A list of the most recent deficiencies for Kin On Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-27 | 2024-03-26 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Develop a communication plan. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-12-27 | 2024-02-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-03 | 2024-02-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-01-03 | 2024-02-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-03 | 2024-02-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-03 | 2024-02-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-03 | 2024-02-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-03 | 2024-02-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-03 | 2024-02-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-03 | 2024-02-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-03 | 2024-02-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-03 | 2024-02-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-03 | 2024-02-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-01-03 | 2024-02-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-03 | 2024-02-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-03 | 2024-02-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-03 | 2024-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-03 | 2024-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-03 | 2024-02-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-01-03 | 2024-02-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Establish methods for sharing information. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Meet other general requirements. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-27 | 2024-01-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-28 | 2022-11-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-28 | 2022-11-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-28 | 2022-11-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-28 | 2022-11-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-28 | 2022-11-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-28 | 2022-11-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-28 | 2022-10-19 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-09-28 | 2022-10-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-26 | 2022-02-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-26 | 2022-02-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-28 | 2021-08-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-26 | 2019-07-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-26 | 2019-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-18 | 2019-07-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-18 | 2019-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-18 | 2019-07-15 | N |
