Kingston Of Ashland

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident representative interview, staff interview, and policy review, the facility failed to notify the physician of a resident fall. This affected one resident (#91) of three residents reviewed for falls.

The facility census was 90.Findings Include: Review of the medical record for Resident #91 revealed an admission date of 10/06/25 and a discharge date of 10/11/25. Diagnoses included metabolic encephalopathy, osteomyelitis of the left radius and ulna, endocarditis, type two diabetes mellitus, chronic pulmonary edema, pneumonia, hypertensive heart disease with heart failure, cardiomegaly, cellulitis of the left upper limb, iron deficiency anemia, congestive heart failure, benign prostatic hyperplasia, urinary retention, anxiety, depression, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #91 dated 10/11/25 revealed the resident had moderately impaired cognition.

Interview on 10/28/25 at 8:52 A.M. with Registered Nurse (RN) #147 revealed Resident #91 fell on [DATE REDACTED], but she was not aware of it until 10/13/25. Interview on 10/28/25 at 10:38 A.M. with the Director of Nursing (DON) revealed Resident #91 fell on [DATE REDACTED] with his son present in the room and he witnessed the fall. The DON stated the fall occurred at approximately 5:57 P.M. on 10/09/25. Interview on 10/28/25 at 11:49 A.M. with Resident #91's son revealed he observed Resident #91's fall on 10/09/25 and stated Resident #91 was walking between his bed and his wheelchair to transfer himself to the wheelchair when he fell. Review of Resident #91's medical record revealed no documentation of notification to the physician of the resident's fall on 10/09/25. Interview on 10/28/25 at 12:46 P.M. with the DON, the Administrator, and the Regional Quality Assurance Registered Nurse (RQA RN) #302, revealed they talked to the facility Physician as well as Nurse Practitioner (NP) and neither could recall being notified of Resident #91's fall on 10/09/25.Interview on 10/29/25 at 12:40 P.M. with NP #305 revealed she did not receive any notification when Resident #91 fell on [DATE REDACTED] and was not aware of his fall until 10/13/25. Interview on 10/29/25 at 12:57 P.M. with Medical Doctor (MD) #306 revealed he did not receiving notification when Resident #91 fell

on [DATE REDACTED] and cannot recall when he was notified of Resident #91's fall that occurred on 10/09/25.Review of the facility policy titled, Change in a Resident's Condition or Status, dated September 2024, revealed the nurse supervisor/charge nurse will notify the resident's attending physician, on-call physician, or nurse practitioner when there has been an accident or injury involving the resident. This deficiency represents non-compliance investigated under Complaint Number 2644890.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kingston of Ashland

20 Amberwood Pkwy Ashland, OH 44805

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident representative interview, and staff interview, the facility failed to ensure a complete and accurate medical record for residents regarding documentation of fall incidents. This affected one (#91) of three residents reviewed for falls. The facility census was 90. Findings Include: Review of the medical record for Resident #91 revealed an admission date of 10/06/25 and a discharge date of 10/11/25.

Diagnoses included metabolic encephalopathy, osteomyelitis of the left radius and ulna, endocarditis, type two diabetes mellitus, chronic pulmonary edema, pneumonia, hypertensive heart disease with heart failure, cardiomegaly, cellulitis of the left upper limb, iron deficiency anemia, congestive heart failure, benign prostatic hyperplasia, urinary retention, anxiety, depression, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #91 dated 10/11/25 revealed the resident was assessed with moderately impaired cognition.Interview on 10/28/25 at 8:52 A.M. with Registered Nurse (RN) #147 revealed Resident #91 fell on [DATE REDACTED], but she was not aware of it until 10/13/25. Interview on 10/28/25 at 10:38 A.M. with the Director of Nursing (DON) revealed Resident #91 fell on [DATE REDACTED] with his son present in the room and witnessed the fall. The DON stated the fall occurred at approximately 5:57 P.M.

on 10/09/25. Interview on 10/28/25 at 11:49 A.M. with Resident #91's son revealed he observed Resident #91's fall on 10/09/25 and confirmed Resident #91 was walking between his bed and his wheelchair to transfer himself into the wheelchair when he fell. Review of the Resident #91's medical record revealed no documentation regarding Resident #91's fall on 10/09/25 at approximately 5:57 P.M. Interview on 10/28/25 at 10:38 A.M. with the DON and the Administrator verified no documentation was present in Resident #91's medical record regarding the fall on 10/09/25 at approximately 5:57 P.M. Interview on 10/28/25 at 12:46 P.M. with the Regional Quality Assurance Registered Nurse (RQA RN) #302 verified no documentation was present in Resident #91's medical record regarding the fall on 10/09/25 at approximately 5:57 P.M.This deficiency represents an incidental finding discovered during the investigation of Complaint Number

1. 2644890. Event ID:

Facility ID:

If continuation sheet

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

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kingston of Ashland

20 Amberwood Pkwy Ashland, OH 44805

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, staff interview, medical record review, and facility policy review, the facility failed to ensure indwelling urinary catheter drainage bags were maintained in a manner to prevent infections. This affected two (#23 and #69) of three residents reviewed for urinary catheters. The facility census was 90. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/01/21 with diagnoses including chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type two diabetes mellitus, hypertensive heart disease with heart failure, congestive heart failure, nonrheumatic aortic valve stenosis, atrial fibrillation, hyperlipidemia, obstructive sleep apnea, morbid obesity, anxiety, obstructive and reflux uropathy, COVID-19, depression, insomnia, and transient ischemic attack. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #23 was assessed with moderately impaired cognition. Observation on 10/28/25 at 7:45 A.M. revealed Resident #23 in her room with the urinary drainage bag for her indwelling urinary catheter laying directly on

the floor. Interview on 10/28/25 at 8:04 A.M. with Licensed Practical Nurse (LPN) #407 verified the urinary drainage bag for Resident #23's indwelling urinary catheter was laying directly on the floor of the resident's room. 2. Review of the medical record for Resident #69 revealed an admission date of 06/14/23 with diagnoses including aphasia following a cerebral infarction, ischemic cardiomyopathy, atherosclerotic heart disease, hypertension, neuromuscular dysfunction of the bladder, pneumonia, vitamin D deficiency, depression, bilateral hearing loss, malignant neoplasm of the prostate, cardiomegaly, occlusion and stenosis of the left coronary artery, and hyperlipidemia. Review of the most recent MDS assessment dated [DATE REDACTED] revealed Resident #69 was assessed with intact cognition. Observation on 10/29/25 at 1:19 P.M. revealed Resident #69's in his room with the urinary drainage bag for his indwelling urinary catheter laying directly on the floor in the room. Interview on 10/29/25 at 1:20 P.M. with Certified Nurse Aide (CNA) #210 verified the urinary drainage bag for Resident #69's indwelling urinary catheter was laying directly on the floor of the resident's room. Review of the facility policy titled, Urinary Catheter Care, dated November 2023, revealed guidelines for facility staff to be sure the catheter tubing and drainage bag are kept off the floor. This deficiency represents an incidental finding discovered during the investigation of Complaint Number 2644890.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet