Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Palace At Kendall Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
Failure to provide privacy during medication administration: an LPN was observed giving meds to a resident in the hallway in front of the nursing station instead of in the resident’s room. The resident had dementia and moderate cognitive impairment. Staff acknowledged meds should be administered in the room with privacy, and the DON stated meds are to be given in rooms.
A resident with severe cognitive impairment and an order for bilateral hearing amplifiers was repeatedly observed without the device in place, while the amplifiers were left on the nightstand, one charging and one in a plastic bag. Although nursing documentation showed the devices were applied after morning care, staff interviews confirmed the resident was not wearing them and there were no notes that the resident refused the amplifiers. The CNA acknowledged not placing the device, and the RN unit manager and DON stated staff were responsible for applying and monitoring the hearing devices per order.
Oxygen therapy was not administered at the ordered rate for a resident with palliative care, viral pneumonia, and acute pulmonary edema. The resident was observed asleep with a nasal cannula in place while the oxygen concentrator was set at 3.5 LPM instead of the ordered 2 LPM PRN. The RN stated the order was for 2 LPM and did not realize the concentrator was set higher; the facility policy required oxygen to be prescribed with a flow rate, delivery method, and frequency.
An LPN left medications and eye drops unattended on top of a medication cart on the first floor while she was in a resident’s room across the hallway. A resident was seen traveling down the hallway during the observation, and the LPN later stated she should not have left the medications unattended because anyone could have taken them. The RN unit manager confirmed staff should not leave medications out of view, and facility policy states the cart must be kept closed and locked when out of sight, with no medications kept on top of the cart.
Repeated F880 infection prevention and control deficiency was identified when staff failed to store respiratory equipment in a plastic bag after use for a resident. The facility had previously been cited for the same deficiency, and the Administrator reported that monthly QAPI meetings reviewed multiple data sources, including survey results, infection control data, complaints, and utilization trends.
Infection prevention and control was not followed for a resident receiving nebulizer treatments when a nebulizer mask was observed sitting on the bedside table instead of being stored in a clean plastic bag when not in use. The resident had COPD and other respiratory diagnoses, and the care plan and physician orders addressed respiratory infection mitigation and routine nebulizer equipment changes. An LPN and the DON stated the mask should be kept in a designated bag when not in use.
The facility failed to follow infection control procedures for six residents receiving enteral feedings, as observed by uncapped tube feeding connectors when feeding was not in progress. These residents, who were severely cognitively impaired and dependent on staff, had their feeding connectors left uncapped, contrary to the facility's infection control policy. Staff interviews confirmed the requirement to cap connectors to prevent contamination, which was not adhered to.
A resident with a seizure disorder had a care plan discrepancy where the physician's order for side rails to be up with padding was not reflected in the care plan, which stated the rails should be down. This was due to the use of an outdated care plan template by the MDS nurse, as noted by the DON.
A resident with Basal Cell Carcinoma was observed with an undated dressing on their face, indicating a failure to follow prescribed care routines. Despite facility protocols requiring dressings to be dated, the dressing was not marked, suggesting a lapse in care standards. The resident, who requires substantial assistance due to cognitive impairment, did not receive care in line with the facility's person-centered care policy.
A resident with a seizure disorder was found with one unpadded side rail, despite facility protocols requiring both rails to be padded for safety. Staff interviews confirmed the requirement for padding, but observations showed non-compliance, leading to a deficiency.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to provide privacy for one resident during medication administration. On 04/20/2026 at 9:20 AM, Staff L, an LPN, was observed administering medications to Resident #38 in the hallway in front of the first-floor nursing station. Staff L did not redirect the resident or reeducate the resident about privacy during medication administration, and the medications were given in a public area rather than in the resident's room. Resident #38 was initially admitted to the facility and later readmitted with diagnoses including encounter for surgical aftercare following surgery on the digestive system and dementia. A Minimum Data Set dated 03/20/2026 showed a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. The facility's policy titled Right to Personal Preferences states that residents have the right to be treated with respect and dignity. During interviews, Staff L stated medications should have been administered in the resident's room with the curtain pulled and acknowledged medications are not allowed in the hallway, while the First Floor Supervisor and DON stated medications are to be administered in rooms and that residents who refuse should be educated and the care plan updated.
