Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 0-10 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 administration and the resident had to be transferred to
the emergency room to receive pain medication. This affected one (Resident #93) of two residents reviewed
for pain management. The facility census was 92.
Residents Affected - Few
Findings Include:
Review of the medical record for Resident #93 revealed an admission date on [DATE] and a discharge date
on [DATE] with the diagnoses including but not limited to surgical amputation of the left lower leg below the
knee, chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), and high blood
pressure.
Review of the physician orders for Resident #93 revealed an order dated [DATE] for narcotic pain
medication Oxycodone 10 mg immediate release tablet, take one tablet by mouth (PO) every four hours as
needed (PRN) for moderate pain, and an order dated [DATE] for acetaminophen (Tylenol) oral tablet 325
mg, give three tablets by mouth every eight hours for moderate pain.
Review of the admission assessment dated [DATE] revealed Resident #93 reported a pain level of six out of
10 on admission. Further review of Resident #93's admission baseline care plan dated [DATE] revealed
Resident #93 was at risk for pain related to surgical procedure of left leg below the knee amputation with
interventions including medications as ordered, repositioning and elevation as needed.
Review of the Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93
had intact cognition. Resident #93 required moderate assistance from staff for transfers, mobility, and
personal hygiene care. Resident #93 received scheduled and as needed pain medication and Resident #93
had experienced pain five days out of the seven days during the review period.
Review of the medication administration record (MAR) dated [DATE] to [DATE] revealed Resident #93 had
received the as needed narcotic pain medication Oxycodone 10 mg for a total of 17 doses for pain levels
ranging from 7 to 10 with the follow up assessment being marked as effective for pain
(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 8
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
04/04/2025
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)
F 0697
management of Resident #93. Resident #93 was also receiving scheduled acetaminophen (Tylenol) oral
tablet 325 mg, give three tablets by mouth every eight hours for moderate pain.
Level of Harm - Actual harm
Residents Affected - Few
Review of Resident #93's progress note authored by Registered Nurse (RN) #337 dated [DATE] at 1:38
A.M. revealed Resident #93 was yelling and moaning complaining of severe pain. Resident #93 requested
narcotic pain medication. RN #337 received in report Resident #93's narcotic pain medication Oxycodone
prescription had not been renewed with the pharmacy. RN #337 notified on-call Nurse Practitioner (NP)
#339 to request the prescription be renewed. NP #339 denied the request to renew the prescription and
instead gave an order for extra strength Tylenol stating will not be giving narcotic orders at 2:00 A.M. RN
#337 informed NP #339 Resident #93 would be transferred to the hospital for pain control if requested.
Review of Resident #93's progress note authored by RN #337 dated [DATE] at 1:41 A.M. revealed Resident
#93 was offered the extra strength Tylenol for pain control, Resident #93 denied the medication and
requested to be transferred to the hospital. RN #337 called emergency medical services (EMS) for
transport of Resident #93 to the hospital. Resident #93 left the facility at 1:50 A.M. with EMS.
Review of the hospital discharge paperwork for Resident #93 dated [DATE] at 2:55 A.M. revealed hospital
diagnoses for Resident #93 was postoperative pain with new orders including Oxycodone - Acetaminophen
(Percocet) 5-325 mg per tablet, give one tablet by mouth every six hours as needed for pain and an order
for Gabapentin (Neurontin) 400 mg give one capsule by mouth three times daily.
Review of the MAR dated [DATE] to [DATE] for Resident #93 revealed Resident #93 received Percocet
5-325mg for a total of three doses with pain level ranging from five to seven out of 10 on the pain scale. The
follow up documentation revealed the medication was effective in controlling Resident #93's pain.
Interview on [DATE] at 10:15 A.M. with RN #337 revealed because Resident #93's prescription for
Oxycodone 10 mg had not been renewed, the pharmacy would not give the authorization for RN #337 to
remove the narcotic pain medication from the facility's emergency medication machine for administration.
Interview on [DATE] at 1:00 P.M. with the Director of Nursing (DON) confirmed Resident #93's narcotic pain
medication prescription for Oxycodone 10 mg had not been renewed with the pharmacy and was
unavailable when Resident #93 was experiencing a severe pain level of 10 on [DATE] resulting in Resident
#93's transfer to the hospital for pain management. The DON stated the original prescription for Resident
#93 had been written for a total of 18 doses and expired on [DATE] with the facility not attempting to renew
the prescription for Resident #93.
Multiple attempts were made on [DATE] during the onsite survey to contact NP #339; however, there was
no return contact made with the surveyor.
Review of the facility's policy titled Pain Assessment and Management undated revealed pain management
is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is
based on his or her clinical condition and established treatment goals.
