Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Crystal Care Center Of Ashland during CMS and state inspections, most recent first.
Staff failed to follow required infection control practices for shared glucometers used for blood glucose monitoring. An LPN used a single uncovered glucometer stored in a medication cart drawer on multiple residents without cleaning it before use, and only briefly wiped it with an alcohol pad afterward. Another LPN also used the same type of shared glucometer on multiple residents, wiping it with alcohol pads for only a few seconds and wrapping it in dry tissue between uses. Facility leadership confirmed that Super Sani Germicidal wipes were the designated product, and manufacturer instructions required specific cleaning and disinfection steps with those wipes after each patient use, with alcohol wipes not listed as an acceptable option.
A resident with paraplegia, multiple chronic conditions, colostomy, urostomy, indwelling catheter, and multiple pressure and diabetic ulcers was discharged home despite being totally or largely dependent for ADLs, transfers, and complex wound and ostomy care. Care plans and MDS data showed the resident required extensive assistance, and MAR/TAR review revealed some wound and skin treatments were undocumented on at least one day before discharge. The record contained no documentation that the resident was educated on ostomy management or how his ADL needs would be met at home. Home health was arranged only for intermittent skilled nursing and therapy, without a home health aide, and the resident’s Medicaid waiver services had been lost, leaving his blind, developmentally disabled spouse as the primary caregiver. Staff interviews confirmed the resident had not been taught to manage his own care and relied on staff for bathing, transfers, and ostomy and wound care, leading surveyors to determine the facility failed to ensure a safe discharge.
A resident with a Stage IV sacral pressure ulcer did not receive appropriate wound care or pressure‑reducing support as outlined in the care plan and clinical guidelines. During an observed dressing change, an RN performed the ordered cleansing, packing, and redressing of the wound but failed to perform hand hygiene at any point, contrary to facility policy requiring handwashing between glove changes and before applying a new dressing. The resident was lying on a standard mattress with a visible indentation rather than a low‑air‑loss or other pressure‑reducing mattress, despite the care plan calling for such a surface and international guidelines recommending reactive support surfaces for Stage IV pressure injuries. Staff acknowledged the lack of an appropriate mattress and the resident reported discomfort and stated that a low‑air‑loss mattress had never been offered.
A resident with type 2 DM and chronic kidney disease, care planned for risk of hyper/hypoglycemia, had a physician order for 2 units of NovoLog via FlexPen to be given SQ before meals with a hold parameter for blood sugar below 70. During a medication pass, an LPN attached a needle to the insulin pen, dialed 2 units, and administered the insulin after the resident had finished breakfast, without priming the pen as required by the manufacturer’s instructions. The LPN stated she no longer primed pens because she had previously broken them while attempting to do so. The DON indicated pens were to be primed before each use, and review of the insulin pen instructions confirmed a 2-unit safety test (priming) was required before every injection. Review of the MAR also showed that routine blood glucose results were not documented, despite the resident receiving daily insulin.
The facility failed to adequately monitor and notify a physician about a resident's worsening cellulitis, resulting in actual harm and hospital admission. Additionally, two other residents were not provided with ordered interventions for constipation and heel protection, as confirmed by record review, interviews, and observations.
The facility did not provide enough CNA staff on certain shifts, as identified in its own Facility Assessment, leading to delayed responses to call lights and untimely care for residents. Multiple residents reported waiting over 30 minutes for assistance, resulting in incidents such as incontinence and self-care attempts. Staff and administrative review confirmed that CNA staffing levels were below what was needed to meet resident needs.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with food items such as crates of onions stored directly on the floor, mold present behind the dishwashing machine, and buildup and debris under tables and behind equipment. These conditions were verified by the Dietary Manager and were not in accordance with the facility's food safety policy.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with issues including a hallway door with a gap allowing outside elements in, a poorly installed window AC unit leaving an open space to the outdoors, broken tiles and unsanitary conditions in a shower room, and damaged or unclean areas in resident rooms and bathrooms. These deficiencies were confirmed by residents, nursing staff, and maintenance personnel.
A resident with significant mobility impairments and a history of chronic wounds did not receive the ordered alternating pressure/low air loss mattress as recommended by wound care. Despite being at high risk for pressure ulcers and having care plans specifying this intervention, observation and staff interviews confirmed the mattress was not in place, indicating a failure to implement necessary pressure ulcer prevention measures.
