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 Kingston Of Ashland during CMS and state inspections, most recent first.
A resident with multiple medical conditions and impaired cognition experienced a fall while transferring from bed to wheelchair, witnessed by a family member. Facility staff did not notify the physician or nurse practitioner of the incident as required by policy, and there was no documentation of such notification in the medical record. Interviews confirmed that medical providers were not made aware of the fall until several days later.
A resident with multiple chronic conditions and moderately impaired cognition experienced a fall while transferring from bed to wheelchair, witnessed by his son. The incident was not documented in the medical record, as confirmed by interviews with nursing staff, the DON, and the administrator.
Two residents with indwelling urinary catheters were found with their drainage bags lying directly on the floor, contrary to facility policy requiring catheter bags to be kept off the floor. These incidents were confirmed by an LPN and a CNA during interviews.
A resident recovering from a recent below-the-knee amputation experienced severe pain when their prescribed Oxycodone was not renewed in time, leaving no narcotic pain medication available. Despite repeated reports of high pain levels and a care plan identifying pain risk, the on-call NP declined to renew the prescription overnight, offering only extra strength Tylenol, which the resident refused. The resident was ultimately transferred to the hospital for pain control.
Three residents experienced significant medication errors when staff failed to follow physician orders and facility protocols. One resident with diabetes was given insulin despite an order to hold it for low blood glucose, resulting in severe hypoglycemia and emergency intervention. Another resident received the wrong medications, including an anticoagulant not prescribed for them. A third resident was administered a diuretic at the wrong frequency due to a transcription error. These incidents demonstrate failures in medication administration and order verification.
A resident with multiple chronic conditions was prescribed Ergocalciferol to be given weekly, but the order was incorrectly transcribed as a daily dose during admission. The MAR reflected daily administration until an LPN identified the error and obtained clarification from the physician. The DON confirmed the transcription mistake, resulting in inaccurate medical records.
A facility failed to document the clinical status of a resident with multiple health conditions, including anemia and congestive heart failure. Despite a physician's order to monitor the resident's confusion and altered mental status, no vital signs or clinical assessments were recorded on a specified day. Interviews confirmed the lack of documentation, which was against the facility's policy.
A resident experienced a significant delay in receiving toileting assistance, with a call light left unanswered for 44 minutes. Despite initial staff acknowledgment, the resident was not attended to promptly, leading to a delay in care. Other residents reported similar issues with call light response times.
A resident with multiple health conditions did not have daily weights documented as ordered, and significant weight changes were not reported to the physician. Additionally, a wound culture was delayed in being sent to the lab, resulting in a delay in identifying an infection. The DON confirmed the delays, citing lab staffing issues.
A resident with severe medical conditions fell out of bed, but the incident was not documented or reported to the family. Despite being a high fall risk, no neurological assessment was conducted, and the family was informed days later. The resident's condition declined, leading to hospitalization and eventual death. The nurse involved was terminated.
A resident did not receive her prescribed Entresto for several days due to a billing issue with the pharmacy, as she was incorrectly listed as deceased in the Medicare system. Despite the LPN contacting the pharmacy multiple times, the medication was not delivered, and the physician was not notified of the issue. The resident developed non-pitting edema in both legs during this period.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to notify the physician of a resident's fall, as required by policy. A resident with multiple complex diagnoses, including metabolic encephalopathy, osteomyelitis, endocarditis, diabetes, heart failure, and impaired cognition, experienced a fall while attempting to transfer from bed to wheelchair. The fall was witnessed by the resident's son, but there was no documentation in the medical record indicating that the physician was notified of the incident. Interviews with nursing staff, the Director of Nursing, and the resident's son confirmed that the fall occurred and that the physician and nurse practitioner were not informed at the time of the event. Further interviews with the nurse practitioner and physician revealed that neither was aware of the fall until several days later. Review of the facility's policy on changes in a resident's condition or status indicated that the nurse supervisor or charge nurse is responsible for notifying the attending physician or nurse practitioner in the event of an accident or injury. The lack of timely notification to the physician following the resident's fall constituted a deficiency as identified during the complaint investigation.
