Below 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 Kinnic Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain a full-time DON after the previous DON resigned, resulting in a gap where only part-time DON coverage was provided and the ADON, an LPN, was on vacation. This left the facility without a full-time DON for an extended period.
A resident with a VP shunt did not receive care in line with professional standards, as staff only performed the mechanical pumping of the shunt without documenting the number of pumps or conducting required assessments for infection or abdominal complications. Nursing staff reported limited training focused solely on pumping, and the DON could not provide evidence of education or assessment protocols for VP shunt care.
Three residents experienced falls, and the facility did not implement immediate interventions, conduct root cause analyses, or update care plans as required by its own policies. Incident reports and care plans lacked documentation of post-fall actions, and facility administration confirmed the absence of interdisciplinary team investigations.
Nursing staff did not receive formal training or competency evaluation for the care of a resident with a VP shunt, despite the resident's care plan requiring specific interventions. Staff training was limited to informal demonstrations, with no documented education on proper technique, assessment, or potential complications. The facility's training materials did not include VP shunt care, and the DON could not provide evidence of staff competency in this area.
Staff did not follow proper food storage and thermometer sanitization procedures, including storing mixing bowls and pans uncovered and not inverted, and failing to allow thermometer probes to air dry after sanitizing before checking food temperatures. These actions had the potential to affect all residents in the facility.
The facility submitted inaccurate direct care staffing data to CMS through the PBJ system, resulting in reports of excessively low weekend staffing for three consecutive quarters. Although actual schedules and staff interviews confirmed consistent staffing levels throughout the week, discrepancies in PBJ data entry—potentially due to unreported staff hours or incorrect timecard entries—led to the deficiency.
The facility failed to conduct and document annual performance reviews for CNAs, as required. A review of records for three CNAs showed no evidence of completed evaluations, and the administrator confirmed that only wage adjustment forms were available. This deficiency had the potential to impact all residents in the facility.
Two residents who were discharged from Medicare Part A services but remained in the facility were not given the required Advanced Beneficiary Notice (ABN) informing them of their financial liability for services not covered by Medicare. The Business Office Manager indicated she had misinterpreted the updated forms and failed to provide the necessary notice.
A resident with a suprapubic catheter did not receive proper site care due to the absence of a facility policy and failure by a registered nurse to perform hand hygiene and glove changes between removing a soiled dressing and applying a new one. The resident, who had a history of UTI with sepsis and complex medical needs, was put at risk due to these lapses in infection control.
A resident with PTSD and a history of childhood trauma was not assessed for trauma triggers, and the care plan lacked individualized, trauma-informed interventions. Staff were unaware of the resident's trauma history or specific care approaches, and the facility did not complete trauma-informed assessments as required by policy.
Surveyors observed that an LPN had not removed an expired bottle of refrigerated omeprazole from the medication storage room, and the medication continued to be administered to a resident after its expiration date. Facility policy requires staff to check expiration dates and remove expired medications, but this was not followed, resulting in expired medication being given to a resident.
A resident with a suprapubic catheter did not receive proper infection control during site care, as an RN failed to perform hand hygiene and change gloves after removing a soiled dressing and before applying a new one. The facility also lacked a specific policy for suprapubic catheter care, and the existing hand hygiene policy was undated and general.
A resident with complex medical needs was denied the right to choose a VA wound care provider, as the DON required use of only in-house providers and disregarded the resident's and family's wishes. When the resident returned from a VA appointment with new wound care orders, the DON instructed staff not to implement them, had the attending physician discontinue the orders, and removed the related supplies, violating the resident's rights.
A resident with severe cognitive impairment and dementia was subjected to verbal abuse by a nurse, while another staff member intimidated the resident and failed to intervene appropriately. The facility did not ensure all staff were trained on abuse prevention policies, as shown by incomplete training records, and did not conduct formal audits or have a written quality improvement plan to address or prevent further abuse.