The facility did not consistently provide or document physician-ordered catheter care for three residents with indwelling or suprapubic catheters. This included missed catheter site cleaning, dressing changes, and application of prescribed ointment, as confirmed by medical records and staff interviews.
A resident with a PEG tube did not have current physician orders or documentation for site care, cleansing, or dressing changes. Staff failed to inspect or document care for the PEG tube site over several weeks, and a visitor observed dried blood around the site that was not addressed. Facility policy requiring daily checks and physician-specified dressing orders was not followed.
A resident with a central line did not have appropriate physician orders for dressing changes or site monitoring, and the dressing was not changed since admission. Observation revealed the dressing was rolled back, discolored, and the line was exposed. Staff confirmed the lack of orders and dressing changes, which did not meet facility policy requiring regular sterile dressing changes and documentation.
A resident with a recent leg fracture and chronic pain did not receive prescribed oxycodone-acetaminophen for severe pain due to pharmacy and administrative delays, resulting in inadequate pain control with only Tylenol provided. Nursing staff communicated the issue but did not administer the stronger medication when it became available, and pain levels were inaccurately documented.
A resident with multiple chronic conditions did not have pharmacy recommendations for medication adjustments reviewed by the physician within the facility's required 30-day timeframe. The pharmacist's recommendations, including a dosage reduction and regulatory compliance for as-needed psychoactive medications, were not addressed by the physician until over a month later, contrary to facility policy as confirmed by staff and policy review.
A resident with pain management needs was found with an unattended dose of Xtampza ER (oxycodone) left at the bedside, after a night shift LPN provided the medication without a physician's order for self-administration or bedside storage. Facility policy requires nurses to observe medication consumption, but this protocol was not followed.
A resident on contact precautions for an MSSA wound infection required staff to don PPE for care. After medication administration, an LPN and a surveyor found no receptacle for contaminated PPE near the room exit, forcing them to walk back through the room to dispose of used PPE in a bin placed across the room. Staff interviews confirmed the bin's placement was due to space limitations, and CDC guidance was not followed regarding PPE disposal.
A resident's family member made multiple requests for medical records, but the facility failed to respond or inform the family of the process, resulting in a delay. The staff responsible was unaware of the request due to absence, and the Administrator was not notified, contrary to facility policy requiring prompt handling of such requests.
Improper Cleaning and Disinfection of Shared Glucometers
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices when using shared glucometers. For one resident with type 2 diabetes mellitus, chronic kidney disease, and daily insulin orders, an LPN removed an uncovered glucometer from the top drawer of the medication cart, where it was lying on top of lancets, and used it to perform a fingerstick blood sugar test without cleaning it beforehand. The LPN stated there was only one glucometer on the cart used for all residents on her assignment and reported that she did not clean the glucometer on day shift because night shift cleaned them. After being questioned, she briefly wiped the front and back of the glucometer with an alcohol wipe for less than five seconds before returning it to the cart. For another resident with diabetes and daily insulin injections, an LPN similarly removed an uncovered glucometer from the top drawer of the medication cart, where it was also lying on top of lancets, and used it for a fingerstick blood sugar test. The LPN wiped the glucometer with an alcohol wipe before entering the room, then after use wiped it again with an alcohol wipe for less than seven seconds and wrapped it in dry tissue before returning it to the cart. The LPN confirmed the same glucometer was used for all residents on that assignment. The ADON identified Super Sani Germicidal Disposable wipes as the product to be used for cleaning the facility glucometers, and the manufacturer’s instructions for the specific glucometer required cleaning and disinfecting after each patient use with Super Sani wipes, including specific horizontal and vertical wiping steps and a two-minute wet contact time. The manufacturer’s instructions did not list alcohol wipes as an acceptable cleaning or disinfecting agent. The deficient practice was identified during a complaint investigation and affected two observed residents, with the potential to affect seven additional residents receiving blood sugar monitoring via glucometer.