Failure to Document Resident Fall Incident in Medical Record
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident regarding documentation of a fall incident. A resident with multiple complex diagnoses, including metabolic encephalopathy, osteomyelitis, endocarditis, diabetes, heart failure, and other chronic conditions, experienced a fall while attempting to transfer from bed to wheelchair. The fall was witnessed by the resident's son, who was present in the room at the time. The resident had been assessed as having moderately impaired cognition. Despite the fall occurring in the presence of a family member, there was no documentation of the incident in the resident's medical record. Multiple interviews with facility staff, including an RN, the DON, and a Regional Quality Assurance RN, confirmed that the fall was not recorded in the medical record. The lack of documentation was verified by both the DON and the facility administrator, as well as the resident's son, who provided details of the incident.
Failure to Maintain Urinary Catheter Drainage Bags Off the Floor
Penalty
Summary
The facility failed to maintain indwelling urinary catheter drainage bags in a manner that would prevent infections, as observed in two out of three residents reviewed for urinary catheters. For one resident with multiple chronic conditions including chronic respiratory failure, heart disease, diabetes, and impaired cognition, the urinary drainage bag was observed lying directly on the floor of the resident's room. This observation was confirmed by an LPN during an interview. Similarly, another resident with a history of aphasia, heart disease, neuromuscular bladder dysfunction, and other significant medical issues was found with their urinary drainage bag also lying directly on the floor. This was verified by a CNA during an interview. Review of the facility's urinary catheter care policy indicated that catheter tubing and drainage bags should be kept off the floor, but this protocol was not followed in these instances.
Failure to Provide Timely Post-Surgical Pain Management
Penalty
Summary
A deficiency occurred when a resident who had recently undergone a below-the-knee amputation was not provided with adequate post-surgical pain management. The resident had a physician's order for Oxycodone 10 mg every four hours as needed for moderate pain, and acetaminophen scheduled every eight hours. The resident consistently reported significant pain, with pain levels ranging from 7 to 10, and had received 17 doses of Oxycodone prior to the incident. The care plan identified the resident as being at risk for pain due to the recent surgical procedure, with interventions including medication and repositioning. On the night of the incident, the resident experienced severe pain rated at 10 out of 10 and requested narcotic pain medication. However, the Oxycodone prescription had expired and was not renewed in a timely manner, resulting in no narcotic pain medication being available. The on-call nurse practitioner declined to renew the prescription during the night and instead ordered extra strength Tylenol, which the resident refused. As a result, the resident requested transfer to the hospital for pain management and was subsequently transported by EMS. Interviews with staff confirmed that the failure to renew the Oxycodone prescription led to the unavailability of the medication when the resident was in severe pain. The DON acknowledged that the prescription had expired and was not renewed, which directly resulted in the resident's transfer to the hospital for pain control. The facility's pain management policy defined pain management as alleviating pain to a level acceptable to the resident, but this standard was not met in this case.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceeding. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. F697 Resident #93 no longer resides in the center. Resident #93 was sent to the ER on 3/7 and script for Percocet obtained at that time. Nurse practitioner #339 was provided education on 4/3 and 4/4 on the pain assessment and management policy, controlled substance prescription policy, and receiving controlled substances policy. The Director of Nursing or designee will review current residents on narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that the narcotic pain medications are available for use. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses and Certified Medication Aides on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee with educated licensed nurses on the pain assessment and management policy on or before 4/17/2025. The Director of Advanced Nurse Practitioners will educate the nurse practitioners on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee will complete an audit on 5 residents weekly for 4 weeks that receive narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that narcotic pain medication is available for use. The results will be presented to the QAA committee for review and consideration for further corrective actions.
