Kin on Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wheelchairs were cleaned for 13 of 16 residents (Residents 81, 73, 71, 70, 12, 37, 45, 47, 41, 22, 9, 76 & 27), reviewed for comfortable/safe equipment use. This failure placed the residents at risk for unsafe equipment and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 5 of 9 residents (Residents 12, 15, 35, 37 & 81), reviewed for dining. The failure to provide residents who were dependent on staff for assistance with meals placed the residents at risk for unmet care needs, poor nutrition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the sanitizing solution concentration within the manufacturer recommended parts per million (ppm) for 1 of 2 kitchen's sanitizing buckets (Red Bucket for the Three Compartment Sink), reviewed for food services. This failure placed residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a new Level I PASARR (or PASRR-an assessment used to identify people [residents] with Serious Mental Illness [SMI], intellectual disabilities, or related conditions) after a significant change in status and failed to notify the PASARR Coordinator for 3 of 6 residents (Residents 10, 47 & 8), reviewed for PASARR. These failures placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for 2 of 7 residents (Residents 47 & 10), reviewed for comprehensive care plans. The failure to develop a care plan for diabetes mellitus (a disease where the body cannot properly regulate blood sugar levels), use of insulin (a hormone that helps regulate blood sugar levels) and hospice care (comfort care for individuals with terminal illness or with six months or less life expectancy) placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to review and revise comprehensive care plans for 2 of 6 residents (Residents 61 & 10), reviewed for care planning. The failure to review and revise care plans for nutrition and discontinuation of psychotropic (mind-altering) medications placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 4 residents (Resident 61), reviewed for accident/hazards. The failure to ensure aspiration precautions (safety measures designed to prevent food, liquids, or saliva from entering the airway and lungs) were implemented, placed the resident at risk for accidents, injury, and other negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications had a record of receipt with sufficient detail to allow for reconciliation and/or have disposal methods that involved a secure and safe method for 1 of 3 medication carts (Station 1 Medication Cart 3), reviewed for medication storage. This failure placed the facility at risk for potential loss/misappropriation, drug diversion, and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure adverse side effects of an antidepressant (medication to treat depression [persistent feeling of sadness and loss of interest]) were monitored for 1 of 5 residents (Resident 63), reviewed for unnecessary medications. This failure placed the resident at risk for negative outcomes, related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 4 medication carts (Station 2 Medication Cart 1), reviewed for medication administration. This failure placed residents at risk for unintended access to medications and biologicals, and negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Transmission Based Precautions (TBP- measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment [PPE-use of gown, gloves, mask and/or face shield/goggles] before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 99), and failed to follow Enhanced Barrier Precautions (EBP- protocols to protect residents from multidrug-resistant organisms [a germ that is resistant to medications that treat infections]) practices were followed by 1 of 3 staff (Staff T), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection, related complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow the plan of care to use a gait belt (a safety device used to assist residents with mobility issues) for 1 of 1 resident (Resident 1), reviewed for accident hazards. Resident 1 experienced harm when they fractured their left clavicle (a break in the bone that connects the breastbone to the shoulder blade) and experienced pain when staff members transferred the resident without the use of a gait belt. The failure to follow plan of care when assisting with transfers placed residents at risk for avoidable injury, unsafe transfers, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe water temperatures and ensure adequate supervision and/or assistance to prevent accidents for 2 of 5 residents (Residents 1 & 2), reviewed for accident hazards. Resident 1 experienced serious injury when unsafe hot water temperature was provided to them sustaining second-degree burns (damage to both the outer and inner layers of the skin) requiring treatment. Resident 2 was at risk of harm when they were observed accessing unsafe hot water temperatures in the nurse's lounge. These failures placed the residents at risk of further injuries, related complications, and a diminished quality of life. An Immediate Jeopardy (IJ) was identified, and the facility was notified of the noncompliance on 05/14/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure injuries of unknown source and abuse allegations were thoroughly investigated for 4 of 5 residents (Residents 1, 2, 3 & 4), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician reviewed the total program of care including treatment and medications and completed progress notes timely for 38 of 38 residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 & 42), reviewed for physician progress notes. This failure had the potential to place the residents at risk for a delay in treatment, unmet medical care needs, and lack of physician oversight.

