Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kendall Lakes Healthcare And Rehab Center during CMS and state inspections, most recent first.
A resident, who was cognitively intact and ambulatory, left the facility undetected through the main exit and was found several blocks away by law enforcement. Staff last observed the resident in a common area before realizing the absence after being contacted by police. The facility's policies required prompt reporting and investigation of missing residents, but staff checks were only performed every hour to hour and a half, leading to a lapse in supervision and a deficiency for not maintaining an environment free of accident hazards.
A resident, who was cognitively intact but required partial assistance to walk and was on multiple medications, left the facility undetected and was found several blocks away by police. Staff did not observe the resident for approximately 20-30 minutes before the elopement was discovered. The incident revealed a failure to provide adequate supervision and to implement appropriate elopement prevention measures as required by facility policy.
The facility failed to promote residents' dignity during dining by allowing staff to stand while feeding two residents. One therapist was unaware of the protocol, while another believed it was acceptable to stand to assess the resident's abilities. The DON confirmed that staff should be seated while assisting with meals and planned further education.
The facility failed to follow pharmacy procedures and medication reconciliation policies. An RN left a medication cart unlocked and unattended, and another RN recorded an incorrect narcotic count for a resident's medication. The resident had orders for Dilaudid to manage moderate pain.
The facility failed to clean the lint screens for two out of three dryers in the laundry room as per protocol. During an observational tour, surveyors found the lint screens covered in a thick layer of lint, despite the lint log indicating they were cleaned earlier that day. The Director of Housekeeping acknowledged the oversight.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident left the facility undetected through the first floor exit/entrance door and was found several blocks away by local law enforcement. The resident was last seen by staff in the common room in front of the nursing station, and staff became aware of the resident's absence only after being notified by the police. The facility is located in a residential neighborhood with busy cross streets and is close to a shopping plaza. At the time of the incident, the temperature was 88 degrees Fahrenheit. The resident involved was cognitively intact, ambulatory without assistive devices, and required partial assistance to walk 10 feet. The resident had been admitted for therapy and was receiving antipsychotic, antidepressant, and antiplatelet medications. On the day of the incident, the resident was able to leave the facility after being told by a therapist that no therapy sessions were scheduled. The resident then left the premises without staff knowledge and was later found by police, who identified him by his bracelet and contacted the facility. Facility policy required staff to promptly report any resident suspected of being missing and to investigate all incidents. However, staff interviews revealed that the resident was last seen approximately 20-30 minutes before being found outside, and routine checks were performed only every hour to an hour and a half. The incident was documented in the facility's abuse/neglect log, and the resident was assessed upon return, showing no signs of injury or distress. The deficiency was cited for failure to provide adequate supervision and ensure the environment was as free of accident hazards as possible.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. F689 Free of Accident Hazards/Supervision/Devices (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents - Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. All residents already identified at risk for elopement were checked for wander guard placement and proper functioning. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By 04/05/2025, the Director of Nursing/designee reviewed and updated elopement binders; ensured binders were current and placed at each nursing station, therapy department, activity department, kitchen, & front desk. Elopement binders were updated when necessary. By 04/05/2025, the Maintenance Director/designee checked all exit doors for proper functioning to include transponder for wander guard system. Daily audits of doors for proper functioning were completed for three days, followed by weekly audits. On 04/05/2025, the Clinical Educator/designee initiated education of all staff on the facility's Elopement standard and guidelines, ANEMMI with an emphasis on Neglect, Alarm Response, and Wander Guard placement and functioning. Newly hired staff will receive this education during orientation. Education continues monthly. On 04/05/2025, the Clinical Educator/designee initiated elopement drills for all staff participation. Drills will be completed on each shift, then move to monthly rotating each shift. On 04/05/2025, a single point of entry was set up at the front doors in the reception area. The front doors were set to remain locked at all times. To gain access, any non-employee will need to ring the doorbell for entry. Once inside, every non-employee must sign in into the visitor's log. Everyone leaving the building must do so from the front door and be let out by the receptionist or be escorted out by a staff member with a fob. Single point of entry and these entry and exit procedures continue to be in place. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator/designee will conduct a weekly Quality Review audit of residents for 4 weeks, then every 2 weeks for 2 months to ensure compliance that supervision is adequate and interventions are appropriate, when necessary. Findings will be reported at the monthly QA/Risk Management meeting. These Quality Reviews will be reported until the committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Operations/designee when completing their Quality Systems Review to maintain compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. N110 FAC Physical Environment-Safe, Clean, Homelike (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. F689 Free of Accident Hazards/Supervision/Devices (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents - Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. All residents already identified at risk for elopement were checked for wander guard placement and proper functioning. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By 04/05/2025, the Director of Nursing/designee reviewed and updated elopement binders; ensured binders were current and placed at each nursing station, therapy department, activity department, kitchen, & front desk. Elopement binders were updated when necessary. By 04/05/2025, the Maintenance Director/designee checked all exit doors for proper functioning to include transponder for wander guard system. Daily audits of doors for proper functioning were completed for three days, followed by weekly audits. On 04/05/2025, the Clinical Educator/designee initiated education of all staff on the facility's Elopement standard and guidelines, ANEMMI with an emphasis on Neglect, Alarm Response, and Wander Guard placement and functioning. Newly hired staff will receive this education during orientation. Education continues monthly. On 04/05/2025, the Clinical Educator/designee initiated elopement drills for all staff participation. Drills will be completed on each shift, then move to monthly rotating each shift. On 04/05/2025, a single point of entry was set up at the front doors in the reception area. The front doors were set to remain locked at all times. To gain access, any non-employee will need to ring the doorbell for entry. Once inside, every non-employee must sign in into the visitor's log. Everyone leaving the building must do so from the front door and be let out by the receptionist or be escorted out by a staff member with a fob. Single point of entry and these entry and exit procedures continue to be in place. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator/designee will conduct a weekly Quality Review audit of residents for 4 weeks, then every 2 weeks for 2 months to ensure compliance that supervision is adequate and interventions are appropriate, when necessary. Findings will be reported at the monthly QA/Risk Management meeting. These Quality Reviews will be reported until the committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Operations/designee when completing their Quality Systems Review to maintain compliance.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident left the facility undetected through the first floor exit/entrance door and was found several blocks away by local law enforcement. The resident, who was cognitively intact but required partial assistance to walk and was receiving antipsychotic, antidepressant, and antiplatelet medications, had been admitted to the facility less than a month prior. On the day of the incident, the resident was last seen by staff in the common room in front of the nursing station and was later reported missing. The facility is located in a residential neighborhood with busy cross streets and a nearby shopping plaza, increasing the risk associated with unsupervised elopement. Facility policy required staff to promptly report and investigate all cases of missing residents, and to attempt to prevent departures in a courteous manner. However, staff interviews revealed that the resident was not observed for a period of approximately 20-30 minutes before being found by police. The resident was able to provide personal information to law enforcement, who contacted the facility and returned the resident. Documentation indicated that the resident was alert, oriented, and in good physical and emotional condition upon return, with no injuries or distress noted. The incident was recorded in the facility's abuse/neglect log and incident notes, and the resident's care plan was updated after the event to reflect the risk for elopement. Prior to the incident, there were no alarms or wander alert devices in use for this resident, and the care plan did not include specific interventions for elopement risk. The deficiency was cited under state and federal regulations requiring the facility to maintain a safe and secure environment and to provide adequate supervision to prevent such incidents.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. N110 FAC Physical Environment-Safe, Clean, Homelike (a) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; On 06/17/2025, the Director of Nursing re-educated Staff B, C, and D on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents Investigating and Reporting policies with an emphasis on adequate supervision and safety. (b) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 04/05/2025, a Quality Review audit was completed on all residents, no new residents were identified as at risk for elopement. By 06/25/2025, all current residents were re-evaluated for changes in conditions or risk factors that may pose a risk for a potential accident. Any issues or concerns were immediately addressed, interventions and care plans revised, as needed. No further discrepancies were observed. All new residents will be assessed for potential accidents upon admission. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By 04/05/2025, Director of Nursing/designee reviewed and updated elopement binders; ensured binders were current and placed at each nursing station, therapy department, activity department, kitchen, & front desk. Elopement binders updated when necessary. By 04/05/2025, Maintenance Director/designee checked all exil doors for proper functioning to include transponder for wander guard system. Daily audit of doors for proper functioning completed for three days, followed by weekly audits. On 04/05/2025, Clinical Educator/designee initiated education of all staff on the facility's Elopement standard and guidelines, ANEMMI with an emphasis on Neglect, Alarm Response, and Wander Guard placement and functioning. Newly hired staff will receive this education during orientation. Education continues monthly. On 04/05/2025, Clinical Educator/designee initiated elopement drills for all staff participation. Drills will be completed on each shift, then move to monthly rotating each shift. On 04/05/2025, a single point of entry was set up at the front doors in the reception area. The front doors were set to remain locked at all times. To gain access, any non-employee will need to ring the doorbell for entry. Once inside, every non-employee must sign in into the visitor's fog. Everyone leaving the building must do so from the front door and be let out by the receptionist or be escorted out by a staff member with a fob. Single point of entry and these entry and exit procedures continue to be in place. On 04/05/2025, Administrator/designee initiated QAPI Plan with interdisciplinary Team, including Medical Director, participation on safety with a focus on elopement. Reviewed during QA Meeting on 04/08/2025. On 04/07/2025, Director of Nursing/designee began daily clinical review of new admissions/re-admissions and change in condition that may require increased supervision and/or risk for elopement evaluation. Admission and re-admission reviews continue during daily clinical meetings (Monday through Friday). On 04/07/2025, Maintenance Director/designee placed a Red Box/ Exit Door Alarm on every exit door to notify personnel of any unauthorized entry/exit attempts on emergency exit doors. By 07/16/2025, all employees will be re-educated by the Clinical educator/designee on the components of this regulation and the facility's Safety and Supervision of Residents & Accidents and Incidents-Investigating and Reporting policies with an emphasis on adequate supervision and safety. Newly hired employees will receive education during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The Administrator/designee will conduct a weekly Quality Review audit of residents for 4 weeks, and then every 2 weeks for 2 months to ensure compliance that supervision is adequate and interventions are appropriate, when necessary. Findings will be reported at the monthly QA/Risk Management meeting. These Quality Reviews will be reported until the committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Operations/designee when completing their Quality Systems Review to maintain compliance.
Failure to Promote Residents' Dignity During Dining
Penalty
Summary
The facility failed to promote residents' dignity and respect during dining for two residents. The first incident involved a speech therapist standing while feeding a resident. The therapist was unaware that standing while feeding was not allowed and immediately corrected his behavior when informed. The Director of Nursing (DON) confirmed that all staff, including the rehabilitation department, had been trained to sit while feeding residents and was providing further education to reinforce this protocol. The second incident involved an occupational therapist standing while assisting a resident with breakfast. The resident had severe cognitive impairment and was dependent on assistance for all activities of daily living. The occupational therapist believed it was acceptable to stand while feeding the resident to assess her abilities. The DON reiterated that staff should be seated while assisting residents with meals to maintain dignity and planned to provide additional education to the occupational therapist. The facility's policies emphasized the importance of treating residents with dignity and respect, including not standing over them while assisting with meals.
Failure to Follow Pharmacy Procedures and Medication Reconciliation
Penalty
Summary
The facility failed to ensure pharmacy procedures were followed as per facility policy and medication reconciliation procedures were adhered to. During a routine observation, a surveyor found an unattended and unlocked medication cart with a computer screen displaying a resident's medication information. The assigned RN admitted to leaving the cart unlocked and unattended, which was against the facility's policy on securing medication carts and protecting health information. Additionally, a discrepancy was found in the narcotic count for a resident's medication. The RN responsible for the medication cart recorded an incorrect number of pills given, which did not match the actual count. The RN acknowledged the mistake and called the Nursing Supervisor to correct the documentation. The resident involved had been admitted with orders for Dilaudid to manage moderate pain related to low back pain. The facility's policies on medication reconciliation and security of medication carts were not followed, leading to these deficiencies.
Failure to Clean Dryer Lint Screens
Penalty
Summary
The facility failed to ensure the lint screens for two out of three dryers in the laundry room were cleaned as per facility protocol. During an observational tour, surveyors, along with the facility's Infection Preventionist and the Director of Housekeeping, found the lint screens covered in a thick layer of lint. The Director of Housekeeping acknowledged that the lint screens were not cleaned, despite the lint log indicating they were cleaned earlier that day. The facility policy requires lint screens to be cleaned every hour and after every load to prevent hazardous situations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 103 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Annes Nursing Center, St Annes Residence Inc | 4.1 mi | ★★★★★ | 4 | 0 |
| Homestead Manor A Palace Community | 6.6 mi | ★★★★★ | 0 | 0 |
| South Dade Nursing And Rehabilitation Center | 6.9 mi | ★★★★★ | 5 | 0 |
| Coral Reef Subacute Care Center Llc | 7 mi | ★★★★★ | 1 | 0 |
| East Ridge Rehabilitation And Nursing Center | 7.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Kendall Lakes Healthcare And Rehab Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.