Failure to Ensure Safe Discharge for Highly Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and adequately planned discharge for Resident #62, a cognitively intact but highly dependent resident with extensive medical and functional needs. The resident had multiple serious diagnoses, including osteomyelitis, spina bifida with paraplegia, cauda equina syndrome, chronic myeloproliferative disease, chronic kidney disease, peripheral vascular disease, chronic myeloid leukemia, Arnold Chiari syndrome, glaucoma, type 2 diabetes with a foot ulcer, urinary incontinence, repeated falls, and pressure ulcers. Care plans documented that the resident was totally dependent for many ADLs, including putting on and taking off footwear, required setup and cleanup for eating and oral hygiene, and needed supervision or assistance for bed mobility, transfers, toileting, showering, and lower body dressing. The resident also had a colostomy, urostomy, indwelling catheter, and multiple wound care needs, with care plans addressing ostomy management and wound treatments to the sacrum, buttocks, and feet. Record review showed that the facility had multiple treatment orders for wound care, ostomy care, catheter care, and skin protection, with documentation on the MAR/TAR indicating some missed or undocumented treatments on at least one day prior to discharge. The discharge MDS indicated the resident remained dependent or required at least partial to substantial assistance for toileting hygiene, lower body dressing, transfers, bathing, and personal hygiene, and used a manual wheelchair. Despite this high level of dependence, there was no documented evidence in the closed record that the resident was educated on ostomy management prior to discharge, nor any documentation describing how his extensive ADL needs would be met at home. Interviews with nursing staff confirmed that they did not provide education on care or medications, and that the resident required assistance with bathing, transfers, ostomy care, and wound care, with nurses performing dressing changes and medication administration and CNAs assisting with transfers and hygiene. Discharge planning notes showed that social services initially discussed discharge with the resident and a developmental disabilities care manager, with an expectation that Passport Medicaid Waiver caregiver services and wound care services would continue at home. However, interviews and an email from the home health agency later confirmed that the resident’s Medicaid waiver had been lost prior to discharge, and the home health services arranged were limited to skilled nursing and therapy without a home health aide. The home health agency reported providing skilled nursing twice weekly for a foot ulcer and that a third-party wound specialist managed the buttocks wound, while the resident’s wife was identified as the primary caregiver. Post-discharge interviews with the resident’s wife, her caregiver, and the resident’s power of attorney revealed that the wife was blind and developmentally disabled, that the resident no longer had waiver services or a caregiver to assist with daily care, and that he was unable to bathe or manage his colostomy and wound care independently, resulting in frequent soiling and inability to clean himself. The administrator confirmed the waiver was not available at discharge, and the social worker designee acknowledged she had believed the waiver was in place earlier and later learned it had been lost, yet the record contained no documentation of how the resident’s ADL and complex care needs would be safely managed at home. These actions and omissions led to the finding that the facility failed to ensure a safe discharge for Resident #62.
Failure to Provide Appropriate Wound Care and Pressure-Reducing Support Surface
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident with a Stage IV sacral pressure ulcer. Record review showed the resident had multiple admissions and discharges and was cognitively intact with a documented Stage IV pressure ulcer present on admission. The care plan identified an actual skin impairment to the sacrum related to pressure and included interventions such as initiating and continuing wound treatment and providing a pressure‑reducing mattress. Physician orders directed daily wound care to the sacrum, including cleansing with wound cleanser, patting dry, lightly packing with normal‑saline‑moistened collagen, and covering with a silicone super‑absorbent dressing. A Weekly Skin Grid report documented that the sacral Stage IV ulcer, first identified months earlier, remained unhealed with full‑thickness tissue loss, exposed structures, and scant drainage. During an observed wound care procedure, the RN/Wound Care Nurse removed the old dressing, cleansed the wound, packed it with saline‑moistened collagen, and applied a new dressing without performing hand hygiene at any point, despite changing gloves. This practice did not follow the facility’s Clean Dressing Change policy, which requires hand hygiene after removing the existing dressing and gloves and again before applying the new dressing. The resident was observed on a standard facility mattress with a visible indentation where the buttocks rested, and both the RN/Wound Care Nurse and the ADON confirmed that the resident did not have an appropriate pressure‑reducing mattress, such as a low‑air‑loss mattress, despite the care plan intervention and guideline recommendations for Stage IV pressure injuries. They could not explain why such a mattress had not been offered, and the resident reported discomfort from sinking into the mattress and stated he had never been offered a low‑air‑loss mattress.
