Kennedy Care Center: Pressure Ulcer Prevention Failures - CA
The resident, identified only as Resident 16, required maximum assistance for basic movements like rolling over or sitting up. Medical records showed the person had encephalopathy, diabetes, and chronic lung disease. An assessment from June indicated severe cognitive impairment and high risk for developing pressure ulcers.
Despite a physician's order dating back to September 2022 requiring a low air loss mattress "set according to resident weight," the mattress remained incorrectly calibrated. When inspectors observed the resident on July 19, 2024, the mattress dial showed 130 pounds — 32 pounds heavier than the resident's actual weight of 98 pounds.
The resident told inspectors the mattress "feels just ok and feels firm."
The next evening, Licensed Vocational Nurse 2 confirmed to inspectors that the 130 setting was wrong. The nurse explained that the dial indicated weight in pounds and said the setting "should be close to 98 lbs. which was Resident 16's current weight."
A second resident faced similar problems with mattress settings, though inspection records don't specify that person's weight or the incorrect setting used.
The facility's failures extended beyond mattress calibration. Resident 292, also at high risk for pressure ulcers, didn't receive bilateral heel protectors despite a physician's order requiring the foam or gel devices while in bed. Heel protectors help prevent pressure ulcers on one of the most vulnerable areas of the body for bedridden patients.
Federal inspectors found that these deficiencies affected three residents total, all considered at high risk for developing pressure injuries. The inspection report noted the problems "placed Residents 1, 16, and 292 at risk of poor wound healing of the current pressure ulcer and development of new pressure injury/ies."
Pressure ulcers, commonly called bedsores, develop when constant pressure cuts off blood flow to skin and underlying tissue. They typically form over bony areas like heels, hips, and the tailbone. The wounds can progress from red, irritated skin to deep craters that expose muscle and bone, potentially leading to life-threatening infections.
Low air loss mattresses work by continuously circulating air through small holes in the mattress surface, reducing pressure points and moisture buildup. The devices must be calibrated to each resident's weight to function properly. Too high a setting can make the mattress too firm, failing to distribute pressure effectively. Too low a setting can cause the resident to "bottom out," creating pressure points against the firm base.
For residents like Resident 16, who cannot reposition themselves and require maximum assistance for basic movements, proper pressure relief becomes critical. The resident's care plan, initiated in November 2023, specifically called for the low air loss mattress "for skin management" and required it be "set according to resident weight."
The facility's own policy emphasized the importance of comprehensive, person-centered care plans with "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs." Yet staff failed to ensure the basic equipment ordered for pressure ulcer prevention functioned correctly.
Medical research consistently shows that proper mattress settings and positioning devices like heel protectors significantly reduce pressure ulcer development in high-risk patients. The devices are considered standard care for residents who cannot move independently.
Kennedy Care Center, located on North Fairfax Avenue, houses residents with complex medical conditions requiring skilled nursing care. Many residents, like those cited in the inspection, depend entirely on staff for basic care and positioning.
The inspection classified the violations as causing "minimal harm or potential for actual harm," but pressure ulcers can quickly progress from minor skin irritation to serious medical emergencies. Once formed, the wounds are notoriously difficult to heal and often require months of intensive treatment.
For Resident 16, the consequences of the improperly set mattress remain unclear from inspection records. The resident continued lying on the incorrectly calibrated device during the inspection period, potentially developing the very pressure injuries the equipment was designed to prevent.
The facility's failure to follow physician orders and its own policies represents a breakdown in basic nursing care standards. Simple equipment checks and adherence to written care plans could have prevented the violations inspectors documented.
Federal regulators completed their inspection on July 22, 2024, finding the pressure ulcer prevention failures among other deficiencies at the facility. The violations affect some of the most vulnerable residents — those who cannot advocate for themselves or make basic adjustments to their own comfort and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kennedy Care Center from 2024-07-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
KENNEDY CARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on July 22, 2024.
The resident, identified only as Resident 16, required maximum assistance for basic movements like rolling over or sitting up.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.