Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kingsbrook Lifecare Center during CMS and state inspections, most recent first.
A resident with multiple health issues was admitted to a facility, but the care plan failed to address the care of his uncircumcised penis, leading to an infection that required surgery. Despite the resident's intact cognitive status and initial skin assessments showing no issues, the care plan lacked specific interventions for perineal care. The deficiency was discovered when a wound was found on the resident's penis, highlighting a lack of awareness and documentation among staff regarding his uncircumcised status.
A resident with a history of myocardial infarction and chronic kidney disease experienced a worsening infection due to inadequate perineal care. Despite complaints of pain during urination, staff failed to reassess redness under the resident's foreskin, leading to a severe infection requiring surgery. Interviews revealed a lack of training on care for uncircumcised males and communication gaps among staff, contributing to the oversight.
The facility failed to properly store and label medications, including tramadol pills in damaged packaging and insulin pens without expiration dates. Additionally, the medication room refrigerator on the Forest Heights Unit was consistently below the recommended temperature range without timely notification to maintenance. These deficiencies highlight lapses in medication management protocols.
Failure to Address Peri Care for Uncircumcised Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 99, specifically neglecting to address the care of his uncircumcised penis. This oversight resulted in the worsening of an infection that required surgical intervention. The resident was admitted with diagnoses including myocardial infarction, congestive heart failure, and chronic kidney disease. Despite having an intact cognitive status and no initial skin issues, the care plan did not include specific interventions for maintaining perineal skin, particularly for an uncircumcised penis. The deficiency was highlighted when the resident developed an open wound on his penis, which was discovered after a nurse retracted the foreskin to evaluate drainage reported by an aide. The wound was found to have purulent drainage and required surgical debridement and partial excision of the glans penis. Interviews with staff revealed a lack of awareness and documentation regarding the resident's uncircumcised status and the necessary peri care, which was not included in the care plan or communicated effectively among the care team. Interviews with the resident and his family indicated that the resident had been experiencing a burning sensation for months, but staff did not assess or address his concerns. The facility's policy required comprehensive care planning with input from all disciplines, but this was not adequately executed for Resident 99. The incident led to discussions and education among staff about the importance of regular skin assessments and the specific needs of uncircumcised residents.
Failure to Provide Adequate Perineal Care for Uncircumcised Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R99, who was assessed for skin care. R99, an uncircumcised male, was admitted with diagnoses including myocardial infarction, congestive heart failure, and chronic kidney disease. Despite complaints of pain during urination, staff did not reassess the identified redness under R99's penile foreskin, leading to a worsening infection that required surgical intervention. The initial skin assessments did not document any issues with the foreskin, and subsequent assessments failed to note the developing condition until it had significantly worsened. Interviews with staff revealed a lack of training and awareness regarding the specific needs of uncircumcised male residents. Several staff members, including nurse aides and LPNs, reported not receiving adequate training on providing perineal care for uncircumcised males. This lack of training contributed to the oversight in R99's care, as staff did not consistently retract the foreskin during assessments, which is a standard practice for proper hygiene and infection prevention. The resident's complaints of burning were initially attributed to a urinary tract infection or groin rash, and appropriate measures were not taken to address the actual cause of the discomfort. The deficiency was further compounded by communication gaps among staff members. Although R99 had been complaining of burning for months, these concerns were not effectively communicated or acted upon by the nursing staff. The issue was only identified when R99 was transferred to a different unit, where a nurse aide noticed the abnormal condition and alerted the nursing staff. This led to the discovery of a significant wound that required hospital intervention. The facility's failure to adhere to professional standards of practice and ensure proper training and communication resulted in a preventable escalation of R99's condition.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, leading to several deficiencies. In one instance, two tramadol pills were found in a damaged blister pack on the Shoreline Unit's medication cart. The Registered Nurse (RN) present was unaware of how the packaging was damaged and acknowledged that the pills should have been wasted with another nurse as a witness. The Resident Care Manager (RCM) and the Director of Nursing (DON) confirmed that the expectation was for damaged narcotics to be wasted to prevent contamination and diversion. Additionally, insulin pens on the Garden View and Forest Heights Units were not labeled with expiration dates after being removed from refrigeration. This oversight was noted during observations with Licensed Practical Nurses (LPNs) who admitted that the insulin might not be effective if out of date, potentially causing harm to residents. The DON was not informed about the lack of labeling, indicating a communication gap within the staff regarding medication management protocols. The medication room refrigerator on the Forest Heights Unit was consistently recorded at temperatures below the recommended range, with no timely notification to the Maintenance Director. The refrigerator contained various medications, including insulin pens and lorazepam, which were not harmed by the colder temperatures according to the pharmacist. However, the failure to maintain proper temperature control and notify maintenance in a timely manner reflects a lapse in adherence to the facility's medication storage policy.
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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) |
|---|---|---|---|---|
| Woodland Oaks | 3.5 mi | ★★★★★ | 0 | 0 |
| Kings Daughters Medical Center | 4.1 mi | — | 0 | 0 |
| Sanctuary At Ohio Valley | 4.9 mi | ★★★★★ | 0 | 0 |
| Boyd Nursing And Rehabilitation | 5 mi | ★★★★★ | 7 | 0 |
| Harbor Healthcare Of Ironton | 5.2 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.