A resident with severe cognitive impairment and multiple medical conditions was subjected to alleged verbal abuse by a nurse, which was not reported by a CNA within the required two-hour timeframe. The incident was instead reported the following morning, and local law enforcement was not notified as required. The facility's investigation and reporting to the state agency were also delayed, resulting in a deficiency in abuse reporting procedures.
A resident with significant hearing and vision impairments did not receive a replacement for a broken hearing aid for several months, despite care plan directives and observed communication difficulties. Staff were required to speak loudly into the resident's functioning ear, and the lack of a systematic process for follow-up led to prolonged inadequate access to necessary assistive devices.
The facility failed to provide written transfer notices to three residents, omitting necessary details such as the reason for transfer, location, and appeal rights. Staff interviews and record reviews revealed that only verbal notifications were given, and the provided transfer forms were incomplete and lacked signatures from the residents' representatives.
A facility failed to create a behavioral care plan for a resident with a history of being on the sex offender list. Despite the resident's intact cognition and need for assistance with mobility, the care plan did not address potential inappropriate sexual behaviors. Interviews with the NHA and DON revealed awareness of the issue but no interventions were in place.
The facility failed to comply with food safety standards as staff, including the Dietary Manager and Dietary Cook, were observed not wearing beard nets while preparing and serving food, despite having facial hair. This non-compliance had the potential to affect all 46 residents.
The facility failed to provide necessary toileting and incontinence care for two residents with cognitive impairments. Staff did not follow care plans, resulting in prolonged periods without toileting assistance, leading to inadequate personal hygiene and potential health risks.
A resident with obstructive sleep apnea did not receive necessary respiratory care as the facility failed to replace CPAP supplies according to the manufacturer's recommendations. Interviews with staff revealed no system in place to track or document the replacement of the resident's CPAP supplies, and the Director of Nursing admitted that they do not review the resident's personal CPAP machine.
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers for two residents, as staff were unaware of this requirement. This deficiency was confirmed by the Director of Nursing and Social Services Director during a survey.
Lack of Full-Time DON Coverage
Penalty
Summary
The facility failed to ensure full-time Director of Nursing (DON) coverage, as required. After the resignation of the previous DON, there was no full-time DON in place from 6/17 to 6/30. During this period, the newly hired DON worked only part-time and was not scheduled to begin full-time until August. The Assistant Director of Nursing (ADON), who is a Licensed Practical Nurse (LPN), was present full-time but was on vacation during the survey. Interviews with staff confirmed that there was no interim full-time DON assigned during this gap, potentially affecting all 48 residents in the facility.
Failure to Monitor and Assess VP Shunt According to Standards
Penalty
Summary
The facility failed to ensure that a resident with a ventriculoperitoneal (VP) shunt received treatment and care in accordance with professional standards of practice. The resident, who had congenital hydrocephalus and a cerebrospinal fluid drainage device, was severely cognitively impaired and required regular monitoring of the VP shunt for complications such as infection or malfunction. The care plan directed nursing staff to pump the shunt as per neurosurgeon instructions but did not include interventions for assessment of the shunt line for infection or abdominal assessment for signs of fluid overload related to cerebrospinal fluid drainage. Review of the resident's records showed that while the shunt was pumped as ordered, there was no documentation of the number of pumps performed, nor were there any documented assessments of the abdomen or the shunt for signs of infection or other complications. Interviews with nursing staff revealed that their training was limited to the mechanical aspect of pumping the shunt, with no education or documentation regarding assessment for potential complications. The Director of Nursing was unable to provide evidence of staff training or assessment protocols related to the VP shunt, and no additional physician orders for assessment were present.
