Kendall House Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Kendall House Wellness & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 24, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents and injury for 1 (Resident #1) of 4 residents reviewed for accidents and supervision as evidenced by: The facility failed to provide adequate supervision and assistance to Resident #1 resulting in Resident #1 receiving a 1st degree burn (a burn affecting the top layer of skin) to her hand and a 2nd degree burn (a burn affecting the top layer of skin, the next layer below it and often causes blisters to the skin) to her thigh after spilling coffee on herself. An Immediate Jeopardy (IJ) was identified on 11/22/2024 at 3:10 p.m. The IJ template was provided to the facility on [DATE] at 3:38 p.m. […]

• No harm, potential for more than minimal, widespreadF727Apr 22, 2021

  Based on observations, interviews and record reviews the facility failed to designate a registered nurse to serve as the Director of Nursing on a full-time basis for 1 of 1 facility reviewed for registered nurse coverage, in that: The Director of Nurse's was terminated on 4/2/2021 and as of 4/21/2021 there was no designated Director of Nurses. This deficient practice placed residents at risk for harm for a decline in health status, by not having a Director of Nursing with the training and experience with nursing oversight. The findings: Observation on 4/19/2021 at 10:00 a.m. revealed no Director of Nurses (DON) was designated for the facility. Interview on 4/19/2021 at 10:00 with the Administrator confirmed the DON was terminated on 4/2/2021 and no DON has been designated for the vacancy. […]

• No harm, potential for more than minimal, patternF812Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen and 1 of 3 residents' (Resident #8) refrigerators in accordance with professional standards for food service safety. The facility failed to ensure sanitizing buckets were not near foods. The facility failed to ensure foods in residents' refrigerators (to include Resident #8) were kept at a temperature for safe food consumption. These failures could place residents at risk for food borne illness. The findings included:Observation and interview on 01/22/26 at 10:41AM revealed there was a bag of yellow corn meal next to two sanitation buckets. The CDM revealed yellow corn meal should not be next to sanitation buckets. […]

• No harm, potential for more than minimal, patternF655Oct 11, 2024

  Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 4 of 16 residents (Residents #15, 27, 80,10) reviewed for baseline care plans. 1. The facility failed to ensure Resident #15's baseline care plan reflected interventions for falls. 2. The facility failed to ensure Resident #27's baseline care plan reflected interventions or problems for falls until 10/08/24 when the resident scored a high risk for falls on 09/18/24, when Resident #27 was admitted . 3. The facility failed to ensure Resident #80's baseline care plan did not address falls. 4. […]

• No harm, potential for more than minimal, patternF755Oct 11, 2024

  Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of eight residents (Residents #20) reviewed for medications and pharmacy services. The facility failed to administer Resident #20's Midodrine (treat low blood pressure) according to doctor's orders. This failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status, including low and high blood pressure, falls, disorientation and physical discomfort. […]