This deficiency represents non-compliance investigated under Complaint Number OH00163865.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365646
If continuation sheet
Page 2 of 8
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
04/04/2025
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Resident #111 required the administration of
glucagon (injection medication to treat hypoglycemia) and emergency medical transport observation until
the resident was stable and hourly blood glucose checks per glucometer to monitor and prevent
reoccurrence. Additionally, two other residents (#302 and #404) were placed at risk for the potential for
more than minimal harm when their physician ordered medications were not administered as prescribed.
This affected three (#111, #302 and #404) of five residents reviewed for medication errors.
Residents Affected - Few
Findings Include:
1. Review of the medical record for Resident #111 revealed an admission date on 04/29/23 with diagnoses
including but not limited to Type II diabetes, high blood pressure, asthma, depression, and anxiety.
Review of Resident #111's at risk care plan dated 09/03/24 revealed Resident #111 was at risk for
fluctuating blood glucose levels related to diagnosis of Type II diabetes with interventions including regularly
monitoring blood glucose levels and administering medications as ordered.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had
mild cognitive impairment with a Brief Interview of Mental Status score of 12 out of possible 15. Resident
#111 had impairment to one side and required limited assistance from staff for personal care, transfers, and
medication administration. Resident #111 received insulin injections for seven days during the review
period.
Review of physician orders for Resident #111 revealed an order dated 02/05/25 for insulin Lantus Solution
pen-injector 100 unit/milliliter (ml) inject 55 units subcutaneous (SQ) at bedtime (HS) for glucose control hold if below (blood glucose level) 200. Blood glucose monitoring four times a day (breakfast, lunch, dinner
and bedtime). Insulin Aspart 100 units per ml, give 30 units with all meals.
Review of Resident #111's blood glucose results dated 02/16/25 at 7:23 P.M. revealed the result was
recorded as 109 mg/dL (the physician orders indicated the resident's Lantus insulin [long-acting insulin
which peaks three to four hours after administration]) was to be held (not administered).
Review of the February 2025 Medication Administration Record (MAR) for Resident #111 revealed on
02/16/25 at 8:30 P.M., Registered Nurse (RN) #337 administered 55 units of Lantus Insulin to Resident
#111.
Review of Resident #111's progress note dated 02/17/25 at 1:30 A.M., revealed the resident was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365646
If continuation sheet
Page 3 of 8
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
04/04/2025
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)
F 0760
Level of Harm - Actual harm
observed to be unresponsive and slouching to the right, with their tongue hanging out of their mouth. The
resident's blood glucose result was 44 mg/dL of blood per glucometer. The on-call nurse practitioner (NP)
was notified, and an order was received for Glucagon 1 milligram (mg) intermuscular and to send Resident
#111 to the hospital if needed.
Residents Affected - Few
Review of Resident #111's progress note dated 02/17/25 at 1:35 A.M. revealed Glucagon 1 mg was
administered via intermuscular injection to the left deltoid.
Review of Resident #111's progress note dated 02/17/25 at 1:50 A.M. revealed emergency medical
services (EMS) were called for transport of Resident #111 to the hospital.
Review of Resident #111's progress note dated 02/17/25 at 1:55 A.M. revealed EMS arrived at the facility.
Resident #111 remained unresponsive. Blood glucose obtained with result of 65 mg/dL. EMS attempted to
initiate intravenous (IV) access and was not successful.
Review of Resident #111's progress note dated 02/17/25 at 2:05 A.M. revealed Resident #111 was awake,
alert and eating a peanut butter and jelly sandwich. Re-check of blood glucose level with a result of 85
mg/dL.
Review of Resident #111's progress note dated 02/17/25 at 2:10 A.M. revealed a recheck of the blood
glucose with a result of 98 mg/dL. EMS stated Resident #111 was stable and left the facility. Resident #111
was not transported to the hospital.
Review of Resident #111's progress note dated 02/17/25 at 3:47 A.M. revealed the on-call NP was notified
Resident #111 remained in the facility with a new order received to obtain blood glucose every hour.
Resident #111 and son were notified of the new order.
Review of Resident #111's progress note dated 02/17/25 at 7:00 A.M. revealed Resident #111's vital signs
were blood pressure 108/70 mmHg (normal 120/60 mmHg), pulse 57 beats per minute (normal range
60-90 bpm), temperature 97.4 degrees Fahrenheit, respirations 18 breaths per minute (normal 12-20
breaths per minute), blood glucose 196 mg/dL. On call NP notified with new order to hold insulin dosage for
breakfast.
