Nspire Healthcare Kendall

Based on observation, record review and interviews the facility failed to properly store medications in two out of two medication rooms as evidenced by an expired emergency kit in the North medication room and a thermometer reading of 52 degrees Fahrenheit in the South medication room. The findings include:Observation on 06/02/2026 at 9:41 AM in the North Medication Room revealed an expired emergency drug kit with an expiration date of 12/25. Photo evidence.Interview on 06/02/2026 at 9:45 AM Staff A, Unit Manager stated: The unit managers are in charge of checking for any expired medications and supplies in the medication room.Observation on 06/02/2026 at 9:51 AM in the South Medication Room, revealed the refrigerator temperature log last signed on 06/02/2026 documented a temperature of 38 degrees Fahrenheit. Further observation revealed the refrigerator contained insulin and the thermometer in the refrigerator indicated a temperature of 52 degrees Fahrenheit. Photo evidence.During an interview on 06/02/2026 at 09:55 AM, the Director of Nursing (DON) stated: We defrosted all the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility did not consistently store, prepare, distribute, and serve food in a sanitary manner within the kitchen and nourishment rooms. This was evidenced by the presence of undated, unlabeled, and expired food items and dietary staff not wearing required hair restraints, including beard guards, during food preparation. There were 117 residents residing in the facility at the time of the survey The findings included: During a tour on 06/01/2026 at 9:53 AM, with the Corporate Kitchen Manager and the facility's Kitchen Manager an opened container of apple juice was noted in a reach-in refrigerator with an open date of 04/10/2026; there was also a clear plastic type pitcher with contents identified as coffee which had no preparation or discard date with a printed sticker indicating: SUN/[NAME]/[NAME]. Additionally, an undated bag of bread was observed in the dry storage area. Observation on 06/02/2026 at 9:46 AM in the North…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to demonstrate or implement effective plan of actions to correct identified quality deficiency in the problem area related to repeated deficient practice for F761- Label/Store Drugs and Biologicals as evidenced by an expired emergency kit and thermometer reading 52 degrees Fahrenheit found in medication rooms during observations on a recertification survey ending [DATE]. There were 117 residents in the facility at the time of survey. Record review of the facility's survey history revealed, during a recertification conducted on [DATE], through [DATE], the facility was cited F761- Label/Store Drugs and Biologicals as the facility failed to ensure proper storage of medications. Review of the facility's policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan undated states: Nspire of Kendall's QAPI program encompasses all areas that impact quality of care, quality of life, resident choice and care transition with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews the facility failed to implement quality of care and service related to a trial for removal of restraints for one resident (Resident #47) out of eight sampled residents as evidenced by; a trial removal of restraints was initiated without a physician's order. There were 110 residents residing in the facility at the time of the recertification survey. The findings included: Record review of the matrix revealed Resident #47 used restraints. On 11/19/24 at 8:48 AM Resident t#47 was observed in bed with eyes closed; the mattress appeared concave. A belt with fastener was observed on a wheelchair next to bed. Record review of a demographic sheet for Resident #47 revealed an admission date of 5/15/2020 with diagnosis that included: Cerebral Infarction. Record review of Resident #47's physicians' orders revealed an order dated 5/22/24 with directions: Soft [fastener brand] belt while in wheelchair when in wheelchair to maintain seating position and minimize risk of falling out of chair release at mealtimes and during personal care every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews the facility failed to provide a safe environment for one resident (Resident #46) out of eight residents sampled as evidenced by an observation of four shaving razors on Resident#46 nightstand. The findings included: Observation on 11/18/24 at 9:20 AM Resident #46 was in bed awake, alert; four disposable shaving razors were in a cup on the nightstand. (photo evidence) Resident#46 stated, I shave myself and the staff give me the razors. On 11/18/24 at 9:23 AM, Staff B, Registered Nurse (RN) was asked what the facility's policy and procedure for shaving residents is and if residents are permitted to keep shaving razors in their room. Staff B, RN replied, Residents are not able to keep razors in their rooms. When residents need to be shaved, the Certified Nursing assistants (CNA) gives the residents the razors and when done, places the used razor inside the sharps container. When I do rounds, I check to make sure the residents are safe. If there is a razor in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews, the facility failed to administer oxygen as prescribed for one resident (Resident #83) out of eight sampled residents, as evidenced by observations of Resident #83 without oxygen in progress. The findings Included: During an Observation on 11/19/24 at 9:31 AM Resident #83 was lying in bed with eyes closed; the there was a nasal cannula on top of a pillow next to the resident and the oxygen concentrator at bedside was running at 2 liters per minute (L/min). On 11/19/24 at 9:31 AM am an interview was held with Resident#83's daughter and who revealed the resident#83 doesn't require continuous oxygen. On 11/20/24 at 2:48 PM Resident #83 observed in the dining room area participating in activities with no oxygen in progress. Record review of Resident #83's demographic face sheet revealed an admission date of 07/15/2024 and readmission of 10/31/2024 with diagnosis that included: Heart Failure, Cerebrovascular Disease, unspecified/Pleural Effusion. Review of Resident #83's Physician Orders revealed an order for: Oxygen at a rate of two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to properly store medications for four residents (Resident #53, Resident #313, Resident #314, and Resident #315) and one medication cart out of three sampled medication carts as evidenced by pills, eye drops, ointments and nasal sprays at the bedside of