Kennedy Care Center
KENNEDY CARE CENTER in LOS ANGELES, CA — inspection on July 22, 2024.
Found 20 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 37's MDS dated [DATE], indicated the resident required set up or clean-up assistance with eating, and was dependent on staff for toileting, bathing, dressing and personal hygiene, bed mobility and transfers.
During an interview on 7/19/24 at 8:04 pm with Resident 50, the resident stated when staff come in her room, sometimes they were speaking in a language the resident did not understand.
During an interview on 7/19/24 at 8:30 pm with Resident 37, the resident stated, it is difficult to communicate with some of the staff because they frequently speak a language he does not understand, and occasionally they do not understand what he is saying.
During an interview on 7/21/24 at 8:44 pm with Director of Nursing (DON), the DON stated the expectation is that the staff speak English in the patient care area, unless the resident speaks a different language then that would be their preference.
A review of the facility's employee handbook (updated June 2021), indicated, English-only rules, an English-only rule will be allowed only for the following . communications with residents, resident's families, coworkers or supervisors who only speak English . for cooperative work assignment to promote efficiency.
055977 07/22/2024
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During a review of Resident 52's Immunization Report and a concurrent interview with the Infection Preventionist Nurse (IPN) on 7/21/2024 at 3:33 p.m , the record indicated Resident 52 received the pneumococcal vaccine in the facility on 10/26/202 and 2/1/2023. IPN reviewed Resident 52's medical record with the surveyor and was unable to find any informed consent that Resident 52 and/or responsible party signed prior to administering the vaccine. IPN stated, an informed consent should be in placed prior to administering the vaccine and an education should be provided regarding adverse reaction and it is residents' rights.
During an interview with the Director of Nursing (DON) on 7/21/2024 at 9:05 p.m., the DON stated, residents should be offered immunizations if they are eligible and an informed consents are needed prior to administering any vaccines in the facility.
A review the facility's policy and procedures (P&P) titled Pneumococcal Vaccine, revised 10/2023 indicated, Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine .
Provision of such education is documented in the resident's medical record.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During an initial tour observation and concurrent interview with Resident 292 on 7/20/24 at 8:27 AM, Resident 292's personal belonging was observed to have observed to have a bottle of Norco (controlled medication issued to relieve moderate to severe pain) 10-325 (unit dose), milligrams (mg-Unit of measure) x 29 pills, at the resident's bedside table. Resident 292 stated he was admitted to the facility on [DATE] and, came with the Norco from the hospital.
During an interview with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 292 was not supposed to have the Norco at bedside unless Resident 292 had a self-administration order and had demonstrated the ability to safely self-administer the medication (Norco). LVN 5 further stated Resident 292 was at risk for overdose if he took the Norco without notifying the nurse. LVN 5 stated that a wandering Resident could gain access to the Norco, placing that resident at risk for overdose or an allergic reaction.
During an interview with the Director of nursing (DON) on 7/21/2024 at 8:30 PM, the DON stated having the medication at bedside placed Resident 292 was at risk for overdose through self-administration of medication.
A review of the facility's policy and procedures (P&P) titled Self-Administration of medication, dated 10/2024 indicated, the interdisciplinary (IDT- a coordinated group of experts from several different fields who work together) assess each Resident's cognitive and physical abilities to determine whether self-administering medications is safe and appropriate for the Resident.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During a concurrent observation with Resident 66 on 7/19/2024 at 7:47 p.m., Resident 66 was observed lying in bed, eyes closed, unable to find Resident 66's call light in bed.
During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 7/19/2024 at 7:49 p.m., LVN 2 observed Resident 66's call light and found that the call light was not connected to Resident 66's bed. LVN 2 stated and confirmed that Resident 66's call light was not within the resident's reach, and this prevents her (Resident 66) from communicating her needs. LVN 2 further stated the call light should still be within the resident's reach.
- A review of Resident 192's admission Record indicated Resident 192 was admitted to the facility on
[DATE], with diagnoses including dysphagia, malignant neoplasm of rectum (rectal cancer - a type of cancer that forms in the tissues of the rectum), and chronic kidney disease.
A review of Resident 192's MDS dated [DATE], indicated Resident 192 had severely impaired cognition for daily decision-making and required maximal assistance from staff for ADL- oral hygiene and toileting hygiene, repositioning from sit to lying and lying to sitting on side of bed.
A review of Resident 192's care plan (CP) for high risk for falls, initiated on 4/18/2024 indicated an intervention that included, Be sure her [Resident 192] call light is within reach and encourage the resident to use it for assistance as needed During a concurrent observation with Resident 192 on 7/19/2024 at 7:44 p.m., Resident 192 was observed lying in bed, eyes closed, call light was on the floor away from Resident 192's reach.