Review of Resident #111's progress note dated 02/17/25 at 10:36 A.M. revealed the NP was notified of
Resident #111's blood glucose reading of 249 mg/dL and ordered to continue to hold the resident's insulin.
Resident #111 was more alert and talkative and consumed 95% of the breakfast meal. Hourly blood
glucose monitoring was discontinued at 8:00 A.M.
Review of the facility's medication error report dated 02/17/25 and completed by RN #337 revealed
Resident #111 was administered 55 units of Lantus Insulin on 02/16/25 at bedtime. Resident #111's blood
glucose reading was 109 mg/dL. The physician order was for Lantus insulin with parameters to hold the
insulin if the blood glucose results were below 200 mg/dL.
Further review of the February 2025 MAR revealed the resident's scheduled insulin was resumed on
02/18/25.
An interview on 03/24/25 at 3:25 P.M. with Resident #111 revealed Resident #111's blood glucose results
fluctuate a lot and usually will be low instead of being high. Resident #111's diabetes is monitored by a
specialist.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365646
If continuation sheet
Page 4 of 8
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
04/04/2025
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)
F 0760
Level of Harm - Actual harm
Residents Affected - Few
An interview on 03/25/25 at 12:47 P.M. with the Director of Nursing confirmed RN #337 had administered
Lantus insulin to Resident #111 when the blood glucose result was 109 mg/dL which was below the
parameters set for the administration of the Lantus insulin. This resulted in a significant medication error.
The resident's Lantus insulin was ordered to be held for a blood glucose level of less than 200 mg/dL, and it
wasn't. The resident developed hypoglycemia which warranted the administration of Glucagon and more
frequent blood glucose monitoring due to low blood sugar.
Review of the facility's policy titled Administering Medications dated 04/01/24 revealed medications shall be
administered in a safe and timely manner, and as prescribed. Medications must be administered in
accordance with the physician orders, including any required time frame.
Review of the manufacturer guidelines for Insulin Glargine (Lantus) revealed the onset of action for Lantus
insulin is three to four hours after administration with no pronounced peak effect.
2. Review of the medical record for Resident #302 revealed an admission date of 12/22/23 with diagnoses
including right femur fracture, COPD, high blood pressure, atherosclerotic heart disease, and
hyperlipidemia.
Review of the physician orders for Resident #302 revealed an order dated 09/03/24 for an antiplatelet
medication Clopidogrel Bisulfate (Plavix) 75 mg give one tablet by mouth in the morning for atherosclerotic
heart disease, and an order dated 09/03/24 for antihypertensive medication Carvedilol (Coreg) 3.125 mg
give one tablet by mouth every morning and at bedtime for high blood pressure.
Review of the quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #302 had
cognitive impairment with a BIMS score of 12 out of possible 15 and required assistance from staff for
personal hygiene care and medication administration.
Review of Resident #302's progress note dated 03/14/25 at 9:20 A.M. revealed Resident #302 had been
administered the wrong morning medications during morning medication pass by LPN #330. LPN #330 had
administered a lower dose of Coreg and a dose of the anticoagulant medication, Eliquis, to Resident #302
(these medications were not ordered for the resident). Resident #302's vital signs were stable and there
was no sign of bleeding. Resident #302's daughter was notified, and the on-call NP was notified.
Review of the facility's medication error report dated 03/14/25 completed by LPN #330 revealed Resident
#302 had received Resident #300's Eliquis and Coreg medications during the morning medication
administration. Resident #302 had a head-to-toe assessment completed by LPN #330 with no negative
findings documented. Resident #300's morning medications were removed from the facility's emergency
medication machine and administered per physician order.
An interview on 03/25/25 at 1:20 P.M. with the DON confirmed on 03/14/25 Resident #302 had been
administered Resident #300's morning medications including the anticoagulant Eliquis and high blood
pressure medication, Coreg. The DON stated the expectation of the facility nurses was to accurately read
the physician orders and check the medications with the resident's MAR and name prior to administration
of the medications.
Review of the facility's policy titled Administering Medications dated 04/01/24 revealed medications ordered
for a particular resident may not be administered to another resident. The individual administering the
medications must verify the resident's identity before giving the resident his/her
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365646
If continuation sheet
Page 5 of 8
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
04/04/2025
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)
F 0760
medications.
Level of Harm - Actual harm
3. Review of the medical record for Resident #404 revealed an admission date on 01/31/25 with a
readmission date from the hospital on [DATE]. The resident had diagnoses including but not limited to
diverticulitis of the large intestine, arterial fibrillation (AFib), heart failure, chronic kidney disease Stage 3,
Type II diabetes, and peripheral vascular disease (PVD).
