Kingston of Ashland

In the surveyor’s words

From the most serious findings on record at Kingston of Ashland, in the surveyor’s own words.

• Actual harm, isolatedF697Apr 4, 2025

  Based on medical record review, interviews with staff, and facility policy review, the facility failed to ensure a comprehensive post-surgical pain management program was maintained to achieve adequate pain control for Resident 93. This resulted in Actual Harm on [DATE] at 1:38 A.M. when Resident #93, who had a surgical amputation of the left leg (below the knee) on [DATE] and had an order for Oxycodone 10 milligrams (mg) immediate release every four hours for moderate pain, complained of severe post-operative pain rated at a 10 out of 10 (on a ,d+[DATE] pain scale with 0 representing no pain and 10 representing the worst pain the resident had ever experienced); however, the resident's Oxycodone had not been reordered timely, resulting in no narcotic pain medication available for… […]

• Actual harm, isolatedF760Apr 4, 2025

  Based on review of medical records, interviews with staff and residents, facility policy review, and medication manufacturer guidelines review, the facility failed to ensure residents were free of significant medication errors. This resulted in actual harm for one resident on 02/16/25 at 7:23 P.M. when Resident #111, who received long-acting insulin and blood glucose monitoring for the management of Type II diabetes, was administered insulin despite a physician order to hold the insulin when the blood glucose level was below 200 milligrams per deciliter (mg/dL) of blood. The resident's blood glucose level was 109 mg/dL (normal range is 70-100 mg/dL). The resident experienced hypoglycemia (low blood glucose level) with a blood glucose level of 44 mg/dL at 1:30 A.M. and was unresponsive. […]

• No harm, potential for more than minimal, widespreadF563May 18, 2023

  Based on observations, resident and staff interviews, and facility policy review, the facility failed to ensure residents were able to have visitors at the time of their choosing. This had the potential to affect all 79 residents residing in the facility. The census was 79. Findings include: Observation of the front door of the facility on 05/15/23 at 7:30 A.M. revealed a sign posted that identified visitation hours Monday through Friday were between 8:00 A.M. and 7:00 P.M., and on Saturday and Sunday between 8:00 A.M. and 4:00 P.M. The sign further indicated after hours visits required prior approval. A meeting occurred with the Resident Council on 05/16/23 at 10:30 A.M. and Resident #40 and Resident #65 voiced concerns with the facility's visitation hours. […]

• No harm, potential for more than minimal, widespreadF812May 18, 2023

  Based on observation, staff interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 76 residents who received food from the kitchen. The facility identified three (#17, #21 and #284) residents who received nothing by mouth. The facility census was 79. Findings include: Observation during the initial tour of the kitchen on 05/15/23 from 8:02 A.M. through 8:15 A.M. revealed the ceiling and wall were peeling in the dry storage area, the exhaust fan above the dish machine had grease and dust covered on the louvers on the exhaust fan, and the tabletop mixer had dried food on the top where the attachments are inserted and on the bowl holder. […]

• No harm, potential for more than minimal, patternF842Apr 4, 2025

  Based on medical record review, interview and facility policy review the facility failed to maintain accurate medical records by not transcribing physician orders correctly. This deficient practice affected one resident (Resident #348) out of five residents reviewed for medication errors. The facility census was 92. Findings Include: Review of the medical record for Resident #348 revealed admitted on 02/22/25 with diagnoses including but not limited to high blood pressure, type two diabetes, Congestive Heart Failure (CHF), and osteoporosis. Review of the hospital discharge orders dated 02/22/25 for Resident #348 revealed an order for Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the morning every Monday for supplemental use. […]