Kin On Health Care Center: Fall Injury Violation - WA
The incident happened on June 8, 2025. Sometime that night, the resident, identified in inspection records only as Resident 1, was found attempting to transfer herself into her wheelchair. A staff member, identified as Staff C, ran to her as her legs began buckling and guided her down to the floor. When the resident grabbed the wheelchair brakes during the descent, the chair unlocked and rolled backward. Two other staff members, Staff D and Staff E, came in after hearing the call for help and positioned themselves on either side of the resident, lifting her up while Staff C got behind her, lifted her bottom, and guided her onto the bed.
Nobody used a gait belt.
Staff C told inspectors on August 11 that they "usually use a gait belt" but didn't have time to get one because the situation required them to act fast. The resident grimaced during the transfer. The next day, she was quieter than usual. Staff C said that quietness told them she was in pain. After the transfer, staff applied pain-relieving cream to her shoulders, neck, and arm and gave her pain medication.
The Director of Nursing, Staff B, said in a July 8 interview that staff were expected to follow each resident's care plan when transferring residents, and that a gait belt should have been used with Resident 1 to help minimize injury. The administrator, Staff A, said the same thing the same afternoon: staff should follow the care plan, staff should have used the gait belt.
Both said what should have happened. Neither disputed that it didn't.
Federal inspectors cited the facility under Tag F0689, which covers accidents and supervision, at a level of actual harm, meaning inspectors determined the resident suffered real injury, not just the risk of it. The citation affects a small number of residents.
The gap at the center of this inspection is a narrow one, in the sense that the staff member who ran to Resident 1 was not indifferent. Staff C moved quickly. Staff C called for help. Staff C noticed the grimacing. Staff C noticed the quiet the next morning and connected it to pain. None of that is the conduct of someone who didn't care.
But Resident 1's care plan existed precisely for moments like June 8. A care plan that specifies how to transfer a resident, including what equipment to use, is built from that resident's particular needs, history, and vulnerabilities. When Staff C said there wasn't time to get the gait belt, they were describing the decision they made under pressure. The Director of Nursing and the administrator, interviewed more than a month later in a controlled setting, both said the belt should have been used regardless.
The inspection report does not describe the nature or severity of Resident 1's injury beyond the pain she experienced during the transfer and the day that followed. It does not say whether she required medical treatment beyond the cream and medication staff applied that night. What it records is that she was in enough pain that a staff member who knew her recognized the change in her behavior and understood what it meant.
She was quieter than usual. That was how it showed.
Kin On Health Care Center is a skilled nursing facility in Seattle. The complaint inspection was conducted on August 11, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kin On Health Care Center from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 26, 2026 · Our methodology
KIN ON HEALTH CARE CENTER in SEATTLE, WA was cited for violations during a health inspection on August 11, 2025.
The incident happened on June 8, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.