Failure to Implement Post-Fall Interventions and Care Plan Revisions
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and interventions to prevent accidents for three residents. Despite having policies in place for falls management and post-fall protocols, the facility did not implement immediate interventions after falls, did not conduct root cause analyses, and did not update or revise care plans following fall incidents. This was observed through record reviews, interviews, and incident reports for three residents who experienced falls. One resident with severe cognitive impairment and a history of multiple falls was found on the floor with a head injury, but the incident report lacked documentation of immediate interventions or care plan updates. Another resident with hemiplegia and a history of falls prior to admission experienced a fall while attempting to put shoes away, yet the incident report did not include immediate interventions, and there was no evidence of an interdisciplinary team investigation or care plan revision. A third resident with severe cognitive impairment and a cerebrospinal fluid drainage device fell from a wheelchair, sustained a hematoma and abrasions, and was sent to the emergency department, but there was no documentation of a root cause analysis or follow-up occupational therapy evaluation as indicated in the care plan. In all three cases, the facility did not follow its own policies regarding post-fall assessment, investigation, and care plan revision. The lack of immediate interventions, root cause investigations, and care plan updates after falls contributed to the deficiency, as confirmed by the absence of interdisciplinary team notes and the statements from facility administration.
Lack of Staff Competency and Training for VP Shunt Care
Penalty
Summary
Licensed nurses at the facility did not have the specific competencies and skill set necessary to care for a resident with a ventriculoperitoneal (VP) shunt, as identified through the resident's assessment and care plan. The facility's own assessment and training documentation indicated that staff competencies should be based on the clinical characteristics of the resident population, with a curriculum and training plan developed accordingly. However, review of facility education and training materials showed that VP shunt care was not included as a topic for training or competency evaluation. The resident in question had a history of congenital hydrocephalus and a cerebrospinal fluid drainage device, with severe cognitive impairment noted on the most recent assessment. The care plan required nursing staff to pump the VP shunt as directed by the neurosurgeon, but did not include assessment for signs or symptoms of infection or fluid overload related to the shunt. Interviews with nursing staff revealed that training on VP shunt care was informal and limited to being shown how to palpate and pump the shunt, with no formal education on the amount of pressure, rate, or depth of compression, nor on potential complications or necessary assessments beyond monitoring neurological status. Staff were unable to articulate additional assessments or complications related to VP shunt malfunction. The Director of Nursing was unable to provide documentation of training or competency evaluation for VP shunt care and confirmed that no current training was in place for this procedure.
Improper Food Storage and Thermometer Sanitization Practices
Penalty
Summary
Staff failed to follow professional standards for food service safety in the preparation, distribution, and serving of food. During a kitchen tour, a surveyor observed that mixing bowls and pans were stored uncovered and not inverted, both on counters and racks. The kitchen aide confirmed that this was the usual practice, and acknowledged understanding of the risk of bacterial contamination associated with storing dishes in this manner. The dietary manager also confirmed that dishes should be covered or inverted, and noted that moisture remaining after dishwashing could promote bacterial growth, especially since the storage areas were not protected from potential contaminants. Additionally, a staff member responsible for checking food temperatures was observed using an alcohol pad to wipe the thermometer probe, but did not allow the probe to air dry before inserting it into multiple food items. The staff member admitted to not being trained to wait for the sanitizer to dry before use and recognized the potential for contaminating food with sanitizer residue. These practices had the potential to affect all 49 residents in the facility.
Inaccurate PBJ Staffing Data Submission Resulted in Reported Low Weekend Staffing
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) via the Payroll Based Journal (PBJ) system for the period from July 1, 2024, to March 31, 2025. Despite scheduling the same number of direct care staff on weekends as on weekdays, the PBJ data submitted indicated excessively low weekend staffing for three consecutive fiscal quarters. This discrepancy was identified through review of CASPER 1705D reports and was not supported by the facility's actual staffing schedules or by interviews with the scheduler and the nursing home administrator (NHA), both of whom confirmed that weekend staffing levels did not differ from weekday levels except for the absence of the DON or ADON. The NHA reported that staff hours worked are submitted to the owner through the payroll system and then entered into the PBJ system by the owner. Attempts to verify the data entry process with the owner were unsuccessful. The NHA suspected that some staff hours may have gone unreported in the PBJ system due to incorrect timecard entries, which may have triggered the low weekend staffing reports. The surveyor did not find evidence of actual low weekend staffing during the review, but the inaccurate PBJ data submission constituted a deficiency affecting all 49 residents in the facility.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility did not ensure that Certified Nursing Assistants (CNAs) received annual performance reviews as required. During a review of personnel records for three CNAs, it was found that none had documentation of a performance review within the past 12 months, despite being employed at the facility for more than a year. The Nursing Home Administrator confirmed that only wage adjustment forms were available, and no annual performance evaluations could be located for any of the CNAs reviewed. This lack of a system for conducting and documenting regular performance reviews was observed to potentially affect all 49 residents in the facility.