Significant Medication Errors Affecting Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as required by regulation. One resident with Type II diabetes was administered a long-acting insulin injection despite a physician order to hold the medication if the blood glucose level was below 200 mg/dL. At the time of administration, the resident's blood glucose was 109 mg/dL. This error led to the resident experiencing severe hypoglycemia, becoming unresponsive, and requiring emergency intervention with glucagon and close monitoring. In another instance, a resident was given the wrong morning medications by an LPN, including a lower dose of an antihypertensive and an anticoagulant that were not prescribed for them. The error was discovered after administration, and the resident was assessed for adverse effects. The facility's policy requires that medications be administered only as prescribed and that staff verify resident identity and orders prior to administration, which was not followed in this case. A third resident received a diuretic medication at an incorrect frequency due to a transcription error of a hospital discharge order. Instead of receiving the medication two times per week as ordered, the resident was given it two times per day for four days. This error was identified during a review of laboratory results and the original discharge paperwork. In each case, the facility's failure to follow physician orders and established medication administration protocols resulted in significant medication errors affecting three residents.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceedings. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #111 was treated at the time of the error in the center with no outstanding negative outcomes noted after treatment for low blood sugar. Resident #111 was assessed by nurse at the time of change in condition on 2/17/2024 with blood sugars being checked hourly until blood sugars were within normal range. Resident #111 was assessed by CNP on 2/24/2025. Resident #111 remains in the center. Resident #404's Lasix order was corrected at the time of discovery with no negative outcome noted. Resident #404 was assessed at the time of discovery by nurse on 2/24/2025. Resident #404 was assessed by CNP on 2/25/2025. Resident #404 remains in the center. Resident #302's had no negative outcome related to being administered another resident's medications. Resident #302 was assessed at the time of discovery by the nurse on 3/14/2025. Resident #302 remains in the center. The Director of Nursing or designee will review current residents with orders for insulin to ensure that the medication is being given per order. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will complete medication administration observations on current residents to ensure that medications are given per order. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses and certified medication aides on the administering medications policy on or before 4/17/2025. The Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025. The Director of Nursing or designee will complete an audit on 5 residents weekly for 4 weeks that receive insulin to ensure medication was given per order. The Director of Nursing or designee will complete medication order audits on 5 new admissions weekly for 4 weeks to ensure that medication orders are transcribed appropriately upon admission. The Director of Nursing or designee will complete medication administration observations on 5 residents weekly for 4 weeks to ensure that medications are given per order. The results will be presented to the QAA committee for review and consideration for further corrective actions. This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceedings. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #348's orders for ergocalciferol and calcitriol were corrected at the time of discovery with no negative outcome noted. Resident #348 no longer resides in the center. The Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025.
Incorrect Transcription of Physician Order for Medication
Penalty
Summary
A deficiency occurred when a facility failed to maintain accurate medical records by not correctly transcribing a physician's order for a resident. The resident, who was admitted with diagnoses including high blood pressure, type 2 diabetes, congestive heart failure, and osteoporosis, had a hospital discharge order for Ergocalciferol (vitamin D2) to be administered once weekly on Mondays. However, during the admission process, the order was incorrectly transcribed as a daily administration instead of weekly. This transcription error was reflected in the resident's Medication Administration Record (MAR), which showed the medication being administered daily. On one occasion, the medication was not administered, and this was documented by an LPN. During a subsequent medication pass, the LPN identified the discrepancy in the order and sought clarification from the physician, after which the correct weekly order was entered. Interviews with the LPN and the Director of Nursing confirmed that the error originated during the admission process and resulted in the resident's medical record not being accurate or complete as required. The facility's policy on administering medications states that medications should be administered as prescribed, which was not followed in this instance.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceeding. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #348's orders for ergocalciferol and calcitriol were corrected at the time of discovery with no negative outcome noted. Resident #348 no longer resides in the center. Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025. Director of Nursing or designee will complete a medication order audit on 5 new admissions weekly for 4 weeks to ensure that medication orders are transcribed appropriately upon admission. The results will be presented to the QAA committee for review and consideration for further corrective actions.
Failure to Document Resident's Clinical Status
Penalty
Summary
The facility failed to complete the medical record and accurately document the clinical status for a resident, identified as Resident #105, among a sample of four residents. Resident #105 had a complex medical history, including anemia, type two diabetes, paroxysmal atrial fibrillation, congestive heart failure, protein calorie malnutrition, macular degeneration, spinal stenosis, presence of a cardiac pacemaker, chronic kidney disease stage three, and cardiomyopathy. The resident expired on a specified date. A review of the vital sign record revealed that vital signs were documented on one date, but no vital signs were recorded on the following day. Additionally, there was a physician's order to monitor the resident's confusion and altered mental status, with instructions to send the resident to the Emergency Department if the condition progressed. However, no clinical assessments were documented on the specified date. Interviews with Registered Nurse #150 and the facility's Administrator and Director of Nursing confirmed that vital signs and assessments were not recorded in the electronic medical record on the specified date. The facility's policy titled 'Change in a Resident's Condition or Status' required the nurse supervisor or charge nurse to record information related to changes in the resident's medical or mental condition. The failure to document vital signs and assessments as per the facility's policy contributed to the deficiency identified during the survey.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to provide timely toileting assistance to a resident who required staff assistance for activities of daily living. The resident, who had intact cognition and was occasionally incontinent of bladder, had a call light on for 44 minutes without receiving assistance. The resident had turned on the call light at around 8:00 A.M. for toileting and dressing assistance before a scheduled speech therapy session at 9:00 A.M. Despite a nursing assistant initially responding and promising to return, the resident was left unattended, leading to a delay in care. This incident was corroborated by observations and interviews with staff and the resident. Additional interviews with other residents revealed similar issues with delayed responses to call lights, with reports of waiting for hours for assistance and staff failing to return after promising to do so. The Director of Nursing acknowledged the complaint and indicated that staff had been educated on the issue. The facility's policy on answering call lights was reviewed, highlighting the purpose of responding to residents' requests and needs. This deficiency was part of a complaint investigation.