During a concurrent observation and interview with LVN 2 on 7/19/2024 at 7:47 p.m., LVN 2 observed Resident 192's call light on the floor, picked it up and put in Resident 192's reach. LVN 2 stated and confirmed, Resident 192's call light was not within her reach, which prevents her (Resident 192) from communicating her needs.
During an interview with the Director of Nursing (DON) on 7/21/2024 AT 8:57 p.m., the DON stated call light should always be within residents' reach.
A review of the facility's policy and procedures (P&P), titled, Answering the Call Light, reviewed on 4/17/2024, indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
Some residents may not be able to use their call light. Be sure you check these residents frequently.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During a concurrent interview and record review with Social Services Director 2 (SSD 2) on 7/20/2024 at 3:32 p.m., Resident 61's medical records were reviewed. SSD 2 stated, Resident 61 does not have an ACHD and there was no indication if facility followed up with Resident 61 and/or if the responsible party was given information if they would like to create one.
A review of Resident 61's Progress Notes, written by SSD 2, dated 7/21/2024 indicated, SSD 2 reached out to resident responsible party . explained and requested a copy of any legal documentation like Advance Directive . advance directive acknowledgment form for signature and clearance of advance directive.
A review of the facility's policy and procedures (P&P) titled, Advance Directive, revised on 5/2024 indicated, A POLST paradigm form is not an advance directive .
Prior to or upon admission of a resident, the social services director or designee inquiries of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
to: maintaining the building in good repair and free from hazards.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
was Resident 16's current weight.
reviewed on 4/17/2024 indicated, A comprehensive, person-centered care plan should include
needs.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
physician's order and a company representative supplying the bed on an individual resident basis will
2b. A review of Resident 16's admission Record indicated the resident was originally admitted on
obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).
A review of Resident 16's MDS dated [DATE], indicated Resident 16 had severely impaired cognition and requiring maximal assistance to total dependence from staff for ADL-repositioning from sit to lying, sit to stand, rolling left and right. MDS also indicated Resident 16 is at risk of developing pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and Resident 16 is on pressure reducing device for bed.
A review of Resident 16's care plan for high risk for developing pressure ulcer related to needs assistance with ADLs, initiated on 11/27/2023 indicated, Low air loss mattress for skin management.
Set according to resident weight.
A review of Resident 16's OSR, dated 9/8/2022 indicated physician ordered, Low-air-loss (LAL - a mattress designed to prevent and treat pressure wounds) for skin management.
Monitor for proper functioning and settings per resident's weight.
A review of facility's policy and procedure (P&P), titled, Beds, Special-Low Air Loss Therapy, reviewed on 4/2024, P&P indicated, the facility to utilize low air loss therapy under the direction of a physician's order and a company representative supplying the bed on an individual resident basis will adjust pressure settings of bed.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During an observation on 7/20/2024 at 1:12 p.m. at Resident 63's room, Resident 63 was observed
while Resident 63 was transferred to the bed. CNA 3 transferred Resident 63 by having Resident 63 draped both legs around CNA 3's waist and both arms around CAN 3's neck.
During an interview with CNA 3 on 7/20/2024 at 1:16 p.m., CNA 3 stated, she transferred both Resident 61 and Resident 63 on her own, and she did not need any assistance from other staff as it is okay to transfer both residents with one person assist. CNA 3 further stated and demonstrated that she had Resident 61 and Resident 63's arms wrap around her neck and both legs draped around her waist.
During an interview with Registered Nurse Supervisor 1 (RNS 1) on 7/20/2024 at 1:17 p.m., RNS 1 stated, staff should use proper body alignment when transferring residents and should transfer residents who are at high risk for falls with two persons assist to prevent falls and injuries. RNS 1 stated, staff should not ask residents to drape both legs around staff's waist and both arm around their neck as this is not the proper body alignment when transferring residents.
During an interview with the Director of Nursing (DON) on 7/21/2024 at 9:08 p.m., The DON stated, when transferring a resident from wheelchair to bed, staff have to slowly transfer residents using proper body alignment and use a two-person assists and/or mechanical lift if needed to prevent injury and accidents.
A review of the facility's policy and procedures (P&P) titled, Repositioning, revised 5/2024 indicated, Repositioning the Resident in Bed: Check the care plan, assignment sheet or the communication system to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete the procedure.
A review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, reviewed 4/17/2024, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.
055977 07/22/2024
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During an interview with Resident 59 on 7/19/24 at 8:30 pm, the resident stated the call lights take a long time to be answered if at all. Resident 59 stated that now the uses the TV by putting the volume all the way up and that seems to bring the staff in to help the resident.