Failure to Provide ABN and Notice of Liability After Medicare Part A Discharge
Penalty
Summary
The facility failed to provide Advanced Beneficiary Notice (ABN) of non-coverage to residents whose Medicare Part A coverage was discontinued while they still had benefit days remaining. Specifically, two residents were discharged from Medicare Part A services but remained in the facility without being given notice of their financial liability for services not covered by Medicare after their coverage ended. Documentation review showed that both residents received a notice of non-coverage, but no ABN or notice of patient liability was provided. During an interview, the Business Office Manager responsible for these notices stated that she had misinterpreted the updated forms and had not been providing the required notice of potential liability to residents who remained in the facility after Medicare coverage ended.
Deficient Suprapubic Catheter Site Care and Infection Control
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not receive appropriate catheter site care due to the facility's lack of a specific policy guiding daily suprapubic catheter site care. During an observation, a registered nurse performed suprapubic catheter care but failed to change gloves or perform hand hygiene after removing the old dressing and before applying a new dressing. This lapse in infection control practice was directly observed and acknowledged by both the nurse and the assistant director of nursing when questioned. The facility's existing policy on suprapubic catheterization did not address hand hygiene between glove changes during site care, and a new policy created during the survey still omitted this critical step. The resident involved had multiple sclerosis, neuromuscular dysfunction of the bladder, and an appendicovesicostomy, and was cognitively intact. The resident had previously experienced a urinary tract infection with sepsis. The lack of a clear policy and failure to follow proper infection control procedures during catheter care were directly linked to the deficiency cited by surveyors.
Failure to Assess and Care Plan Trauma-Informed Approaches for Resident with PTSD
Penalty
Summary
The facility failed to assess and care plan person-centered, trauma-informed approaches for a resident with a known history of trauma and a diagnosis of post-traumatic stress disorder (PTSD). The facility's policy requires a multi-pronged approach to identifying trauma history and triggers, including the use of assessment tools and direct inquiry with the resident. However, the resident's record did not contain any trauma-specific assessment, and the care plan lacked individualized interventions to prevent re-traumatization. The resident in question was admitted with multiple mental health diagnoses, including major depressive disorder, Alzheimer's disease, unspecified psychosis, panic disorder, and PTSD related to the death of her sister during childhood. Although the care plan acknowledged the PTSD diagnosis and referenced the traumatic event, it only included general interventions such as medication administration, encouragement to express feelings, and monitoring for symptoms of depression or anxiety. There were no documented efforts to identify specific trauma triggers or to develop targeted strategies to minimize re-traumatization, as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's trauma history and the absence of trauma-informed care approaches. The Social Service Director confirmed that trauma-informed assessments were not being completed for residents with identified trauma, and direct care staff were unaware of the resident's PTSD diagnosis or any specific interventions related to her trauma. Staff noted the resident's sensitivity to environmental stimuli and recent distress related to news events, but had not been provided with guidance on how to address these issues in a trauma-informed manner.
