Palace at Kendall Nursing and Rehabilitation Cente

In the surveyor’s words

From the most serious findings on record at Palace at Kendall Nursing and Rehabilitation Cente, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Oct 3, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF583Apr 23, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF685Apr 23, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF695Apr 23, 2026

  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]. […]

• No harm, potential for more than minimal, isolatedF761Apr 23, 2026

  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. […]