Kendall Lakes Healthcare And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review an interviews, the facility failed to provide adequate supervision for one (Resident #1) out of three residents sampled for elopement; as evidenced by on 04/05/2025 Resident #1 a vulnerable resident left the facility undetected through the facility's first floor exit/entrance door; Resident #1 was found on the sidewalk several blocks from the facility by the local law enforcement and returned to the facility within twenty (20) minutes after last seen in the facility by staff. There were 139 residents residing in the facility at the time of the survey. The findings included: The facility's location is in a residential neighborhood with busy cross streets and close to a shopping plaza located 0.1 mile from the facility. The temperature on 04/05/2025 was 88 degrees Fahrenheit. according to https://www.accuweather.com. Review of the facility policy titled Elopements revision date 12/2002 states: Staff shall investigate and report on all cases of missing residents. Policy…

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, interview, and record review the facility failed to promote residents' dignity and respect during dining for two (Resident #62, Resident #380) out of 33 sampled residents. As evidenced by facility staff observed standing while feeding residents who required assistance with meals. The findings included: 1) On 04/17/24 at 01:18 PM during dining observation of residents, surveyor observed the Speech Therapist (Staff A) standing while feeding Resident #62. Speech therapist (Staff A) was asked why he was standing while feeding the resident, Staff A stated he was not aware that he was not allowed to stand and feed the resident, he immediately got a chair that was in the room, placed it close to the resident's bedside and continued to feed the resident. Interview on 04/18/24 at 09:22 AM. The Director of Nursing (DON) stated all staff including the rehabilitation department have been trained and are aware that they are supposed to be sitting down while feeding the residents. Currently I am providing further education and in-service to the staff regarding feeding…

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 pharmacy procedures were followed as per facility policy and medication reconciliation procedures were followed for one out of four medication carts observed/reviewed. There were 139 residents residing in the facility at the time of the survey. The findings included: On 04/17/24 at 10:01 AM during routine observation the surveyor observed the 400 Unit Medication Cart # 1, computer screen opened to resident's medication screen and the medication cart was unlocked in the 400-406 hallway, no staff in attendance at the cart; surveyor went looking for the assigned Registered Nurse (Staff C), Staff C was found in front of room [ROOM NUMBER], and stated she was sorry the cart was left unlocked and unattended, and it was her mistake. On 04/17/24 at 11:50 AM During medication cart observation with Registered Nurse (Staff D) assigned to the 500-unit Medication Cart #3. The narcotic count for Resident #87 was incorrect-The count on the bingo…

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, interview, and record review the facility failed to ensure the lint screens for two out of three dryers observed in the laundry room were cleaned as per facility protocol. There were 139 residents residing in the facility at the time of the survey. The findings included: On 04/17/24 at 09:23 AM during an observational tour of the laundry area by two surveyors on the team with the facility's Infection Preventionist (Staff B) and the Director of housekeeping, the lint screens of two out of three clothes dryers were checked and observed covered in a thick layer of lint. Each dryer has a load capacity of 150 pounds and was in working order. On 4/17/24 at 9:40AM, the Director of housekeeping acknowledged that the lint screens for the two dryers were full of lint and was not cleaned, the lint log posted on the wall opposite the dryers documented-the lint screens were last cleaned on 4/17/24 at 9:00 AM. The Director of Housekeeping stated that the dryer lint screens are supposed to be cleaned every hour by the staff on duty. Review of the undated facility policy…

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 and interview, the facility failed to maintain a quiet homelike environment for 1 of 3 sampled residents for oxygen use (Resident #117). The findings included: Resident #117 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive one-person assist with activities of daily living, and required the use of oxygen. An observation of the 500 unit was conducted on 12/05/22 at 10:00 AM. A loud humming noise was heard coming from Resident #117's room. Upon entering Resident #117's room, surveyor observed the resident receiving oxygen by nasal cannula. Further observation revealed the loud noise was coming from the oxygen concentrator (device that delivers oxygen). An interview was conducted with Staff G, a Licensed Practical Nurse, on 12/05/22 at 12:00 PM. Surveyor was walking down the 500 unit hallway with Staff G. Staff G acknowledged the loud humming sound heard in the hallway was coming from…