Failure to Administer Insulin per Order and Insulin Pen Instructions
Penalty
Summary
The deficiency involves the failure to administer insulin according to the physician’s order and manufacturer instructions for an insulin pen. A resident with type 2 diabetes mellitus, diabetic chronic kidney disease, and muscle weakness was care planned as being at risk for hyper/hypoglycemia, with an intervention to administer medications per physician orders. The physician’s order directed that NovoLog FlexPen insulin be given subcutaneously at 2 units before meals, with the dose held for blood sugar below 70. During a medication pass, an LPN removed the resident’s NovoLog FlexPen from the medication cart, attached a needle, dialed the pen to 2 units, and administered the insulin subcutaneously after the resident had finished breakfast, rather than before the meal as ordered. The LPN did not prime the insulin pen before administration. She confirmed that she only primes insulin pens when they are new and reported that she had previously broken pens when attempting to prime them, so she stopped priming altogether. The DON stated that insulin pens were to be primed before each use. Review of the insulin pen instruction manual showed that a safety test (priming) of 2 units must be performed before each injection to ensure the pen and needle are working properly and to ensure the correct dose is delivered. Additionally, review of the MAR showed that routine blood sugar results were not documented, despite the resident receiving daily hypoglycemic medication and insulin injections.
Failure to Monitor and Intervene for Skin Integrity, Constipation, and Heel Protection
Penalty
Summary
The facility failed to provide appropriate monitoring and timely intervention for a resident with cellulitis, resulting in actual harm. The resident, who had a history of right tibia fracture, atrial fibrillation, COPD, and cellulitis, developed new redness and pain in the right lower leg. Although a nurse practitioner assessed the resident and ordered antibiotics with instructions for close monitoring and physician notification if the condition worsened, there was no documented evidence that the resident's skin condition was monitored or that the physician was notified of the decline. The resident's family member discovered the worsening condition, which had spread up the leg and onto the buttocks, and requested hospital transfer, where the resident was admitted and treated with IV antibiotics. Additionally, the facility failed to implement interventions for constipation for another resident who had a physician's order for lactulose as needed and a care plan indicating risk for constipation. Despite documentation showing no bowel movements for several days, there was no evidence that the ordered medication was administered or that the bowel protocol was initiated, as required by facility policy. The administrator confirmed the lack of intervention during this period. A third resident, who had orders for heel protection devices (Prevalon boots) while in bed due to risk factors such as atherosclerosis, end stage renal disease, and diabetes, was not provided with these devices. Multiple observations and interviews confirmed that the resident never received the ordered heel protectors since admission, despite being willing to use them. These failures affected three residents and were identified through medical record review, staff and resident interviews, and direct observation.
Insufficient CNA Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents as identified in its Facility Assessment (FA). Multiple residents reported that call lights were not answered in a timely manner, with some waiting over 30 minutes for assistance, resulting in incidents such as incontinence and residents attempting to care for themselves against staff instructions. Residents specifically noted delays during the second and third shifts, and staff interviews confirmed that CNA staffing was inadequate to handle the workload and respond to resident needs promptly. A review of staffing records revealed that on the date in question, the number of CNAs working during the second and third shifts was below the minimum required by the facility's own FA. During the second shift, only four CNAs were present for part of the shift when six were needed, and during the third shift, only three CNAs were present for part of the shift when four were required. The facility administrator confirmed the staffing shortfall during a review of the clock in and out reports.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen environment and did not store food items according to professional standards. Specifically, three crates of onions were found stacked directly on the floor in the dry storage area of the main kitchen. Additionally, there was an unknown black substance, identified as mold by the Dietary Manager, present on the wall behind the dishwashing machine, extending from mid-wall to the floor. Further observations revealed buildup and debris under a metal table, as well as against a wall and behind a refrigerator in the kitchen. The facility's policy required that food items in dry storage be kept off the floor and that food safety standards be followed, but these standards were not met during the survey. All 59 residents who received meals from the kitchen were potentially affected by these conditions. No specific medical history or condition of individual residents was mentioned in the report.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident and staff interviews. One door at the end of a hallway had a visible gap at the bottom, allowing outside elements such as heat, cold air, and potentially insects to enter, which was confirmed by a resident who reported discomfort and concern, especially during winter. Another resident's room had a window air conditioning unit that was not properly installed, leaving an open space to the outdoors, which the resident believed allowed spiders and insects to enter. The Director of Maintenance confirmed the improper installation. Further deficiencies were observed in the shower room, where broken tiles surrounded the drain, a blood-soaked item was found on the floor, a dried red substance was present on the wall, and the door had multiple scuffed and chipped areas. Additionally, in a shared bathroom, the baseboard was unattached, and in a resident's room, there was a large area of scraped paint and food particles scattered on the floor. These findings were verified by staff interviews. Facility policies reviewed indicated that residents have the right to a safe, clean, and comfortable environment, which was not upheld in these instances.
