Kendall Lakes Healthcare and Rehab Center

In the surveyor’s words

From the most serious findings on record at Kendall Lakes Healthcare and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Jun 16, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF550Apr 18, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF755Apr 18, 2024

  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… […]

• No harm, potential for more than minimal, isolatedF921Apr 18, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF584Dec 8, 2022

  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. […]