Inspectors wroteBased on interview and record review, the facility failed to report significant injury of unknown origin for 1 of 5 residents (Resident 3) reviewed for abuse investigations. The facility's failure to report large bruises of unknown origin on the resident's chest and torso, placed the residents at risk for repeated incidents and unidentified abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide care and services in a manner that maintained and promoted dignity before entering resident rooms for 4 of 11 rooms (Rooms 121, 122, 126 & 119), reviewed for dignity. This failure placed the residents at risk for a diminished self-worth and over-all well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the survey result binder included the recertification and complaint survey results that resulted in citations for 2 of 3 years (2022 & 2024), reviewed for availability of survey reports. In addition, the facility failed to post notice of the availability of survey reports in areas of the facility that are prominent and accessible to the public. These failures prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of corrections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement care plans for 7 of 8 residents (Residents 43, 78, 1, 9, 80, 3 & 85), reviewed for care planning. The failure to develop person-centered care plans for use of bed rails placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 18 residents (Residents 76, 1, 492 & 58), reviewed for care plan revision. The failure to revise care plans for residents with diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), missing/broken denture and discharge planning placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess residents for the use of bed rails for 7 of 8 residents (Residents 1, 9, 80, 3, 43, 78 & 85) reviewed for bed rails. This failure placed residents at risk for potential injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked after the start of each shift for 5 of 7 days (02/19/2025, 02/20/25, 02/21/2025, 02/24/2025 & 02/26/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided per professional standards of practice for 4 of 9 residents (Residents 39, 14, 49 & 6), reviewed for medication management. The failure to clarify physician's order, document medication, and properly identify residents prior to medication administration placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were monitored for safe storage of vaccines (biological preparation that provides immunity to a particular disease) were followed for 1 of 1 medication room refrigerator (Station 2 Medication Room Refrigerator), and failed to ensure expired medical supplies and/or biologicals (diverse group of medicines made from natural sources) were removed or discarded in accordance with current accepted professional standards for 1 of 1 clean utility room (Station 2 Clean Utility Room), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications and medical supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the sanitizing solution/agent was at the correct concentration used to ensure proper sanitation of food preparation surfaces in accordance with professional standards for 1 of 1 kitchen, reviewed for food safety. This failure placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a communicable disease (infectious disease that can spread through direct or indirect contact) outbreak (two or more cases of a highly contagious disease) for 1 of 1 outbreak, and failed to ensure proper infection control practices were followed during resident care and medication administration for 2 of 12 residents (Resident 65 & 6), reviewed for infection control. In addition, the facility failed to ensure Transmission Based Precautions (TBP- additional infection control measures used when standard precautions are not enough to prevent the spread of an infection) practices were followed for 2 of 7 residents (Residents 11 & 57). These failures placed the residents, staff, and visitors at an increased risk of infection and related complications.

