Health inspection·October 5, 2023

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, staff interview, and record review the facility facility failed to transcribe and implement physician ordered laboratory testing for Resident #90. This affected one (Resident #90) of three residents reviewed for laboratory services. The facility census was 88. Residents Affected - Few Findings include: Closed medical record review for Resident #90 revealed an admission date of 09/08/23. Diagnoses included osteomyelitis (bone infection) of the right foot and ankle status post surgical debridement and malnutrition. Resident #90 was transferred to the hospital on [DATE]. Review of Resident #90's physician orders, dated 09/08/23, revealed an order for Vancomycin (antibiotic) one gram daily intravenously and Zosyn (antibiotic) 3.375 grams three times daily intravenously to treat osteomyelitis. Review of Resident #90's hand-written physician's orders, dated 09/11/23, revealed laboratory testing to include a complete blood count (CBC), a basic metabolic panel (BMP), a C-Reactive Protein (CRP) level, and a Vancomycin trough (a level for monitoring therapeutic level of the medication in the bloodstream) was to be drawn on 09/13/23. Review of Resident #90's medical record revealed no evidence of the facility nursing staff having transcribed or implemented the physician-ordered laboratory testing during Resident #90's stay at the facility. Interview on 10/04/23 at 11:33 A.M. with the Director of Nursing (DON) verified there was no evidence of Resident #90's physician-ordered laboratory testing having been completed while a resident of the facility. The DON stated the orders must have been missed as they were never put into the electronic medical record, which was integrated with the laboratory provider's system. Review of the policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated 12/27/22, revealed the facility must provide laboratory services or have a contractual agreement with an outside company who can meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. The provider will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests, the laboratory, diagnostic or radiology provider or other testing source will report test results to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00146986. (continued on next page) 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 2 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 10/05/2023 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)