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 interviews, observations, and record review, the facility failed to aid during dining for 1 of 1 sampled resident reviewed for Activities of Daily Livings (ADLs) (Resident #111). The findings included: In an observation conducted on 12/06/22 at 8:00 AM, Resident #111 was noted eating her breakfast tray with no staff in the room. At 8:10 AM, Resident #111 was still eating with no assistance from staff and consumed about 50 percent of her breakfast meal. In an observation conducted on 12/06/22 at 12:04 PM, Resident #111 was in the room with the lunch tray at her bedside, and no staff was noted. At 12:15 PM, she ate 10% of her lunch meal, and no staff member was in the room to assist her with her lunch. Continued observation at 12:20 PM showed that she ate 25% of her meal with no staff in the room. (photographic evidence obtained) A chart review showed that Resident #111 was admitted on [DATE] with diagnoses of Dysphagia, Dementia, and Anemia. The MDS (Minimum Data Set) dated 09/05/22 showed that under…

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 the facility failed to ensure proper use of splints per physician's order for 2 of 3 residents reviewed for splints (Resident #74 and 122). The findings included: 1) During the initial tour of the facility conducted on 12/05/22 at 9:40 AM, the surveyor noted Resident #74 was wearing splints on both of her hands while lying in bed. Clinical records revealed Resident #74 was admitted to the facility on [DATE]. Resident #74 had a medical history significant for Parkinson's disease, fibromyalgia, depression, anxiety, dementia, and contractures of her hands and ankles. A Quarterly Minimum Data Set (MDS) was done on 09/20/22. This MDS documented Resident #74 had a Brief Interview of Mental Status (BIMS) score of 5, which indicates she had severe cognitive impairment. This MDS also documented Resident #74 required extensive assistance from staff for all activities of daily living. Review of Resident #74's Care Plans revealed there was a care plan in place regarding…

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 reviews, the facility failed to follow tube feeding orders for 1 out of 7 sampled residents reviewed for tube feeding (resident #58). The findings included: A review of the facility ' s policy titled Enteral Tube Feeding via Continuous Pump, revised in March 2115, showed to position the head of the bed at 30-45 degrees for feeding unless medically contradicted. It further showed to check the label on the enteral formula against the physician's order. A review of the Physician's orders for Resident #58 revealed a Physician's order dated 07/25/22 for tube feeding Osmolite 1.5 (formulary type) at 60 milliliters (ml) per hour for 20 hours via peg tube, held from 8:00 AM to 1:00 PM. Another order dated 06/18/22 to elevate the Head of the bed at least 30-45 degrees while feeding is in progress. In an observation conducted on 12/05/22 at 9:15 AM, Resident #58 was noted in bed. Closer observation showed a tube feeding that was on hold with Osmolite 1.5 at 60 ml an hour and…

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, the facility failed to follow Physician's orders and failed to update dialysis care plan for discontinued fluid restrictions for 1 out of resident reviewed for dialysis (Resident #47). The findings included: Review of the facility's policy titled Policy and Procedure: Fluid Restrictions dated 08/07/20, included the following: Fluid restrictions may be utilized to assist in controlling body fluid balance, when a resident's clinical condition warrants. Fluid is only restricted when clinically necessary, and for a limited time, when possible, to preserve resident quality of life. A specific physician's order for the amount of fluids to be provided in a 24-hour period is required. When an order is received for fluid restriction, the dietary manager or dietician confers with the nursing department to determine how much fluid each department is to provide. This is based on the number of medications ordered, as well as the total fluid volume permitted. The Food…

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, interviews, and record reviews the facility failed to ensure proper storage of medications for Resident #26 and 69. The findings included: Review of the facility policy titled Storage of Medications, revision date 08/2020 revealed the following: Medications and biologicals are stored safely, securely, and properly. Also, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. 1) During the initial tour of the facility conducted on 12/05/22 at 9:25 AM, the surveyor found a bottle of prescription shampoo in the bathroom of Resident #26 (photographic evidence obtained). A review of Resident #26's record revealed a Quarterly Minimum Data Set (MDS) was done on 10/27/22. This MDS documented Resident #26 had a Brief Interview of Mental Status (BIMS) score of 13, which indicates she had mild cognitive impairment. This MDS also documented Resident #26 required extensive assistance from staff members for personal hygiene and transfers-this indicates she was unable to shower herself. Review of…

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 and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, including holding cold foods at regulatory temperature and using personal items in the food production area. The findings include the following: In a tour of the central kitchen conducted during lunch tray line observation on 12/07/22 at 11:35 AM, the following was noted: 1. The facility's Certified Dietary Manager was observed using the facility's calibrated thermometer. The temperature of a tossed salad was taken and showed to be at 60.4 degrees Fahrenheit, and another tossed salad showed a temperature of 59.3 degrees Fahrenheit. This had the potential to affect the other 13 tossed salads that were noted in the reach-in refrigerator. (photographic evidence obtained) 2. The facility's Certified Dietary Manager was observed using the facility's calibrated thermometer. The temperature of the fruit salad was taken and showed to be 55.7 degrees Fahrenheit, and another fruit salad showed a…

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.