LOS ANGELES, CA - Federal inspectors documented serious infection control violations at Kennedy Care Center that placed vulnerable residents at increased risk of acquiring dangerous antibiotic-resistant infections and other communicable diseases.
Multiple Infection Control Breakdowns Discovered
During a July 2024 inspection, surveyors found that Kennedy Care Center staff failed to follow basic infection prevention protocols for residents with confirmed infections, including Extended Spectrum Beta-Lactamase (ESBL) and E. coli bacteria.
A resident with ESBL infection remained in a shared room despite facility policies requiring private room placement when beds were available. ESBL bacteria produce enzymes that render many common antibiotics ineffective, making proper isolation critical to prevent transmission to other vulnerable residents.
Inspectors documented that the facility had 10-12 empty beds available during the survey period, yet continued housing the infected resident with a roommate. The Infection Preventionist Nurse acknowledged that private rooms were available and confirmed the practice "places other residents at risk of contacting the infection."
Staff Ignore Personal Protective Equipment Requirements
Perhaps more concerning, nursing staff were observed entering contact isolation rooms without wearing required personal protective equipment (PPE). A Certified Nursing Assistant was documented feeding a resident in a contact isolation room while wearing no protective gear.
When questioned, the CNA stated she believed PPE was unnecessary and had been told by other staff during shift reports that full protection wasn't required. This represents a fundamental breakdown in infection control training and supervision.
The facility's Licensed Vocational Nurse confirmed that all staff should wear full PPE before entering any contact isolation room, as failure to do so creates transmission risks for other residents, staff, and visitors.
Dangerous Transfer Practices Observed
Inspectors also documented unsafe patient handling that placed high-risk residents in immediate danger of falls and injuries. Staff were observed performing solo transfers of residents who required two-person assistance according to their care plans and physical therapy assessments.
A Certified Nursing Assistant was seen transferring two separate residents - both at high risk for falls and requiring extensive assistance - by having them wrap their arms around her neck and drape their legs around her waist. This technique violates proper body alignment principles and facility policies.
Both residents had severely impaired cognitive function and required maximal assistance for basic activities like transfers and repositioning. One resident had experienced previous falls and was specifically noted as needing two-person assists in physical therapy documentation.
The facility's Director of Nursing confirmed that high-risk residents should be transferred using proper body alignment with two-person assists or mechanical lifts to prevent injuries and accidents.
Wound Care Deficiencies Compromise Healing
Critical failures in wound care management were documented involving a resident with diabetic ulcers on both heels. The resident was supposed to have protective heel boots applied at all times according to physician orders, but was found with exposed wounds resting directly on the mattress.
The resident reported that heel protectors had been removed the previous evening and were missing. Diabetic ulcers heal poorly due to reduced circulation and elevated blood sugar levels, making proper offloading essential to prevent worsening tissue damage.
Medical records showed the resident had significant ulcerations measuring 5.0 cm by 8.0 cm on the left heel and 3.0 cm by 3.0 cm on the right heel with unknown depth due to tissue damage. The facility's Director of Nursing acknowledged that failing to follow doctor's orders could delay wound healing.
Pressure-Relief Equipment Improperly Set
Additional wound prevention failures involved incorrect settings on specialized pressure-reducing mattresses. Two residents weighing 178 pounds each had their Low Air Loss (LAL) mattresses set for patients in the 80-160 pound range instead of the appropriate 160-240 pound setting.
These therapeutic mattresses redistribute pressure to prevent skin breakdown in immobile residents. Incorrect weight settings compromise their effectiveness and increase pressure ulcer risk for patients already vulnerable due to conditions like diabetes and limited mobility.
Medication Management Violations
The inspection revealed concerning medication safety issues, including improper storage of respiratory medications and failures in psychotropic drug monitoring. Staff were storing Yupelri inhalation solution in refrigeration when manufacturer guidelines require room temperature storage between 68-77 degrees Fahrenheit.
The Director of Nursing confirmed that refrigeration could affect the medication's potency and effectiveness for treating respiratory conditions.
Call Light Response Delays Create Care Gaps
Multiple residents reported significant delays in staff response to call lights, with wait times extending beyond 45 minutes in some cases. These delays affected residents who required frequent assistance throughout the day and sometimes caused schedule disruptions for physical therapy sessions.
One resident reported using the television at maximum volume to attract staff attention when call lights went unanswered. The facility's policy requires answering resident calls "as soon as possible," but this standard was not being met consistently across all shifts.
Administrative Oversight Concerns
During the inspection period, the facility operated without proper administrative supervision. The licensed Administrator was absent due to family issues, leaving an Administrator in Training to manage daily operations without required preceptor oversight.
Federal regulations mandate that nursing facilities maintain qualified administrative leadership to ensure compliance with health and safety standards. The Administrator in Training's employment documentation confirmed the position requires "direct oversight by a licensed precepting Administrator."
Food Service and Safety Issues
Additional violations included food quality problems with residents reporting bland, unseasoned meals that lacked variety and appeal. Test tray evaluations by surveyors documented hamburgers without seasoning and soggy bun presentation.
Food safety concerns included expired items in resident nutrition refrigerators that should have been discarded according to facility policies for perishable foods brought by families.
Regulatory Response and Oversight
The inspection identified violations across multiple federal regulations governing nursing home operations, including infection prevention, accident prevention, nursing services, medication management, and food services.
Kennedy Care Center must submit a plan of correction addressing each identified deficiency and demonstrate sustainable improvements to maintain its Medicare and Medicaid certification. The facility's 97-bed capacity serves a vulnerable population requiring skilled nursing care and rehabilitation services.
The violations highlight the critical importance of robust infection control protocols in long-term care settings, where residents often have compromised immune systems and multiple chronic conditions that increase their susceptibility to healthcare-associated infections.
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.
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