Inspectors wroteBased on interview, and record review, the facility failed to initiate and resolve a grievance for 1 of 3 residents (Resident 1), reviewed for grievances. The failure to initiate, investigate, and resolve grievances for missing personal item placed the resident at risk for feelings of frustration, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure injuries of unknown source and falls were thoroughly investigated for 2 of 2 residents (Residents 81 & 65), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess 2 of 18 residents (Residents 1 & 57), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments of the MDS Section L (Oral/Dental Status) and Section N (Medications) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), intellectual disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 1 of 5 residents (Resident 58), reviewed for unnecessary medications. This failure placed the resident at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate staff supervision and/or assistance was provided during meals for 1 of 2 residents (Resident 65) and failed to ensure bed rails/enablers were secured for 1 of 5 residents (Residents 3), reviewed for accident hazards. These failures placed the residents at risk for choking episodes, aspiration (when food or liquid enters the airways or lungs), accidents, injury, and other negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on for 1 of 5 residents (Resident 76), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medications and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of financial exploitation was thoroughly investigated for 1 of 1 resident (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified financial exploitation, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services consistent with professional standards of practice related to managing signs and symptoms and/or treatment of urinary tract infection (UTI-bladder infection) for 1 of 1 resident (Resident 2), reviewed for quality of care. This failure placed the resident at risk of unmet care needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure possible allegations of abuse were investigated for 4 of 4 residents (Residents 1, 2, 3 & 4), reviewed for abuse investigations. This failure placed the residents at risk for unidentified abuse, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice to ensure 5 of 6 licensed staff (Staff O, DD, EE, FF & N) observed for medication administration follow medication administration practices regarding crushing medications, Insulin (a medication to manage blood sugar) administration, Lidocaine patch (pain medication) application, clarifying physician orders and signing off medications. These failures placed the residents at risk for possible medication errors, potential negative outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). The failure to properly administer 4 of 26 medications for 4 of 8 residents (Residents 34, 52, 59 & 69), observed during medication pass resulted in a medication error rate of 15.38%. This failure placed the residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired laboratory/medical supplies were discarded for 1 of 2 medication storage room (Station 2 Medication Room), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised medical supplies, possible infections, and adverse consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen, 1 of 1 dining room, and 1 of 2 station units (Station 1 Unit), reviewed for food services. The failure to label and date food items and perform hand hygiene prior/after serving food placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene practices and proper glove use were followed during glove changes for 1 of 2 staff (Staff V), failed to clean and disinfect resident-care equipment after use for 1 of 1 resident room (room [ROOM NUMBER]), and failed to ensure clean linens were transported properly. These failures placed the residents at risk for facility acquired or healthcare-associated infections, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident and/or their designated representative were notified before administering a psychotropic (mind altering) medication for 1 of 5 residents (Resident 95), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives (healthcare directives) were offered to residents and/or their representatives for 3 of 4 residents (Residents 5, 6 & 1), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the residents/representatives and to the Office of the State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) describing the reason for transfers for 3 of 4 residents (Residents 27, 72 & 95), reviewed for hospitalization. This failure placed the residents at risk for not having an opportunity to make informed decision about transfers/discharge and access to an advocate who informed residents about options and residents rights.

Inspectors wroteBased on interview and record review, the facility failed to provide written summary of the baseline care plan to the residents and/or their representatives for 3 of 3 residents (Residents 248, 249 & 198), reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for 1 of 23 residents (Resident 32), reviewed for care planning. The failure to identify the resident's preferred spoken language placed the resident at risk for communication difficulty, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan interventions were revised for 2 of 2 residents (Residents 23 & 36), reviewed for care planning. This failure placed the residents at risk for skin breakdown, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide turning and repositioning per plan of care for 1 of 6 residents (Resident 10), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for unmet care needs, skin impairment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 6 residents (Resident 25), reviewed for accidents. The failure to provide necessary supervision placed the resident at risk for accidents, injury, and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 2 residents (Resident 82 & 73), reviewed for urinary catheter. The failure to ensure urinary catheter was off the floor placed the residents at risk for infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain, label, and properly store nebulizer machine (breathing treatment) tubing, oxygen and/or suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) cannula/tubing for 3 of 4 residents (Residents 65, 85 & 10), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses had the appropriate competencies, skills set and proficiencies to administer medications for 3 of 5 nursing staff (Staff N, Staff O & Staff P), reviewed for competent nurse staffing. This failure placed the residents at risk for unmet care needs, potential medication errors, and adverse medication outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring was in place for psychotropic (mind altering) medication management for 1 of 5 residents (Resident 23), reviewed for unnecessary medications. This failure placed the resident at risk for unmet care needs, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided education about COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccinations for 3 of 5 residents (Resident 5, 83 and 94), reviewed for COVID-19 immunizations. The failure to educate residents regarding the risks, benefits, and the potential side effects of COVID-19 vaccinations placed the residents at risk for having insufficient information to make informed decisions.