Kinder Retirement and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents with an order for psychotropic medication were not subjected to chemical restraints for 7 (#9, #12, #13, #24, #25, #60, and #73) of 11 (#5, #8, #9, #10, #12, #13, #24, #25, #26, #60, and #73) residents reviewed for unnecessary medications. The facility failed to:Ensure PRN orders for psychotropic medication were limited to 14 days for Residents #9, #12, #13, #25, #60, and #73; andEnsure Resident #24 was free from chemical restraints imposed for discipline or convenience. Resident #12 Review of Resident #12’s medical record revealed an admission date of 07/17/2025 with diagnoses which included Spinal Stenosis and Pain. Review of Resident #12’s physician’s orders revealed the following, in part… 07/17/2025 Morphine Sulfate 30mg tablet by mouth every 12 hours as needed for pain. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all care and services were provided according to accepted standards of clinical practice. The facility failed to document appropriately in Resident #25's medical record the administration of controlled medications. Total sample size was 32.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided to a resident who requires such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #25) of 2 (Resident #9 and Resident #25) sampled residents reviewed for pain. The facility failed to ensure Resident #25, who reported pain, received a thorough pain assessment and medication or interventions to alleviate the pain.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of residents for 1 (Resident #25) of 32 sampled residents. The facility failed to provide pain medications and/or biologicals to Resident #25, who complained of pain.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: Nursing carts were free of loose pills for 1 (Cart C) of 2 (Cart B and Cart C) carts reviewed; Medications were labeled with the date they were opened; Expired medications were not available for use on 1 (Cart C) of 2 (Cart B and Cart C) medication carts reviewed; and Expired medications were not available for use in 1 (Room X) of 1 medication room reviewed. Observation of Cart C on 08/05/2025 at 12:14 p.m. with oversight from S7 LPN revealed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #60) resident. The total sample size was 32 residents. Review of Resident #60's admission MDS with an ARD of 07/18/2025 revealed Resident #60 was not taking an opioid medication. Review of Resident #60's physician's orders revealed Oxycodone 5mg capsule by mouth every 6 hours as needed ordered on 07/15/2025. Review of Resident #60's 07/2025 MAR revealed Oxycodone 5mg was administered on 07/16/2025 and 07/17/2025. Interview with S8LPN on 08/06/2025 at 1:11 p.m. revealed Resident #60 received Oxycodone 5mg on 07/16/2025 and 07/17/2025. S8LPN confirmed Resident #60's admission MDS with an ARD of 07/18/2025 did not accurately reflect the resident's status, but should have.

Inspectors wroteBased on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff decontaminated reusable medical equipment between residents. Observation on 08/05/2025 from 8:00 a.m. until 8:50 a.m. revealed S7 LPN using a wrist blood pressure (BP) cuff to monitor the BP of multiple residents. The BP cuff was not decontaminated between uses on different residents. Interview with S7 LPN on 08/05/2025 at 8:50 a.m. confirmed she did not decontaminate the wrist BP cuff between uses on residents, but should have. Observation on 08/06/2025 from 8:35 a.m. until 8:55 a.m. revealed S5 LPN using a wrist BP cuff to monitor the blood pressure of a resident. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an accurate account of controlled drugs for 2 residents (#5 and #6) of 7 sampled residents (#1, #2, #3, #4, #5, #6 and #7). The facility had a total census of 73 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure that items in the Medication Carts were properly stored by: 1. Having loose pills in all 3 medication carts. 2. Failing to remove discontinued controlled medications from Medication Cart B. There was a total of 73 residents residing in the facility.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure licensed nurses had the appropriate competencies and skill sets to provide nursing services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being as evidenced by the failure to ensure two transcribed verbal narcotic medication orders included the strength of the drug, failure to ensure two written narcotic orders were correctly entered into the electronic medical record, failure to ensure electronic narcotic medication orders included valid dosing instructions, failure to ensure dosing of narcotic medication on narcotic sign-out log matched dosing information on Medication Administration Record, and by failing to ensure all narcotic medication doses signed out on Narcotic Medication Record were documented as given on Medication Administration Record for 1 [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure responsible party notification was documented in the medical record of a resident who was tranferred to the hospital for 1 (#12) of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) sampled residents. The total facility census was 75 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 51 residents that received regular diets prepared by the facility kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure pureed foods were prepared according to the approved recipe by methods, which conserved nutritional value for 7 residents that are served pureed diets by the facility's kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (Resident #10) out of 21 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as possible, by failing to ensure hot water temperatures were not greater than 120 degrees Fahrenheit on 3 of 3 halls (Hall A, Hall B, and Hall C). This deficient practice resulted in an Immediate Jeopardy situation on 01/23/2024 at 11:29 a.m., when hot water temperatures were observed to be 122 degrees Fahrenheit to 148 degrees Fahrenheit in the following rooms: 1. Hall A - Bathrooms sinks in Room A, the adjoining bathroom of Rooms B and C, and Room M; 2. Hall B - Bathroom sinks in the adjoining bathroom of Rooms D and E, the adjoining bathroom of Rooms F and G, and the adjoining bathroom of Rooms H and I; and 3. Hall C - Bathroom sink in the adjoining bathroom of Rooms J and K. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive assessment which included the resident's cognitive patterns and mood as required for 1 (Resident #16) of 39 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to conduct a quarterly MDS assessment timely using the quarterly review instrument for 2 (Resident #8 and Resident #58) of 39 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order was implemented as required in the person centered plan of care for 2 (Resident #41 and Resident #43) of 39 sampled residents. The facility failed to ensure Resident #41 received an initial dose of Levaquin timely. The facility failed to ensure Resident #43 received an initial dose of Azithromycin and Prednisone as ordered for 5 days.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a resident received the necessary care and services in accordance with the resident's comprehensive assessment and professional standards of practice for 1 (Resident #61) of 2 (#57, #61) residents reviewed for skin conditions out of a total sample of 39 residents. The facility failed ensure a weekly wound assessment was completed on 2 wounds for Resident #61 and failed to assess and immediately consult with the physician after a new wound was found for Resident #61.