Kinnic Health and Rehabilitation Center

Inspectors wroteBased on interviews, the facility did not ensure full time Director of Nursing (DON) coverage. This has the potential to affect all 48 residents. Former DON C resigned effective 06/17/25. The facility did not have a full time DON from 6/17 - 6/30/25. This is evidenced by: On 06/30/25 at 8:15 AM, Surveyors entered the facility and requested to meet with the Nursing Home Administrator (NHA) A or DON B. Social Worker Assistant (SWA) D stated DON B works part-time Tuesday, Wednesday, Thursday and the Assistant Director of Nursing (ADON) E is on vacation. On 06/30/25 at 4:05 PM, Surveyor interviewed NHA A asking about a full-time 40 hour a week DON. NHA A stated DON C left on 06/17/25 with no advance notice and DON B was initially hired to start in August in full-time status. DON B agreed to start on 06/17/25 part-time until August, when DON B could work full time. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 out of 1 resident sampled, R1. The facility did not adequately monitor and assess R1's ventriculoperitoneal (VP) shunt having the potential to result in serious complications. This is evidenced by: According to the National Institute of Health, VP shunts should be regularly monitored and assessed for complications. Signs and symptoms of shunt malfunction/infection include headache, lethargy, diplopia, nausea, vomiting, seizure, irritability, fever, and neck rigidity. Shunt system has to be assessed manually for proper function and visible for evidence of redness or swelling along the shunt tubing. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R), R2, R5, and R1 reviewed. R2, R5 and R1 had fallen; the facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall and review and revise care plan fall interventions. This is evidenced by: Facility policy titled, Falls Management, with no initiated or reviewed date, states in part: Policy: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for fall risk factors. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure licensed nurses had the specific competencies and skill set necessary to care for a resident's needs, as identified through resident assessment, and described in the plan of care, for 1 of 1 resident (R) reviewed for ventriculoperitoneal (VP) shunt care, R1. The facility did not provide training and education to licensed staff to ensure competency in the care of R1's VP shunt. This is evidenced by: Facility Assessment, dated 08/07/24, states in part: .Competencies: Kinnic considered the .clinical characteristics of the resident population to determine the skills and competencies required to meet our resident needs. We identified four categories of competencies: knowledge, assessment, pharmacological/treatment/care considerations, and technical/hands-on skills. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure Certified Nursing Assistant (CNA) received a performance review every 12 months for three of three CNAs reviewed (CNA C, CNA D, CNA P). The facility failed to have a system in place to ensure that performance reviews were being done for any of the facility CNAs. This had the potential to affect all 49 residents residing in the facility. This is evidenced by: On 06/10/25, a sample of CNAs employed by the facility was selected for review for the completion of annual performance reviews. The facility provided the following information: CNA C has been employed at the facility since 12/15/20. An annual performance review could not be located. CNA D has been employed at the facility since 09/2019. An annual performance review could not be located. CNA P has been employed at the facility since 12/06/21. [...]

Inspectors wroteBased on observation, interview and policy review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff were observed not allowing thermometer to dry prior to checking temperatures of food items and not inverting mixer and bowls in storage. This had the potential to affect all 49 residents in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system from 7/1/24 - 3/31/25 which triggered excessively low weekend staffing. This has the potential to affect all 49 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to allow resident the right to choose physicians/treatment options for 1 of 18 residents (R) reviewed. (R4). -Facility denied R4 the right to follow up with the wound provider of choice. R4 wanted to follow up with the VA wound provider and not the facility in-house provider. -R4 was seen by provider of choice and when returned to the facility with new orders, staff told R4 the facility will not do those treatments and had the attending physician discontinue the orders.

Inspectors wroteBased on staff interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN) of non-coverage for residents (R) whose Medicare Part A coverage was discontinued with benefit days remaining for 2 of 3 residents (R) reviewed. (R43, R33) R43 and R33 were discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility did not provide an ABN informing the residents of their liability once Medicare coverage ended.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 of 18 residents (R) reviewed for abuse (R98). The facility did not ensure all staff were trained on the abuse policy, did not complete audits of staff to protect residents from abuse, or ensure staff knowledge of the abuse and reporting policy, and did not have a quality improvement plan to prevent further verbal abuse. This is evidenced by: Facility's policy titled Abuse, Neglect and Exploitation with no date implemented, read in part, II. Employee Training, B. Existing staff will receive annual education through planned in-services and as needed .III. Prevention of Abuse, Neglect and Exploitation, H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors .VIII. Coordination with QAPI, A. [...]