During an interview with Resident 37 on 7/20/24 at 8:41 am, the resident stated the staff take a long time to answer the call light and he needs help frequently throughout the day.
Sometimes he will have to wait for the Certified Nursing Assistants (CNAs) to help him get cleaned up and then that can delay his physical therapy. Resident 37 stated they (facility) needs a better coordination.
During an interview with Director of Nursing (DON) on 7/21/24 at 8:44 pm, the DON stated, the call lights should be answered as soon as possible and by everyone, no one should pass by a call light.
They should step in and ask if the resident needs help.
A review of the facility's policy and procedures Answering the Call Light, reviewed 4/17/24, indicated, the purpose of this procedure is to respond to the resident's requests and needs .
Answer the resident's call as soon as possible.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During an observation on 7/19/2024 at 9:19 p.m., located in the nurses' station, nurse staffing hours information dated 7/19/2024 was posted with missing actual nursing staffing hours.
During an observation on 7/20/2024 at 9:45 a.m., located in the nurses' station, nurse staffing hours information dated 7/20/2024 was posted with missing actual nursing staffing hours.
During an observation on 7/21/2024 at 9:52 a.m., located in the nurses' station, nurse staffing hours information dated 7/21/2024 was posted with missing actual nursing staffing hours.
During an interview with the Director of Staff and Development (DSD) on 7/21/2024 at 9:54 a.m., the DSD stated DSD only post the projected hours, not the actual hours.
The DSD stated, it was important to post the actual nursing hours to make sure that the required nursing hours are being followed and that they have the sufficient nursing staff working each shift.
During an interview with the Director of Nursing (DON) on 7/21/2024 at 8:45 pm., The DON stated the nursing actual and projected hours should be posted on a daily basis.
A review of facility's policy and procedure (P&P), titled, Posting Direct Care Daily Staffing Numbers reviewed 5/2024, indicated, the facility will post the following information within two hours of the beginning of each shift the following: i.
Facility name ii.
Current date iii.
Resident census iv.
Actual hours worked of all the licensed and unlicensed nursing staff directly responsible for resident care per shift.
The P&P also indicated, the previous shift's forms are maintained with the current shift form for a total of 24 hours of staffing in a single location.
055977 07/22/2024
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During a concurrent interview with the DON on 7/21/2024 at 8:57 p.m., the DON stated, an informed consent should be in place and timely signed for all psychotropic medications.
A review of facility's P&P titled, Psychoactive/Psychotropic Medication Use, revised on 7/2024 indicated, Prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record.
055977 07/22/2024
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During a concurrent observation and interview with Registered Nurse Supervisor 1 (RNS 1) on 7/20/2024 at 2:46 p.m., observed Resident 29's Yupelri box inside the medication fridge. RNS 1 stated RNS 1 was not aware that it should be in the fridge and will follow up with the pharmacist for storing medication.
During an interview with Licensed Vocational Nurse 5 (LVN 5) on 7/20/2024 at 2:51 p.m., LVN 5 stated LVN 5 had put Yupelri medication in the fridge since it was supposed to be refrigerated until it is being used due to medication being in a liquid form.
During an interview with the Director of Nursing (DON) on 7/21/2024 at 1:13 p.m., The DON stated that Yupelri was not supposed to be refrigerated and putting the medication in the fridge can affect the patency of the medication.
A review of Yupelri's package inserts, undated, indicated, per manufacturer's policy, under storage and handling, to store medication at room temperature from 68-degree Fahrenheit to 77-degree Fahrenheit.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
interdisciplinary team.
Modifications to diet will only be ordered with the resident's or
resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.
055977 07/22/2024
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During an observation with concurrent interview on 7/21/24 at 10:38 a.m. with the Dietary Supervisor (DS), the facility's resident nutrition refrigerator was reviewed.
There was one container of food labeled with a use by date of 6/27/24 and another with a brought in date of 7/18/24.
The DS stated those containers of food with past use by dates should have been thrown out, because it is past the use by date or 48 hours after the food was brought in.
A review of the facility's policy and procedures (P&P), titled Foods Brought by Family/Visitors, reviewed 4/17/24, indicated, Food brought to facility by visitors and family is permitted .
Family/visitors are asked to prepare and transport food using safe flood handling practices .
Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility prepared food .
Containers are labeled with the resident's name, the item and the use by date.
The nursing staff will discard perishable foods on or before the use by date.
055977 07/22/2024
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
Based on observations, interviews, and record review the facility's governing body (individuals such
establish and implement policies regarding the management and operations of the facility) failed provide effective leadership oversight of processes and policies and procedures by failing to ensure the administrator was onsite and available via phone on a full-time basis.
