Palace At Kendall Nursing And Rehabilitation Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observations, record reviews, and interviews; the facility's staff failed to provide privacy for one (Resident #38) out of two sampled residents during medication administration. Staff administered medications to Resident #38 in the hallway in front of the first-floor nursing station. There were 176 residents residing in the facility at the time of the survey. The findings includeObservation on 04/20/2026 at 9:20 AM revealed Staff L, a Licensed Practical Nurse (LPN) administering medications to Resident # 38 in the hallway in front of the first-floor nursing station. Staff L, LPN did not redirect or reeducate Resident #38 about privacy during medication administration.Record review of a demographic sheet revealed Residet # 38 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Encounter for surgical aftercare following surgery on the digestive system and Dementia.Record review of a Minimum Data Set reference dated 03/20/2026 revealed Resident # 38 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews the facility's staff failed to ensure that an assistive device for hearing was in place for one (Resident #70) out of two sampled residents with a hearing device. Observations showed Resident #70's prescribed hearing device was not in place, even though staff documented in the Electronic Health Records that they had applied the device. At the time of the survey, 16 residents resided in the facility that used hearing devices.The findings included: Observation on 04/20/2026 at 9:43 AM revealed Resident #70 in bed, pulling on a call light wrapped around the bed railing and biting it. Resident #70 shrugged shoulders when greeted. There were two hearing aid devices on the nightstand; one was on a charging device and the other inside a plastic bag (photo evidence). A follow up observation on 04/20/2026 at 11:48 AM revealed Resident #70 seated in a recliner in the dining area not wearing a hearing aid device. Resident #70 was not following staff directions. On…

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, records reviewed interviews facility staff did not administer oxygen therapy at the prescribed rate for one resident (Resident #81) out of one resident investigated as evidenced by Resident # 81 was observed receiving oxygen via nasal cannula at 3.5 Liters Per Minute (LPM) instead of 2 LPM. At the time of the survey, 72 residents in the facility had oxygen orders. The findings included. On 04/21/2026 at 8:20 AM, Resident #81 was observed in bed sleeping the oxygen concentrator was set at 3.5 LPM.On 04/22/2026 at 9:34 AM, Resident #81 was observed asleep with the nasal cannula in place and the oxygen concentrator was set at 3.5 LPM. Record review Resident #81's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but were not limited to: Encounter for Palliative Care; Other Viral Pneumonia; Acute Pulmonary Edema. Review of orders dated 03/10/2026 showed Oxygen at a rate of 2 Liter per Minute as needed. Change Oxygen tubing and/or mask 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.

Based on observations interviews and records reviewed the facility's staff failed to safely secure medications and biologicals on one (First floor cart one) out of three medication carts on the facility's first floor. As evidenced by medications observed unsecured on unattended medication cart one. This deficient practice increased the risk to residents' safety. The findings included. During an observation on 04/20/2026 at 8:33 AM, it was noted that medications and eye drops were left unattended on medication cart one located on the first floor. The cart was parked next to the hallway, and the nurse was in a resident's room two doors across the hallway. A resident was observed propelling in wheelchair down the hallway. (Photo evidence).On 04/20/2026 at 8:48 AM Staff B, Licensed Practical Nurse (LPN) returned to the medication cart.In an interview on 04/20/2026 Staff B, LPN, was asked about the unattended medications left on top of the cart. Staff B, LPN revealed a resident had an emergency and she should not have left the medications on top the cart unattended because anyone could…

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 did not implement effective plans of action to correct identified quality deficiencies in the problem area related to repeated deficient practices for F880 Infection Prevention and Control, as evidenced by staff failed to store respiratory equipment in a plastic bag after use for Resident #131. The findings included.Review of the facility's survey history revealed the facility was cited F880 Infection Prevention and Control during the recertification survey with an exit dated 13/03/2024.The Administrator stated in an interview on 04/23/2026 at 1:10 PM that the facility held its Quality Assurance and Performance Improvement (QAPI) meetings on the third Wednesday of every month. Committee members included the Administrator, Risk Manager/Director of Social Services/Director of Nursing, Medical Director, Infection Control/Prevention Officer, Consultant Pharmacist, and Department Heads. The QAPI team reviewed multiple data sources to identify gaps, trends, or opportunities for improvement in systems of care. These…