Inspectors wroteBased on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of verbal abuse in accordance with section 1150B of the Act when an allegation of verbal abuse was not reported immediately but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 1 of 2 residents (R) reviewed (R98). This is evidenced by: Facility's policy titled Abuse, Neglect and Exploitation with no date implemented, read in part, VII. Reporting/Response, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure residents (R) received proper treatment and assistive devices to maintain hearing abilities. This affected 1 of 3 residents reviewed who needed hearing aids (R28). R28's hearing aid was broken and not replaced for several months. R28 continues with no left ear hearing aid, which impacts R28's ability to adequately hear. Findings Include: R28 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, primary open-angle glaucoma right eye-moderate state, low vision right eye, blindness left eye, disorientation-unspecified, and cognitive communication deficit. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with a suprapubic catheter received the appropriate care and services for 1 of 2 residents (R2), observed during catheter cares. -The facility had no policy to direct staff for daily suprapubic catheter site care. -R2 had a urinary tract infection (UTI) with sepsis in September 2024. -Registered Nurse (RN) G did not perform hand hygiene or glove change during suprapubic catheter care.

Inspectors wroteBased on observation, interview and record review, the facility did not assess trauma and care plan person centered approaches to prevent re-traumatization for 1 out of 1 resident reviewed for trauma informed care (R30). R30's diagnosis includes post-traumatic stress disorder (PTSD) and past trauma of her sister dying. The facility did not assess R30's trauma and care plan individual person-centered approaches to prevent potential re-traumatization. Findings Include: The facility policy titled Trauma Informed Care not dated, states the following: Policy: It is the policy of this facility to provide care and services, which in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/re re-traumatization. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure expired medications were removed from currently used supply in the medication storage room refrigerator. This occurred for 1 of 1 medication storage rooms observed. An opened bottle of a resident's (R) multiuse medication kept in the medication storage room refrigerator was labeled with a beyond use date of 6/7/25. This medication was expired and had been given to resident (R34) since it expired, resulting in the potential to affect 1 out of 49 residents that reside in the facility (R34).

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R2), observed during catheter cares. Registered Nurse (RN) G did not perform hand hygiene or glove change during suprapubic catheter care.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure written notice of transfer was provided for three residents (R) (R2, R7, and R8) of three residents reviewed for hospitalizations. These failures had the potential to contribute to confusion at discharge or a lack of understanding of appeal rights.

Inspectors wroteBased on interview and record review, the facility did not develop and initiate a comprehensive care plan with targeted interventions for a resident to identify and manage behavioral tendencies. This occurred for 1 of 5 residents (R) reviewed for care planning (R4). Facility did not develop and implement a behavioral care plan with intervention identified for handling potential inappropriate sexual behaviors for R4.

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff were observed not wearing covering over facial hair while preparing and serving food in the kitchen. This had the potential to affect all 46 residents in the facility.

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 2 of 4 sampled residents (R) who are unable to carry out activities of daily living received the necessary services of toileting and incontinence care to maintain good personal hygiene. (R16 and R29)

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice for 1 of 1 resident (R) reviewed for respiratory care. (R9) The facility has no system in place to replace R9's continuous positive airway pressure (CPAP) equipment according to manufacturer's recommendations. This is evidenced by: The facility policy, entitled CPAP/BiPAP Cleaning, dated 2023, states: Follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. The user guide for ResMed AirSense10 states: Caring for you device Check the air filter and replace it at least every 6 months. Design Life air tubing: 6 months R9 utilizes a CPAP mask ResMed Quaatro. [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide written notification of transfer to the Office of State Long-Term Care Ombudsman for 2 of 2 residents (R5 and R46) reviewed for transfers. The facility failed to have a system in place to ensure notifying the State Long-Term Care Ombudsman of hospital transfers. This had the potential to affect all 46 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not do hand hygiene between glove changes during wound care observation for 1 of 2 residents (R). (R39) Residents were not provided hand hygiene prior to meals in the dining room and resident rooms. This affected 17 residents in the dining room (R23, R37, R8, R152, R18, R45, R1, R25, R26, R9, R17, R47, R20, R19, R7, R21, R6) and 4 residents in their rooms (R3, R5, R28, and R13)

Inspectors wroteBased on interview and record review, the facility did not ensure each residents' drug regimen is free from unnecessary drugs in 1 (R11) of 4 residents reviewed. An unnecessary drug is any drug when used in the presence of adverse consequences, which indicate the dose should be reduced or discontinued, or without adequate indications for use. R11 was prescribed an antibiotic (Keflex) for a UTI (urinary tract infection) 3x week without having localizing symptoms of a UTI or adequate diagnosis. The facility had no evidence that R11 met criteria for continued use of the prophylactic antibiotic or signs and symptoms exhibited by R11 since last recertification survey of 2/10/2022. This is evidenced by: 04/25/23 Reviewed facility policy Infection Surveillance and Infection Prevention and Control Program implemented on 8/22 and reviewed and revised 4/23, stating, in part: [...]