Failure to Ensure Hearing Amplifier Was Applied
Penalty
Summary
The facility failed to ensure that a prescribed hearing amplifier was in place for one resident with hearing devices. Resident #70 had diagnoses including unspecified dementia and cerebrovascular disease, a BIMS score of 00 indicating severe cognitive impairment, and was documented as using a hearing aid and usually understanding others. The resident’s care plan noted bilateral hearing amplifiers kept at bedside per family preference, and physician orders directed staff to apply the left and right hearing amplifiers after morning care and remove them after evening care. Observations showed the resident repeatedly without the hearing device in place while the devices were left on the nightstand, one on a charging device and the other inside a plastic bag. On multiple observations, the resident was seen in bed, in a recliner in the dining area, and later in the activities area without the hearing amplifier in place. During one observation, the resident was pulling on a call light wrapped around the bed railing and biting it, and later was not following staff directions and was not engaged in activity. Record review showed nursing staff documented that both hearing amplifiers were applied after morning care on two dates, but there were no progress notes indicating the resident refused to wear them. Interviews confirmed that staff were aware of the order and that CNAs were informed during morning discussion that the resident required a hearing amplifier. A CNA stated the hearing aid was not placed on the resident that day and acknowledged it should have been. The RN unit manager stated the order required the amplifier after morning care and that staff were aware of it, while also noting there were no notes indicating the resident removed it. The DON stated staff were responsible for applying and removing hearing devices according to the physician’s order and for documenting if a resident was noncompliant, but no staff reported that this resident did not want to wear the amplifiers.
Oxygen Flow Rate Not Set Per Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for Resident #81 when oxygen was administered at the wrong flow rate. Resident #81 was observed on 04/21/2026 and again on 04/22/2026 asleep in bed with the nasal cannula in place while the oxygen concentrator was set at 3.5 LPM, although the physician order dated 03/10/2026 specified oxygen at 2 LPM as needed. The resident’s clinical record showed diagnoses including Encounter for Palliative Care, Other Viral Pneumonia, and Acute Pulmonary Edema, and the admission MDS documented a BIMS score of 12 out of 15, substantial/maximal assistance with ADLs, and oxygen therapy as needed. The care plan initiated on 03/11/2026 identified the resident as at risk for altered airway clearance and shortness of breath related to heart failure and pneumonia/pulmonary edema, with an intervention to administer oxygen via nasal cannula as ordered by the physician. During interview, the RN stated the order was for 2 LPM and that the concentrator had been set at 3.5 LPM without realizing it. The facility’s oxygen administration policy stated that oxygen is a medication and must be prescribed with a flow rate, delivery method, and frequency.
Unattended medications left on medication cart
Penalty
Summary
Staff failed to safely secure medications and biologicals on one of three medication carts on the facility’s first floor. During an observation on 04/20/2026 at 8:33 AM, medications and eye drops were seen left unattended on medication cart one, which was parked next to the hallway while the nurse was in a resident’s room two doors across the hallway. A resident was observed propelling in a wheelchair down the hallway while the medications remained on the cart. Photo evidence was obtained. At 8:48 AM, Staff B, LPN returned to the medication cart and stated that a resident had an emergency, but she should not have left the medications on top of the cart unattended because anyone could have taken them. On 04/23/2026 at 1:51 PM, Staff G, RN, the first floor unit manager, was informed of the concern and reviewed the photographic evidence, stating that staff should not leave medications out of view and that Staff B should have taken the medications with her. The facility’s Medication Storage policy states medications are to be safely stored to minimize diversion and reduce dispensing errors, and the Medication Preparation and General Guidelines policy states the medication cart must be kept closed and locked when out of sight, with no medications kept on top of the cart.
Repeated Infection Control Deficiency and QAPI Review
Penalty
Summary
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. The facility was cited for repeated deficient practices related to F880 Infection Prevention and Control, based on observations, interviews, and record reviews showing that staff failed to store respiratory equipment in a plastic bag after use for Resident #131. The facility’s survey history showed it had previously been cited for F880 Infection Prevention and Control during the recertification survey with an exit date of 03/13/2024. In an interview, the Administrator stated that the facility held monthly QAPI meetings on the third Wednesday and that the committee included the Administrator, Risk Manager/Director of Social Services/Director of Nursing, Medical Director, Infection Control/Prevention Officer, Consultant Pharmacist, and Department Heads. The Administrator also stated that the QAPI team reviewed multiple data sources, including MDS patterns, Nursing Home Compare indicators, state survey results, resident care plan progress, complaint trends, satisfaction feedback, caregiver turnover, emergency room visits, hospital utilization, and infection control data.
Nebulizer Mask Left Unbagged at Bedside
Penalty
Summary
Provide and implement an infection prevention and control program was not followed for one resident receiving respiratory treatments. During an observation on 04/21/2026 at 09:28 AM, Resident #50 was found in bed awake, alert, and oriented with a nebulizer mask sitting on the bedside table and not stored in a plastic bag. The resident stated the mask had been sitting on the bedside table since 06:00 AM that morning. Photographic evidence was obtained. Record review showed Resident #50 was admitted with diagnoses including COPD, wheezing, and pulmonary edema. The care plan included mitigation strategies to prevent respiratory exposure/infection, including hand hygiene, standard and transmission-based precautions, and assessment each shift for fever, bilateral breath sounds, shortness of breath, coughing, sneezing, or other respiratory symptoms. Physician orders included nebulizer treatments with albuterol sulfate and ipratropium bromide, and an order to change the aerosol mask and tubing weekly and as needed. During interviews, an LPN stated that when a nebulizer mask is not in use, it should be stored in a clean plastic bag at the bedside, and the DON stated oxygen-related equipment such as a nebulizer mask is stored in a designated bag and kept there when not in use.