Expired Medication Not Removed from Active Stock
Penalty
Summary
Surveyors found that the facility failed to ensure expired medications were removed from active stock in the medication storage room refrigerator. During an observation with an LPN, a bottle of refrigerated liquid omeprazole intended for a resident was found to be labeled with a beyond use date that had already passed. The medication had continued to be administered to the resident after its expiration date, and no other expiration dates were noted on the bottle at the time of observation. The facility's policy requires staff to observe proper storage and labeling requirements for all medications, including the removal of expired medications from active stock. The Assistant Director of Nursing confirmed that nursing staff are expected to check expiration dates before administering medications and that all refrigerated medications are inspected weekly. Despite these expectations, the expired medication remained in use and was not removed in a timely manner, affecting one resident.
Failure to Perform Hand Hygiene and Glove Change During Catheter Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to perform appropriate hand hygiene and glove changes during suprapubic catheter site care for a resident. The RN performed hand hygiene and donned personal protective equipment upon entering the room, but after removing the old dressing from the catheter site, did not change gloves or perform hand hygiene before cleaning the site and applying a new dressing. The RN only performed hand hygiene after completing the procedure and removing personal protective equipment. This practice was observed directly by the surveyor. Additionally, the facility did not have a specific policy in place to guide staff on the care of suprapubic catheter sites. The existing hand hygiene policy was undated and only provided general guidance on when hand hygiene should be performed, such as after handling contaminated objects or before invasive procedures. Interviews with facility staff confirmed that hand hygiene and glove changes should occur after removing a soiled dressing and before applying a new one, but this was not followed during the observed care. The resident involved was cognitively intact and had a history of multiple sclerosis, neuromuscular bladder dysfunction, and an appendicovesicostomy.
Failure to Honor Resident's Right to Choose Physician and Treatment
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician and treatment options. A resident with multiple medical conditions, including a left femur fracture, diabetes, heart failure, chronic kidney disease, peripheral vascular disease, and venous ulcers, expressed a preference to continue wound care with a VA provider rather than the facility's in-house provider. Despite this, the resident was told upon admission to cancel all VA appointments except for orthopedic care and to use only in-house providers. When the resident and their daughter arranged for VA wound care and returned with new treatment orders, the Director of Nursing (DON) instructed staff not to follow the VA provider's orders and had the attending physician discontinue them without the resident's consent. The supplies for the VA-ordered treatments were removed from use and stored away, and the new orders were not transcribed or implemented. Interviews with staff confirmed that the DON directed all care decisions through the medical director and disregarded the resident's expressed wishes and the VA provider's orders. The Social Services Director acknowledged that residents have the right to choose their own physicians, as stated in the admission packet, and agreed that changing provider orders without resident consent was a violation of rights. The Director of Rehab also reported that the DON refused to allow staff to implement the VA provider's orders and removed the related supplies. The Nursing Home Administrator confirmed awareness of the DON's actions and stated that residents have the right to select their providers.
Failure to Protect Resident from Verbal Abuse and Inadequate Staff Training
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. A resident with severe cognitive impairment, dementia, and other significant medical conditions was subjected to verbal abuse when a registered nurse raised his voice and swore at the resident while providing care. Additionally, a certified nursing assistant was reported to have intimidated the resident and did not attempt appropriate interventions. The incident was reported by another staff member, and the facility's investigation confirmed the occurrence of verbal abuse. The facility did not ensure that all staff were trained on the abuse policy, as evidenced by incomplete staff sign-in sheets for abuse education and reporting. Out of 78 staff employed at the time, only a portion received documented training following the incident, and some staff, including the involved nurse, were not listed as having received prior abuse training. Furthermore, the facility did not conduct formal audits of staff interactions or knowledge of the abuse policy to prevent further incidents. There was also no written quality improvement or performance improvement plan in place to address or track patterns of abuse occurrences.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of an allegation of verbal abuse in accordance with section 1150B of the Act. Specifically, a certified nursing assistant (CNA) witnessed a registered nurse (RN) raising his voice and swearing at a resident with severe cognitive impairment during care. The CNA did not report the incident immediately or within the required two-hour timeframe, instead waiting until the following morning to inform the Assistant Director of Nursing (ADON). The ADON then reported the incident to the Director of Nursing (DON), who subsequently notified the Nursing Home Administrator (NHA). The incident was not reported to local law enforcement as required by state law, and the facility's investigation was not completed and reported to the state agency until several days later. The resident involved had significant medical conditions, including a nondisplaced femur fracture, dementia with severe cognitive impairment, and required moderate assistance with daily activities. The Minimum Data Set (MDS) assessment documented the resident's severe cognitive impairment and need for extensive support. The failure to report the alleged verbal abuse in a timely manner, as outlined in facility policy and federal requirements, constituted a deficiency in the facility's abuse reporting procedures.
