status, no one contacted his physicians that evening or the following days.
Registered Nurse 147 told inspectors on October 28 that while the resident fell on the date in question, she wasn't aware of the incident until October 13 — four days after it happened.
The facility's Director of Nursing confirmed the fall occurred on October 9 with the resident's son present in the room. But when inspectors reviewed the resident's medical record, they found no documentation showing physicians had been notified of the fall.
Both the resident's attending physician and nurse practitioner told inspectors they never received notification about the October 9 fall.
Nurse Practitioner 305 said during an October 29 interview that she received no notification when the resident fell and wasn't aware of the incident until October 13. Medical Doctor 306 similarly told inspectors he didn't receive notification of the fall and couldn't recall when he was eventually told about it.
The communication breakdown occurred despite clear facility policy requiring immediate physician notification. The nursing home's own policy, dated September 2024, states that nurse supervisors and charge nurses must notify the resident's attending physician, on-call physician, or nurse practitioner when there has been an accident or injury involving a resident.
The Director of Nursing, Administrator, and Regional Quality Assurance Registered Nurse all confirmed during interviews that they had spoken with both the facility physician and nurse practitioner, and neither could recall being notified of the fall on the day it occurred.
The failure affected one of three residents reviewed by inspectors for falls. The facility had 90 residents at the time of the inspection.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The deficiency was investigated as part of a complaint filed against the facility.
For a resident with multiple serious medical conditions including heart failure, bone infections, and cognitive impairment, prompt medical evaluation after a fall is critical for detecting potential injuries and preventing complications. The four-day delay in notifying physicians meant any assessment of injury or changes in the resident's condition was significantly delayed.
The inspection occurred on October 30, following up on the complaint about the facility's handling of the fall. Inspectors found that despite having written policies requiring immediate physician notification of accidents and injuries, staff failed to follow those procedures in this case.
The resident had been discharged by the time inspectors arrived, but the failure to notify physicians about his fall while he remained in the facility's care represented a breakdown in the communication protocols designed to protect vulnerable residents.
Kingston of Ashland must submit a plan of correction to address how it will ensure physicians receive timely notification of resident falls and other incidents that could affect their patients' health and safety.
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.