Failure to Monitor Weight and Process Lab Tests Timely
Penalty
Summary
The facility failed to ensure that daily weights and laboratory tests were obtained and reported as ordered for a resident. The resident, who had multiple diagnoses including congestive heart failure and chronic kidney disease, was ordered to have daily weights taken and to notify the provider of significant weight changes. However, there were multiple days where weights were not documented, and significant weight gains were not reported to the physician as required. This oversight in monitoring the resident's weight could have impacted the management of her health conditions. Additionally, the facility did not timely process a wound culture for the same resident. The culture, ordered due to a change in drainage color, was collected but not sent to the lab until two days later, resulting in a delay in identifying a pseudomonas aeruginosa infection. The delay in processing the lab test and the subsequent delay in treatment could have affected the resident's care. The DON confirmed the delay but attributed it to staffing issues at the lab.
Failure to Document and Assess Post-Fall Incident
Penalty
Summary
The facility failed to complete a thorough and timely post-fall assessment and notify the family of a fall for Resident #109. Resident #109, who had a history of severe medical conditions including hemiplegia, cerebral infarction, and a brain bleed, was found on the floor next to his bed. Despite being a high fall risk and having fall prevention measures in place, such as a low bed and fall mats, the resident rolled out of bed. The incident was not documented, and no neurological assessment was conducted immediately following the fall. Interviews with staff revealed that the nurse on duty did not consider the incident a fall and therefore did not document it or notify the family. The resident was found by a State tested Nursing Assistant (STNA) and was assisted back to bed using a Hoyer lift. The nurse checked the resident for injuries but did not perform a neurological assessment or document the incident. The family was not informed of the fall until days later, after the resident's condition had declined significantly. The family expressed concerns about the resident's care, noting delays in response to call lights and the resident's deteriorating condition. The resident was eventually sent to the hospital at the family's request, where a head scan confirmed a brain bleed. The resident was placed on comfort care and later passed away. The facility's Director of Nursing confirmed the lack of documentation and assessment following the fall, and the nurse involved was terminated.
Failure to Provide Timely Medication for Resident
Penalty
Summary
The facility failed to ensure timely procurement of medication for Resident #20, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, heart conditions, and chronic pain syndrome. Despite having intact cognition, Resident #20 did not receive her prescribed Entresto, a heart failure medication, from the time of admission until several days later. The Medication Administration Record (MAR) indicated that the medication was not administered, and progress notes showed the resident developed non-pitting edema in both legs during this period. Interviews with staff revealed that the Licensed Practical Nurse (LPN) contacted the pharmacy multiple times regarding the medication, but it was not delivered due to a billing issue. The Director of Nursing (DON) confirmed that the pharmacy withheld the medication because Resident #20 was incorrectly listed as deceased in the Medicare system, affecting her insurance status. There was no documentation of the physician being notified about the unavailability of the medication, which contributed to the delay in addressing the resident's medical needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Care Center Of Ashland | 0.8 mi | — | 4 | 0 |
| Brethren Care Village Health Care Center | 1.5 mi | — | 0 | 0 |
| Good Shepherd The | 1.9 mi | — | 0 | 0 |
| Country Pointe | 9.5 mi | — | 0 | 0 |
| Arbors At Mifflin | 10.6 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Kingston Of Ashland.
100% money-back within 48 hours.
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.