Failure to Replace Resident's Hearing Aid in Timely Manner
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, low vision, blindness in one eye, and mild cognitive impairment did not receive proper treatment and assistive devices to maintain hearing abilities. The resident's care plan indicated the need for bilateral hearing aids and assistance with their use, as well as regular monitoring and referral to audiology as needed. Despite these documented needs, the resident's left hearing aid was broken and not replaced for several months, resulting in ongoing difficulty hearing from the left side. Staff were observed speaking loudly into the resident's right ear, and the resident was unable to respond when addressed from the left side, indicating a significant impact on communication. Interviews revealed that the process for replacing the hearing aid was not effectively managed. The Social Service Director acknowledged that follow-up was delayed, partly due to a change in the resident's Power of Attorney after the death of a family member who had possession of the hearing aid. The lack of a systematic approach to tracking and replacing assistive devices contributed to the prolonged period without the necessary hearing aid, directly affecting the resident's ability to communicate and participate in daily activities.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notice of transfer to three residents, which included necessary information such as the reason for transfer, the location, and appeal rights. This deficiency was identified during a review of the facility's policy and records, as well as through interviews with staff. The policy required that the transfer/discharge notice be provided in a language and manner understandable to the resident and their representative, including specific details about the transfer and appeal rights. For Resident 2, the electronic medical record showed no evidence of a written notice of transfer being provided. The registered nurse on duty at the time of the transfer confirmed that no written notice was given, only a verbal notification to the resident's responsible party. The administrator later provided a transfer form that lacked the necessary contact information for filing an appeal and did not have a signature from the resident's wife. Similarly, for Residents 7 and 8, there was no evidence of written notice of transfer with the required information being provided. The administrator provided transfer forms that were incomplete and lacked signatures from the residents' representatives. Interviews with the administrator and the director of nursing revealed that while a bed hold notice was given, it did not include the required details about the transfer or appeal rights.
Lack of Behavioral Care Plan for Resident with History of Sexual Offense
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident identified as R4, who was admitted with a history of being registered on the sex offender list for minor issues. Despite R4 having intact cognition and requiring assistance for mobility and transfers, the facility did not create a behavioral care plan to address potential inappropriate sexual behaviors. The Minimum Data Set (MDS) assessment confirmed R4's cognitive status, and the admission documentation noted R4's history of illicit sexual behavior. However, the care plan lacked targeted interventions to manage these potential behaviors. During interviews, both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged the absence of a behavioral care plan for R4. The NHA admitted that the facility was trying to keep the situation low key to avoid turmoil for R4, while the DON confirmed that no complaints had been made about R4's behavior and described R4 as pleasant. Despite this, both agreed that interventions should be in place to address any potential inappropriate sexual behaviors, but no such care plan existed at the time of the survey.
Non-Compliance with Food Safety Standards Due to Lack of Facial Hair Coverings
Penalty
Summary
The facility did not adhere to professional standards for food service safety, as staff were observed not wearing appropriate facial hair coverings while preparing and serving food in the kitchen. Specifically, the Dietary Manager (DM) and Dietary Cook (DC) were seen without beard nets, despite having facial hair. The FDA Food Code 2022 mandates that food employees wear hair restraints, including beard nets, to prevent hair from contacting exposed food and clean equipment. The facility's policy also requires staff to wear hair restraints when handling food. However, both DM and DC were observed multiple times without beard nets while working in food prep areas and serving food to residents. During interviews, the DM and DC were unsure about the specific policy regarding facial hair but acknowledged the need to wear beard nets. The DM admitted to instructing staff to either shave or wear beard nets but did not follow this guideline himself, believing it was unnecessary since he was not directly handling food. This non-compliance with food safety standards had the potential to affect all 46 residents in the facility.