This deficienct practice had the potential to not meet/address direct the day-to day functions of the facility in accordance with current federal, state, and local standard, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care is provided to the residents.
Findings
During an initial facility tour on 7/19/2024 at 8:30PM, the Administrator in Training (AIT) was observed present and working in the facility without the supervision of a licensed and qualified Administrator (ADM) on 7/19/2024 at 5:30pm.
During a concurrent interview, the AIT stated, I am newly licensed Administrator and is scheduled to take over the daily operations of the facility on 8/1/2024.
During an interview on 07/21/24 at 08:15 PM with the AIT, the AIT stated, AIT started to work at the facility on 7/1/2024.
The AIT stated the facility's current ADM, will not be available during the recertification survey due to family issue.
The AIT stated AIT is aware that the current licensed ADM should in the facility to follow/supervise the AIT.
The AIT stated that the facility's current, Administrator is aware that the recertification survey is currently in process in the facility.
A review of the AIT's employment offer letter dated 11/19/2023, indicated, the AIT started working at facility on 7/1/2024.
A review of the facility's job description titled Administrator in Training (AIT) dated 03/2017, indicated, AIT reports to Administrator-preceptor, the roles, and responsibilities of the AIT . is a training position with direct oversight by a licensed precepting Administrator.
The job description further states All Essential Duties and Responsibilities of this position (AIT) are under the direct supervision of the Preceptor (ADM).
A review of the facility's job description titled Administrator (ADM), dated 12/2018, indicated, the primary purpose of your position is to direct the day-to day functions of the facility in accordance with current federal, state, and local standard, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be always provided to residents.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
Enhanced Barrier Precautions, reviewed on 4/17/2024 indicated, Contact precautions are
resident-care items in the resident's environment.
A review of Centers of Disease Control and Prevention (CDC), Infection Control Guidelines titled, Type and Duration of Precautions Recommended for Selected Infections and Conditions, updated 9/2018 indicated, CDC recommends, for E. coli infection, residents should be placed under Contact Precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks.
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Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During the general observations of the residents' rooms from 7/19/2024 to 7/21/2024, the residents in room [ROOM NUMBER] had ample space to move freely inside the rooms.
There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents.
There was also sufficient space for beds, side tables and resident care equipment.
During an interview with Certified Nurse Assistant 6 (CNA 6) on 07/21/24 4:23 PM, CNA 6 stated, room [ROOM NUMBER] feels small, when cleaning or changing Residents. CNA 6 stated CNA 6 must move the residents chair and bedside table out of the room to have enough space to do activities of daily living (ADLs). CNA 6 stated no Resident's or family have complained about the room size.
During an interview with the Director of nursing (DON) on 7/21/2024 at 8:30 PM, the DON stated offloading heels is important to promote healing, not following doctor's orders could delay healing of wounds.
A review of the facility's policy and procedures titled Prevention of Pressure Ulcers dated, 04/2020 indicated, . provide support devices and assistance as needed.
43261
2a. A review of Resident 1's Admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), obesity (a disorder involving excessive body fat that increases the risk of health problems), and diabetes mellitus (DM-a long term condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 1's MDS dated [DATE], indicated Resident 1 had a severely impaired cognition (ability to think and make decisions) and requiring maximal assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).MDS also indicated Resident 9 was admitted with a stage four (4) pressure ulcer.
A review of Resident 1's Order Summary Report (OSR), dated 9/10/2023, the OSR indicated that Resident 1 has an order for pressure reducing mattress.
A review of Resident 1's Weight Summary Report (WSR), dated 7/9/2024, the WSR indicated Resident 1 weighed 178 pounds (lbs - unit of measurement).
During a concurrent observation and interview with Licensed Vocational Nurse 7 (LVN 7) on 7/19/2024 at 7:48 p.m., Resident 1's LAL mattress was observed at a setting between 80 lbs. to 160 lbs. with a weight sticker posted in the LAL mattress machine, indicating 119 lbs. LVN 7 stated the LAL mattress should be set via weight or the comfort of the resident. LVN 7 also stated that Resident 1's LAL mattress setting should be between 160 lbs. to 240 lbs. since Resident 1 weighed 178 lbs.
055977
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055977 B.
Wing 07/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
During an observation of Resident 16 on 7/19/2024 at 6:49 p.m., Resident 16 was in bed, lying on a LAL mattress with the LAL mattress knob set at 130. Resident 16 stated, the LAL mattress, feels just ok and feels firm.
055977
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055977 B.
Wing 07/22/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Kennedy Care Center 619 N.
Fairfax Ave Los Angeles, CA 90036
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.