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 follow infection control protocol for one (Resident #50) out of two residents sampled who receive respiratory treatments as evidenced by two separate observations of Resident # 50's respiratory equipment not being stored in plastic bag after use. The findings included:Observation and interview on 04/21/2026 at 09:28 AM revealed Resident #50 in bed awake, alert and oriented a nebulizer mask noted on the bedside table was not in a plastic bag. (Photographic evidence). When asked about the nebulizer mask Resident # 50 revealed the mask had been sitting on the bedside table since 06:00 AM that morning (04/21/2026). Record review of Resident #50's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but are not limited to: Chronic obstructive pulmonary disease (COPD), wheezing and pulmonary edema. Record review of Resident #50's Care Plan for April 2026 revealed Mitigation strategies to…

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 interviews, the facility failed to follow infection control procedures and protocols for six residents (#73, #78, #14, #109, #115, #133) out of ten residents receiving enteral feedings as evidenced by observations of tube feeding connectors uncapped while feeding was not in progress. The findings include: During observation on 09/30/24 at 10:01 AM resident #73 was not in room; on the right side of the resident's bed A feeding bottle labeled [Formula Brand] was observed hanging on a pole, not in progress, and the connector tip was uncapped. Review of the medical records for Resident # 73 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Dysphagia, oropharyngeal phase. Review of the Physician's Orders Sheet (POS) for 10/01/2024 revealed the Resident #73 had orders that included but not limited to: [formula] at 50 milliliters per hour via PEG (Percutaneous endoscopic gastrostomy) x (times) 18 hours. Special…

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 update a side rails care plan for one resident with a seizure disorder (#109) out of 18 residents with padded assist rails as evidenced by a physician's order for Resident #109 with directions to keep both side rails in the up position and a care plan with interventions that included side rails to be in the down position. There were 171 residents residing in the facility at the time of survey. The findings included: On 9/30/24 at 10:25 AM Resident #109 was observed in bed with eyes open, holding a toy. Two quarter length side rails observed in the up position. The right-side rail had a blue padding attached and the left side rail had no padding. A padding was noted on the recliner near the resident. Record review of a demographic sheet for Resident #109 revealed an admission date of 5/2/24 with diagnosis that included but not limited to: seizures, psychotic disturbance, anxiety disorder restlessness and agitation. Record review of a Significant Change in Status Minimum Data Set (MDS) with a reference date 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 observations, interviews and record review the facility failed to ensure one resident (Resident #137) out of two sampled residents receive quality of care and treatment in accordance with professional standards as evidenced by observations of an undated dressing on the left side of Resident #137's face. The findings included: On 09/30/24 at 10:14 AM two surveyors observed Resident #137 in bed with a dressing on the left side of Resident #137's face that also covered the left ear with no date. On 10/01/24 at 9:49 AM two surveyors observed Resident#137 in bed with a dressing on the left side of Resident #137's face that also covered the left ear with no date. Record review of the demographic sheet for Resident#137 revealed an admission date of 7/15/2022 with diagnosis that included: Other specified disorders of left ear with left ear skin lesion and changes in skin texture. Record review of a Significant Change in Status Minimum Data Set (MDS) with a reference date of 7/15/2024 Section C (Cognitive Status) revealed a Brief Interview for Mental Status (BIMS) score of 7 on 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.