Failure to Provide Ordered Pressure-Relieving Mattress for High-Risk Resident
Penalty
Summary
The facility failed to implement wound care recommendations for a resident who was at high risk for pressure ulcer development. The resident, who had diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, required substantial to maximal assistance for bed mobility and had impairments in both lower extremities. The care plan and wound care progress notes specified the need for an alternating pressure/low air loss mattress to prevent skin breakdown and pressure ulcers, with instructions to ensure the mattress settings were appropriate for the resident's needs. Despite these documented interventions, observation and staff interviews confirmed that the resident did not have the recommended mattress in place. The resident had a history of chronic wounds and pressure ulcers, and was noted to be at high risk for further pressure ulcer formation due to decreased mobility, incontinence, and limited ability to reposition. Facility policy required regular review of skin assessments and compliance with interventions, but the lack of the prescribed mattress indicated a failure to follow these protocols. The deficiency was identified through observation, interviews, and medical record review, affecting one of three residents reviewed for pressure ulcers.
Failure to Provide and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to ensure that physician-ordered catheter care was provided and properly documented for three residents with indwelling or suprapubic catheters. For one resident with a suprapubic catheter and diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, there were multiple instances where the Treatment Administration Record (TAR) showed no documentation of required catheter site cleaning and dressing changes, as ordered by the physician. The resident reported that staff sometimes went several days without changing the dressing, and facility staff confirmed the lack of documentation for these treatments. Another resident with an indwelling urinary catheter and diagnoses of type II diabetes mellitus and obstructive and reflux uropathy also had missing documentation of catheter care on several shifts, as confirmed by nursing staff. A third resident with a suprapubic catheter and diagnoses including diabetes mellitus type II, peripheral vascular disease, and congestive heart failure had no documentation of required catheter care and application of prescribed Mupirocin ointment on multiple occasions. Facility policy required catheter care every shift, but records and staff interviews confirmed that care was not consistently provided or documented as ordered.
Failure to Obtain Physician Orders and Document PEG Tube Care
Penalty
Summary
The facility failed to obtain and maintain current physician orders for the care and monitoring of a resident's percutaneous endoscopic gastrostomy (PEG) tube. The resident, who was severely cognitively impaired and had multiple diagnoses including dysphagia and muscle weakness, was admitted with a PEG tube in place. The care plan included interventions such as cleansing the PEG tube site, applying a dressing, and daily inspection for signs of infection or skin breakdown. However, a review of physician orders for the relevant month revealed there were no active orders for cleansing, inspecting, or dressing the PEG tube site, and a previous order did not specify the type of dressing required. Further review of the Treatment Administration Record showed no documentation that staff had inspected, cleansed, or dressed the PEG tube site for a period of nearly three weeks. A visitor reported observing dried blood around the PEG tube and noted that staff did not return to clean the site after being informed. Observation confirmed the presence of a dressing only on the day of the survey, and an LPN verified the absence of physician orders and documentation for PEG tube care. Facility policies required daily checks of feeding tube sites and physician-specified dressing orders, which were not followed in this case.
Failure to Maintain and Monitor Central Line Dressing
Penalty
Summary
The facility failed to ensure proper care and management of a central line for a resident who was admitted with multiple diagnoses, including end stage renal disease and diabetes mellitus. The resident had a central line in place, and the plan of care included interventions such as changing the dressing as ordered and per facility policy, and monitoring for signs of infiltration and infection. However, there were no physician orders for monitoring the IV site or for dressing changes, including the type or frequency. Medical record review showed no evidence that the central line dressing had been changed since admission. During observation, the central line dressing was found to be rolled back, discolored, and the line was completely uncovered and exposed, with the date on the dressing illegible. Staff interviews confirmed that there were no orders for dressing changes or site monitoring, and that the dressing had not been changed since admission. Facility policy required sterile dressings to be maintained and changed every five to seven days or when compromised, with documentation of dressing changes and site assessments, but these standards were not met for this resident.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure effective pain management for a resident admitted with a left lower leg fracture, chronic pain, and anxiety. Upon admission, the resident had physician orders for Tylenol and oxycodone-acetaminophen as needed for pain. However, due to an issue with obtaining a resident identification number, the pharmacy was unable to fill the oxycodone-acetaminophen prescription, resulting in the resident only receiving Tylenol for pain management. Documentation shows that Tylenol was administered when the resident reported significant pain, but the stronger pain medication was not given until much later, despite the resident experiencing severe pain that was not adequately controlled by Tylenol alone. Interviews with the resident and nursing staff confirmed that the resident experienced severe pain, rating it as high as ten out of ten, and that the Tylenol provided only minimal and short-lived relief. Nursing staff communicated the medication issue to administration and the DON, but delays persisted in providing the prescribed pain medication. Additionally, there was inaccurate documentation of the resident's pain level in the medical record. The facility's pain management policy requires that pain management be consistent with professional standards and resident preferences, which was not met in this instance.