Residents Affected - Few
Review of Resident #404's Medicare 5 - Day MDS assessment dated [DATE] revealed Resident #404 had
impaired cognition with a BIMS score of 11 out of 15. Resident #404 required assistance from staff for
personal care, transfers, and medication administration. Resident #404 was receiving diuretic medication
and heart failure was marked as a diagnosis.
Review of the hospital discharge paperwork and physician orders for Resident #404 dated 02/20/25
revealed an order for Furosemide oral tablet (Lasix) 20mg, give one tablet two times per week.
Review of Resident #404's physician orders revealed an order dated 02/24/25 for diuretic medication
Furosemide oral tablet (Lasix) 20 mg, give one tablet by mouth in the morning every Monday, Thursday, and
Saturday for heart failure. Further review revealed a discontinued order dated 02/20/25 to 02/24/25 for
diuretic medication Furosemide oral tablet (Lasix) 20 mg, give one tablet twice a day for heart failure.
Review of Resident #404's MAR dated 02/20/25 to 02/24/25 revealed Resident #404 had been
administered Furosemide 20mg, two times per day for a total of four days.
Review of Resident #404's progress note dated 02/24/25 at 12:10 P.M. authored by LPN #217 revealed the
order for Furosemide 20 mg and been clarified and changed to administration two times per week instead
of two times daily.
Review of the facility's medication error report completed by LPN #217 revealed Resident #404's
discharged physician order from the hospital dated 02/20/25 for Furosemide 20 mg had been transcribed
incorrectly instead of being administered two times weekly, the order had been transcribed to be
administered two times per day with Resident #404 receiving the Furosemide 20 mg two times per day for
four days resulting in a significant medication error.
An interview on 03/25/25 at 8:50 A.M. with LPN #217 revealed on 02/24/25 LPN #217 was reviewing
Resident #404's recent laboratory results with NP #312 which indicated abnormal results with kidney
function. LPN #217 reviewed Resident #404's hospital discharge medication orders dated 02/20/25 and
saw where the Furosemide 20 mg order had been transcribed incorrectly in Resident #404's medical
record. NP #312 clarified Resident #404's Furosemide order and LPN #217 updated the Furosemide order
to reflect Furosemide 20mg to be administered two times per week.
An interview on 03/25/25 at 1:10 P.M. with the DON confirmed Resident #404's hospital discharge order for
Furosemide 20 mg, give one tablet by mouth two times per week had been transcribed incorrectly into
Resident #404's medical record for Furosemide 20 mg to be given two times daily resulting in a significant
medication error. The DON stated the expectation of the facility nurses is to accurately read the physician
orders and check the medications with the resident's MAR and name prior to administration of the
medications.
Review of the facility's policy titled administering medications dated 04/01/24 revealed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365646
If continuation sheet
Page 6 of 8
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
04/04/2025
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)
F 0760
medications shall be administered in a safe and timely manner, and as prescribed.
Level of Harm - Actual harm
This deficiency represents non-compliance investigated under Complaint Number OH00163865.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365646
If continuation sheet
Page 7 of 8
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
04/04/2025
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
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 admission date 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.
Review of the physician orders for Resident #348 revealed an order dated 02/22/25 for a vitamin D2
supplement Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the
morning for supplemental use (daily).
Review of the Medication Administration Record (MAR) dated 02/22/25 to 02/28/25 revealed the order for
Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the morning (daily)
for supplemental use was marked as being administered on 02/23/24 in the morning. Further review of the
MAR revealed on 02/24/25 the order was marked as not administrated by Licensed Practical Nurse (LPN)
#217.
An interview on 03/25/25 at 8:05 A.M. with LPN #217 revealed on 02/24/25 during the morning medication
administration for Resident #348 LPN #217 recognized the order for Ergocalciferol oral capsule 1.25
milligrams (mg) (50,000 units) had been transcribed incorrectly during Resident #348's admission process
on 02/22/25. LPN #217 notified the physician for clarification and entered the correct order for Ergocalciferol
oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the morning every Monday for
supplemental use.
An interview on 03/25/25 at 1:18 P.M. with the Director of Nursing (DON) confirmed Resident #348's order
for vitamin D2 supplement Ergocalciferol had been incorrectly transcribed during Resident #348's
admission process on 02/22/25.
A review of the facility's policy titled Administering Medications dated 02/01/23 revealed medications shall
be administered in a safe and timely manner, and as prescribed.
This deficiency represents non-compliance investigated under Complaint Number OH00163865
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365646
If continuation sheet
Page 8 of 8
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the April 4, 2025 survey of Kingston of Ashland?
This was a inspection survey of Kingston of Ashland on April 4, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Kingston of Ashland on April 4, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe, appropriate pain management for a resident who requires such services."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.