residents and an expired Moxifloxacin eye drop on the North 2100 medication cart. There were 110 residents residing in the facility at the time of recertification survey. The findings included: Observation on [DATE] at 9:29 AM revealed a tubing labeled, Triamcinolone at Resident # 53's bedside (photo evidence). On [DATE] at 9:50 AM two eye drops were observed at Resident #313's bedside. (photo evidence) On [DATE] at 10:26 AM two eye drops, a nasal spray and two small circular pink colored pills inside a cup were observed at Resident # 314's bedside. (photo evidence). On [DATE] at 9:56 AM an ointment and two nasal sprays were observed at Resident #315's bedside. (photo evidence). On [DATE] at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews, the facility failed to follow infection control protocol in the laundry room. As evidenced by observation of lint traps that were not cleaned, the lint log indicated lint traps were cleaned every two hours and was signed daily at 5:00 AM although laundry staff start at 6:00 AM. The findings included: On 11/21/24 at 11:00 AM a laundry tour was conducted with Maintenance and Housekeeping Director, Staff A, Laundry staff. During the tour, there were two working dryers with 75-pound capacity each. The surveyor asked if there was a lint log kept in the laundry room to indicate when the traps were last cleaned. The Maintenance and Housekeeping Director stated, There is a lint log to show when staff clean the traps. The Maintenance and Housekeeping Director gave the surveyor a lint log sheet. The Lint log was reviewed, and it was noted that it was last signed at 7:00 AM on 11/21/24 (photo evidence). Both dryers were in progress. The Maintenance and Housekeeping Director opened the dryers and both lint traps were noted to be full of lint.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to treat one resident (Resident #18) out of one resident with dignity and respect who was observed during dining, as evidenced by staff member standing while feeding the resident. This deficient practice had a potential to affect the health and wellbeing of all 39 residents who are dependent with eating. The findings included: Observation of resident #18 on 08/06/2023 at 12:34PM revealed, the resident sitting up in bed, Staff A, Certified Nursing Assistant (CNA) started to set up the lunch tray and open containers. Staff A was observed feeding the resident and standing by the resident's bed. Interview with Staff A, (CNA) on 08/06/2023 at 12:45 PM. She stated that she never grabs a chair and sits to feed the resident. She stated it doesn't matter if she's standing when feeding the resident. Record review of Demographic Face sheet revealed, resident # 18 was admitted on [DATE] and discharged on 08/08/2023 with diagnoses to include Metabolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to electronically transmit the Quarterly Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) System within 14 days after completing the resident's assessment for one out of one sampled resident (Resident # 43 ) reviewed for timely submissions of resident assessments. Findings included: Review of the resident #43's MDS Quarterly assessment revealed a completion date of 05/10/2023 but the MDS had not been submitted. During an interview with Staff C, the MDS Coordinator, on 08/09/23 at 09:38 AM, Staff C stated, What happened is someone put do not submit. I've only been here since March 2023. The person that was before me, always put do not submit or maybe that's how the system was set up. I don't know why they do that. Maybe because the resident was Medicare Part A, and he changed his insurance to another insurance. I don't know what really happened. Up here it says do not submit to CMS. It was completed. I'm going to submit it now. On 08/09/23 at 09:53 AM, a review of the resident MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow pharmaceutical procedures for Residents (#44, #295) as evidenced by medications being left on the overbed table for Resident #44, Omission of one (1) medication for Resident #295 during the medication administration observation and two (2) loose pills found in the medication drawer of North Station 2100 Hall cart. Three residents were observed for medication administration totaling 29 opportunities. Three medication carts and One medication storage room was observed. There were 116 residents residing in the facility at the time of the survey. The Findings included: During an observation on 08/06/23 at 12:17 PM, Resident #44 was observed in the room about to have lunch, several pills observed in a medication cup on the resident's overbed table (Photographic evidence obtained). Resident #44 was unable to communicate properly, has a speech impediment, is hard of hearing and speaks primarily Spanish. Resident #44 refused to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident was free of a significant medication error, as evidenced by Resident #295 Extended Release (ER) blood pressure medication being crushed by the nurse to be administered to the resident during the medication administration observation. Three residents were observed during medication administration totaling 29 opportunities. There were 116 residents residing in the facility at the time of the survey. The findings included: During the medication administration interview/observation on 8/7/23 at 10:05AM with Staff D, Licensed Practical Nurse recorded the resident's Blood pressure 118/45, dispensed medications from the bingo cards, crushed all the resident's medications, mixed with apple sauce, proceeded to enter resident's room to give the resident medications. The Surveyor requested the nurse to return to medication cart. Staff D was asked to check the Nifedipine ER 30 MG tablet, Staff D stated the ER means extended release…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F640 Encoding/Transmitting Resident Assessments and F755 Pharmacy Services/Procedures/Pharmacist/Records. This practice has the potential to increase the risk of negative resident outcomes and affect all 116 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with an exit date 07/28/2022, Encoding/Transmitting Resident Assessments was cited related to the facility failed to timely transmit an Minimum Data Set (MDS) assessment for one resident reviewed for timely submissions of resident assessments and failed to provide pharmacy services to meet the needs of the residents. Review of the facility's policy titled, Performance Improvement Quality Assurance/Quality Improvement (QAPI)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.