Failure to Provide Necessary Toileting and Incontinence Care
Penalty
Summary
The facility did not ensure that two residents who were unable to carry out activities of daily living received the necessary services of toileting and incontinence care to maintain good personal hygiene. Resident R16, who has severe cognitive impairment and is frequently incontinent, was observed multiple times throughout the day without being offered toileting assistance. Despite R16's care plan specifying that staff should reattempt toileting every 5-10 minutes if the resident resists, staff did not follow this protocol. R16 was left in a soaked brief for an extended period, leading to redness on the resident's bottom, indicating potential skin breakdown and discomfort. Similarly, Resident R29, who has moderate cognitive impairment and is incontinent of urine, was not offered toileting assistance at appropriate intervals. Observations showed that R29 was taken to various locations within the facility without being asked if toileting was needed. It was only after a significant period that staff noticed a strong urine smell and found R29's brief soaked with urine. The resident had not been toileted or checked since the morning, contrary to the care plan that requires regular checks and toileting every two hours. Both residents' care plans were not adhered to, resulting in prolonged periods without necessary toileting and incontinence care. The staff's failure to follow the individualized care plans and reattempt toileting as specified led to inadequate personal hygiene and potential health risks for the residents. The observations and interviews with staff highlighted a lack of compliance with the care plans, contributing to the deficiencies noted in the report.
Failure to Replace CPAP Supplies According to Manufacturer's Recommendations
Penalty
Summary
The facility did not ensure that a resident received necessary respiratory care and services in accordance with professional standards of practice. The resident, who has diagnoses including obstructive sleep apnea, insomnia, muscle weakness, and hypertension, uses a CPAP machine. The facility's policy requires following the manufacturer's instructions for the frequency of cleaning and replacing CPAP equipment. However, the facility failed to document or replace the resident's CPAP supplies, such as the mask, hose, headgear, air filter, and water chamber, according to the manufacturer's recommendations. The resident and their significant other expressed concerns about the lack of replacement of CPAP supplies for an extended period. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that there was no system in place to track or document the replacement of the resident's CPAP supplies. The LPN was unable to find any records indicating when the supplies were last replaced, and the DON admitted that they do not review or inspect the resident's personal CPAP machine. The facility relies on a respiratory therapist from an external provider to inspect supplies monthly, but there was no information available about the last replacement of the resident's CPAP supplies.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility did not provide written notification of transfer to the Office of State Long-Term Care Ombudsman for two residents reviewed for transfers. The facility lacked a system to ensure the Ombudsman was notified of hospital transfers, which had the potential to affect all 46 residents in the facility. This deficiency was identified during a survey when the Director of Nursing (DON) and Social Services Director (SSD) confirmed that staff were unaware of the requirement to notify the Ombudsman. One resident was hospitalized in September 2023, and the surveyor requested the Ombudsman notification on May 1, 2024. The DON confirmed that the facility had not been providing the required notifications. Another resident, who had multiple diagnoses including type 2 diabetes mellitus and chronic kidney disease, experienced a change in condition and was transferred to the emergency room. The surveyor found no documentation of Ombudsman notification for this transfer, which was confirmed by the DON.
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What surveyors actually found near you
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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 River Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Community Home | 10.1 mi | ★★★★★ | 0 | 0 |
| Ellsworth Health Services | 10.4 mi | ★★★★★ | 6 | 0 |
| Prescott Nursing And Rehab Community | 11.3 mi | ★★★★★ | 6 | 0 |
| Hammond Health Services | 11.6 mi | ★★★★★ | 3 | 0 |
| Baldwin Care Center | 13.2 mi | ★★★★★ | 11 | 0 |
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