Failure to Cap Feeding Tube Connectors
Penalty
Summary
The facility failed to adhere to infection control procedures for six residents receiving enteral feedings. Observations revealed that the tube feeding connectors for these residents were left uncapped when the feeding was not in progress. This was noted for residents who were severely cognitively impaired and dependent on staff for all activities of daily living. The uncapped connectors were observed hanging on poles next to the residents' beds, posing a risk of contamination. The medical records of the affected residents indicated that they had various diagnoses requiring enteral feeding through percutaneous endoscopic gastrostomy (PEG) tubes. The physician's orders specified the feeding schedules and the need for flushing the PEG tubes with water. Despite these instructions, the connectors were found uncapped during periods when the feeding was not active, contrary to the infection control protocols outlined in the facility's policy. Interviews with staff members, including registered nurses and the Director of Nursing, confirmed that the connectors should be capped when not in use to prevent contamination. The staff acknowledged the oversight and indicated that the entire tubing system should be replaced if found uncapped. The facility's infection control policy, last revised in January 2021, mandates maintaining a safe and sanitary environment to prevent the transmission of infections, which was not followed in these instances.
Care Plan Discrepancy for Seizure Precautions
Penalty
Summary
The facility failed to update the care plan for a resident with a seizure disorder, resulting in a discrepancy between the physician's order and the care plan interventions. The resident, who was dependent on staff for all activities of daily living and had a history of seizures, was observed with two quarter-length side rails in the up position, contrary to the care plan which indicated the side rails should be down. The physician's order specified that the side rails should be up with padding as a seizure precaution, but the care plan had not been updated to reflect this order. The discrepancy was attributed to the use of an outdated care plan template by the MDS nurse, as explained by the Director of Nursing. The facility's policy on care planning emphasizes the development and implementation of personalized care plans to meet residents' individualized needs. However, in this case, the care plan did not align with the physician's order, leading to a failure in ensuring the resident's safety and adherence to prescribed precautions.
Undated Dressing on Resident's Face Indicates Care Deficiency
Penalty
Summary
The facility failed to provide quality care and treatment in accordance with professional standards for a resident with a dressing on the left side of their face, which was observed to be undated on multiple occasions. The resident, who has a diagnosis of Basal Cell Carcinoma of the skin of the left ear and external auricular canal, was observed by surveyors on two separate days with an undated dressing covering the left ear. The resident's care plan included specific instructions for dressing changes, which were not followed as the dressing was not dated, indicating a lapse in adherence to the prescribed care routine. The resident's medical records indicated a moderate cognitive impairment and a need for substantial assistance with personal care. The facility's policy requires that dressings be dated to track when they were last changed, a practice confirmed by both the RN unit manager and the DON. Despite these protocols, the dressing on the resident's face was not dated, suggesting a failure in the facility's implementation of its person-centered care policy, which aims to meet residents' physical, mental, and psychosocial needs in accordance with their preferences and professional standards.
Failure to Ensure Padded Side Rails for Seizure Precautions
Penalty
Summary
The facility failed to maintain a safe environment for a resident with a seizure disorder by not ensuring that both side rails on the resident's bed were padded as required. Observations on two separate occasions revealed that while the right side rail had padding, the left side rail did not, despite the presence of padding on a nearby recliner. The resident, who was dependent on staff for all activities of daily living and had a history of seizures, was observed in bed with the side rails in the up position, contrary to the care plan that specified both rails should be padded. Interviews with staff, including a Registered Nurse Unit Manager, a Registered Nurse, and a Certified Nursing Assistant, confirmed that the resident was supposed to have both side rails padded for seizure precautions. The staff acknowledged their responsibility to ensure the padding was in place at all times, except during hygiene care. The Director of Nursing also confirmed the requirement for padding as an extra measure to protect against trauma and friction due to involuntary movements. Despite these protocols, the facility did not adhere to the prescribed safety measures, resulting in a deficiency.
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 240 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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) |
|---|---|---|---|---|
| Harmony Health Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Nspire Healthcare Kendall | 2.8 mi | ★★★★★ | 0 | 0 |
| Coral Reef Subacute Care Center Llc | 4.5 mi | ★★★★★ | 1 | 0 |
| West Gables Health Care Center | 5.3 mi | ★★★★★ | 3 | 0 |
| South Dade Nursing And Rehabilitation Center | 5.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Palace At Kendall Nursing And Rehabilitation Cente.
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.