Kinder Retirement and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Kinder Retirement and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jan 29, 2024

  Based 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. […]

• Immediate jeopardy, patternF600Jan 25, 2023

  Based on interview and record review the facility failed to ensure 2 residents' (#3 and #5) rights to be free from abuse by facility staff in a sample of 5 residents (#1, #2, #3, #4 and #5). The facility failed to Protect Resident #3 from verbal abuse by S15 CNA, and failed to immediately protect Resident #5 from unwanted, non-consensual sexual contact by Resident #1. This deficient practice resulted in an Immediate Jeopardy situation on 12/07/2022 at 3:55 p.m. when S16 CNA reported witnessing S15 CNA telling Resident #3, a moderately cognitively impaired resident, that her vagina stinks, she is gross, she hopes she dies, and she hopes she would fall out of the lift. […]

• Immediate jeopardy, patternF835Jan 25, 2023

  Based on record review and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and protect Resident #3 from verbal abuse by staff, and protect Resident #5 from sexual abuse by a resident, in a sample of 5 (#1, #2, #3, #4 and #5). The facility's administration failed to: 1. Protect Resident #3 from verbal abuse by S15 CNA; 2. Protect Resident #5 from sexual abuse by Resident #1 and ensure staff (S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary) implemented the facility's Abuse Preventions and Investigation Policy, and immediately intervene while watching Resident #5 being sexually abused by Resident #1; 3. […]

• No harm, potential for more than minimal, patternF605Aug 6, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF658Aug 6, 2025

  Based 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. Findings: Review of an undated facility policy titled, Medications-Controlled Substances revealed the following in part.All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. […]