Based on observation, record review and interviews, the facility failed to provide an environment free from potential safety hazards for one resident (R#109) out of out of 18 residents with padded assist rails as evidenced by observations of two quarter side rails in the up position and one was without padding. The findings included: On 9/30/24 at 10:25 AM Resident #109 was observed in bed with eyes open, holding a toy. Two quarter length side rails observed in the up position. The right-side rail had a blue padding attached and the left side rail had no padding. There was a padding on the recliner near the resident. (see photos) On 10/01/24 at 8:57 AM, Resident #109 was observed in bed, two quarter side rails noted in the up position. The left sided rail had no padding. There was a padding on the recliner near the resident. (see photos) Record review of a demographic sheet for Resident #109 revealed an admission date of 5/2/24 with diagnosis that included: Seizure. Record review of a Significant Change in Status Minimum Data Set (MDS) with a reference date of 9/5/24 Section C…

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 ensure 1 out of 2 residents sampled for food preferences (Resident #702) was honored in his choice of food preferences during meal times. The facility had a census of 172 residents at the time of the survey. The findings included: Review of the facility's resident rights policy and procedures last reviewed January 13, 2023 revealed: The facility respect and honor resident rights. The facility informs residents about their rights and responsibilities upon admission. The facility respects the resident cultural, psychosocial, personal, and spiritual values, beliefs, and preferences, respects the resident rights to participate in decisions about his or her care, treatment, and services. Review of the facility's policy and procedures on resident food preferences revised on January 13, 2023 revealed: The purpose of the food preferences and assessment is to best meet resident's dietary needs, food habits, calorie intake, and quality of life. It…

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 accurately code the Minimum Data Set (MDS) assessment for two (Resident #13, and Resident #195) out of 3 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section O for Special Treatments, Procedures, and Programs. Oxygen therapy for Resident #13 and Hospice care for Resident #195. There were 172 residents residing in the facility at the time of this survey. The Findings Included: During observation on 05/07/23 at 09:00 AM, resident #13 was observed in the wheel chair eating breakfast, oxygen (02) was running via nasal canula (NC). On 05/08/23 at 08:24 AM, the resident was observed in bed asleep, the 02 was running at 2 liters per minute (LPM) via NC, the call light was on the bed. On 05/09/23 at 09:30 AM, the resident was observed in bed asleep, the 02 was running at the correct rate. Review of the medical records for Resident #13 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses…

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 maintain an accurate receipt of administration of controlled medications and failed to store medications for 1 out of 5 carts checked. The findings included: On 05/09/23 at 11:22 AM, during an observation with Staff C, Licensed Practical (LPN) of cart number three on the third floor. A purple pill which was Levothyroxine 75 mg was found on the bottom of the drawer below the resident's medication blister packs. Staff C placed the medication in a drug buster container and shook the bottle. During the review of the controlled medication record book for resident #176's Hydrocodone 10-325 mg (milligram) tabs controlled medication record. The record bood documented there were 28 tablets remaining, but in the blister pack there were 27. Staff C corrected the sheet that it was 27 remaining. At 5/9/23 8:51 AM, Staff had given a Hydrocodone tab to resident #176. On 05/09/23 at 01:27 PM, during an interview with Staff C, LPN. Staff C was asked, What…

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 maintain communication with hospice to ensure continuation of care for 1 (Resident #7) out of 5 residents reviewed for hospice care, as evidenced by no updated hospice communication notes available in Resident #7's medical records. This had the potential to affect the 38 residents receiving hospice care in the facility at the time of this survey. The findings included: During Observation on 05/07/23 at 08:54 AM, Resident #7 was in bed being fed by a Certified Nursing Assistant, a unilateral floor mat was at the beside. On 05/08/23 at 08:24 AM, Resident #7 was in bed asleep, no distress was noted. On 05/09/23 at 12:04 PM, resident #7 was in bed awake watching Television, no distress was noted. Record review of the facility's hospice notes revealed, the most recent documentation available for Resident #7: was on 4/3/23-Focus visit plan completed, 4/5/23 -nursing comprehensive assessment was completed. Review of the medical records for Resident #7…

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.