Health inspection·September 26, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, family interview and staff interviews, the facility failed to ensure a resident was provided with assistance of removing facial hair. This affected one (#64) of three residents reviewed for assistance with activities of daily living. The facility census was 93. Residents Affected - Few Findings include: Review of Resident #64's medical record revealed an admission on [DATE], with medical diagnoses including: chronic lymphedema, Alzheimer's disease, history of Covid-19 virus and benign prostatic hypertrophy (BPH) with indwelling urinary catheter. The most recent facility quarterly minimum data set assessment (MDS) dated [DATE] identified the resident had moderately impaired cognition. The assessment identified Resident #64 required one-person physical assistance with Activities of Daily Living (ADL's). Review of a physician order dated 09/09/23 revealed an order for Resident not to shave himself. Observation on 09/25/23 at 8:02 A.M., revealed Resident #64 was in bed and was observed with a large amount of facial hair, that appeared to be growing a beard and mustache. Interview with Resident #64, at this time, revealed he does not want to be growing a beard or mustache and stated, it's way too long. Observation on 09/25/23 at 10:02 A.M., with State Tested Nurse Assistant (STNA) #104 identified Resident #64 can shave himself using an electric razor. STNA #104 verified the resident has not been shaved in a very long time. Interview on 09/25/23 at 12:23 P.M., with Resident #64's son revealed Resident #64 likes to be clean shaven every day. Resident #64's son stated he does not feel the resident is able to safely shave himself any longer and identified staff need to shave him. Observation and interview on 09/25/23 at 12:50 P.M., with the Director of Nursing (DON) verified Resident #64 has a large amount of facial hair at this time and needs shaved. The DON stated it does appear he has not been shaved in a long period of time and the staff should be shaving the resident and not himself. This deficiency represents non-compliance investigated under Complaint Number OH00146181. 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 Page 1 of 3 Event ID: 365646 Printed: 05/15/2026 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 365646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 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)