Delayed Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed by the physician within the required timeframe, as outlined in facility policy. Specifically, for one resident with multiple diagnoses including asthma, type II diabetes mellitus, schizoaffective disorder, depression, anxiety disorder, schizophrenia, and insomnia, pharmacy recommendations regarding medication adjustments were not reviewed and signed by the physician until more than 30 days after the recommendations were made. The facility's policy required that such recommendations be reviewed by the medical provider within 30 days. Medical record review showed that the pharmacist recommended a dosage reduction for Famotidine and highlighted regulatory requirements for limiting as-needed psychoactive medications to 14 days unless reassessed and justified by the provider. In both instances, the physician did not review and sign the recommendations until 31 and 34 days after they were made, respectively. Staff interview confirmed the facility's policy for timely review, and policy documentation supported this requirement.
Unattended Controlled Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a medication, specifically Xtampza ER (extended release oxycodone), was left unattended at a resident's bedside without a physician's order permitting self-administration or bedside storage. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and unspecified pain, was observed with a medication cup containing an unknown pill on his bedside table. The resident reported that the night shift nurse had given him the medication, but he fell asleep and forgot to take it. Further investigation confirmed that the medication was left by the night shift LPN, who acknowledged that there was no order to leave medications at the bedside for this resident. Facility policy requires that nurses observe residents consuming their medications to ensure compliance with medication administration protocols. The unattended medication was verified by another LPN during the morning shift, confirming a failure to properly store and administer medications as required.
Improper Placement of Contaminated PPE Receptacle During Contact Precautions
Penalty
Summary
Staff failed to ensure that receptacles for contaminated personal protective equipment (PPE) were appropriately placed to prevent the transmission of pathogens. During an observation of medication administration for a resident with a history of methicillin susceptible Staphylococcus aureus (MSSA) infection of the left hip joint, it was noted that both the LPN and the surveyor donned PPE to enter the resident's room, which was under contact precautions. After administering IV medication, they exited the room and found there was no receptacle available near the exit to dispose of contaminated PPE. Instead, the only available bin for contaminated PPE was located on the opposite side of the room, near the window, requiring staff to walk back through the room to dispose of their used PPE. Interviews with the LPN and the Infection Control Preventionist confirmed that the placement of the contaminated PPE bin was due to space constraints, as the room was small and the bin did not fit by the door. Review of CDC guidance indicated that proper discarding of PPE should occur before exiting the patient room to contain pathogens. The facility's failure to provide an appropriately placed receptacle for contaminated PPE resulted in staff having to traverse the resident's environment with used PPE, contrary to recommended infection control practices.
Failure to Timely Address Medical Record Request
Penalty
Summary
The facility failed to address a request for medical records in a timely manner for a resident with severe cognitive impairment and multiple diagnoses, including altered mental status, psychosis, encephalopathy, anxiety, restlessness and agitation, depression, sepsis, hypertension, and a history of cerebral infarction. The resident's family member initially requested the medical records via email, followed by a second email one week later, but did not receive a response from the facility regarding the process for obtaining the records. Staff interviews revealed that the Social Service Designee (SSD) was unaware of the request until after returning from vacation, and the Administrator had not been notified of the request at all. Facility policy required that requests for records be referred to the DON, Administrator, or another designated staff member, with records to be provided within two days after payment. The lack of response and failure to follow policy resulted in the deficiency.
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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.
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Nursing homes near Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kingston Of Ashland | 0.8 mi | — | 3 | 0 |
| Good Shepherd The | 1.2 mi | — | 0 | 0 |
| Brethren Care Village Health Care Center | 1.2 mi | — | 0 | 0 |
| Arbors At Mifflin | 10 mi | — | 0 | 0 |
| Oak Grove Manor | 10 mi | — | 4 | 0 |
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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.