Kennedy Care Center

F-F656

Findings:

A review of Resident 292's Admission Record indicated Resident 292 was originally admitted to the facility

on [DATE REDACTED] with diagnoses that included Paraplegia (the inability to voluntarily move the lower parts of the body), Dorsalgia (low back pain, mid back pain or sciatic nerve related pain, that originate in muscles, nerves or joints), muscle weakness, immunodeficiency (The decreased ability of the body to fight infections and other diseases), Malignant neoplasm of prostate (a cancerous tumor in the gland of the male reproductive system), and type 2 diabetes (elevated levels of blood glucose (blood sugar)).

A review of Resident 292's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 7/16/2024 indicated Resident 292's cognition ((the mental ability to understand and make decisions of daily living) was moderately impaired, was independent with eating, required partial/moderate assistance with upper body dressing and lower body dressing. The MDS indicated Resident 292 was non-ambulatory.

Findings:

During an initial tour observation and concurrent interview with Resident 292 on 7/20/24 at 8:27 AM, Resident 292 stated he had pressure sores (ulcer/injury) on bilateral (both) heels, he has been wearing waffle boots (heel protectors) but did not know where they were placed after they were moved yesterday evening (7/19/2024). Resident 292's bilateral heels were observed open to air and resting directly on his nursing home bed mattress.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an interview with the Treatment Nurse 1 (TXT1) on 7/20/2024 at 8:38 AM, TXT1 stated Resident 292, has wounds to bilateral heels. He is supposed to have waffle boots placed on his bilateral heels to promote Level of Harm - Minimal harm or wound healing and prevent worsening of the wounds. potential for actual harm

A review of Resident 292's medical record titled Progress Notes dated 7/10/2024, indicated, Resident 292 Residents Affected - Some had a diabetic ulcer to the left heel measuring 5.0 cm Length (L) x 8.0 cm Width (W) x UTD cm Depth (D)., and right heel measuring 3.0 cm L x 3.0 cm W x (unstageable full thickness skin/tissue loss- Depth unknown (UTD) cm D.

A review of Resident 292's medical record titled Order Summary Report, dated 7/21/2024, indicated an order to offload bilateral heel with heel protector at all times.

A review of Resident 292's medical record titled care plan revised 7/17/2024, indicated Administer treatment as ordered.

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 REDACTED] and was readmitted on [DATE REDACTED] 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 REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an interview with the Director of Nursing (DON) on 7/21/2024 at 1:27 p.m., the DON stated that the LAL common nursing practice for the LAL mattress setting should be based on resident's weight. The DON Level of Harm - Minimal harm or stated that since Resident 1 weighed 178 lbs., Resident 1's LAL mattress setting should be between 160 lbs. potential for actual harm to 240 lbs. The DON also verified that Resident 1 was unable to state any discomfort.

Residents Affected - Some A review of facility's policy and procedures (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.

43454

2b. A review of Resident 16's Admission Record indicated the resident was originally admitted on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including encephalopathy, DM, and chronic 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 REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 61 and Resident 63), who were at high risk for fall and injuries and who required extensive assistance during repositioning according to the residents care plan.

This failure had the potential to place Residents 61 and 63 at risk for falls or injury possible fracture (break in bone) while being transferred from wheelchair to the bed solely by Certified Nursing Assistant 3 (CNA 3).

Findings:

A. A review of Resident 61's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including unspecified sequelae of cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), type two diabetes mellitus (DM-a long term condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy).

A review of the Minimum Data Set (MDS-standardized screening and assessment tool), dated 5/2/2024, indicated Resident 61's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired and required moderate to maximal assistance from staff for activities of daily living (ADLs- repositioning from sit to lying, sit to stand and chair/bed-to-chair transfer).

A review of Resident 61's Care Plan (CP) for high risk for falls and injuries related to history of falling, initiated on 11/1/2022, indicated, with interventions/task including: the resident needs a safe environment.

A review of Resident 61's Physical Therapist (PT - a health specialist who evaluates and treats human body disorders) Treatment Notes, dated 7/10/2024 indicated, Resident 61 required maximal assists with two persons assist during transfers.

During an observation on 7/20/2024 at 1:08 p.m. at Resident 61's room, Resident 61 was observed being transferred from a wheelchair to the bed by CNA 3, no other staff assisting CNA 3 was observed while Resident 61 was transferred to the bed. CNA 3 transferred Resident 61 by having Resident 61 draped both legs around CNA 3's waist and both arms wrapped around CNA 3's neck.

B. A review of Resident 63's Admission Record indicated the resident was originally admitted to the facility

on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including muscle weakness, acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the MDS dated [DATE REDACTED], indicated Resident 63's skills for daily decision-making were severely impaired and required total dependence from staff for ADLs- repositioning from sit to stand and Level of Harm - Minimal harm or chair/bed-to-chair transfer). potential for actual harm

A review of Resident 63's CP for falls: unwitnessed fall and is at risk for change in neurological status, injury, Residents Affected - Few pain, recurring falls, initiated on 12/16/2023 indicated a goal that resident will not have any major injuries related to the occurrence of a fall.

During an observation on 7/20/2024 at 1:12 p.m. at Resident 63's room, Resident 63 was observed being transferred from a wheelchair to the bed by CNA 3, no other staff assisting CNA 3 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252

Residents Affected - Few Based on interview and record review the facility failed to ensure the call lights were answered timely for three of six residents sampled (Residents 37, 50 and 59).

This deficient practice resulted in a delay to services and care required by Residents 37, 50, and 59.

Findings:

A review of Resident 37's Admission Record, dated 7/21/24, indicated Resident 37 was admitted to the facility on [DATE REDACTED], with diagnoses including diabetes mellitus type two, ulcerative colitis (an inflammatory bowel disease causing irritation and ulcers in the lining of your large intestine), generalized muscle weakness, abnormal gait and mobility, and hypertensive (high blood pressure) heart failure (a condition in which the heart has trouble pumping blood thought the body).

A review of Resident 37's History and Physical (H&P), dated 7/18/24, indicated, the resident has the capacity to understand and make decisions.

A review of Resident 37's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 6/5/24, 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.

A review of Resident 50's Admission Record, dated 7/21/24, indicated Resident 50 was admitted to the facility on [DATE REDACTED], with diagnoses including diabetes mellitus type two (a condition were your body has trouble controlling the level of sugar in the blood), end stage renal disease (ESRD, the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) with dependance on dialysis (treatment that helps your body remove extra fluid and waste products from your blood), generalized muscle weakness, ad reduced mobility.

A review of Resident 50's MDS, dated [DATE REDACTED], the MDS indicated, Resident 50 had intact cognition (ability to think, understand and make daily decisions). The MDS indicated Resident 50 required partial/moderate assistance from staff for eating and oral hygiene, and was dependent on staff for toileting, bathing, dressing and personal hygiene, bed mobility and transfers.

A review of Resident 59's Admission Record, dated 7/21/24, indicated Resident 59 was admitted to the facility on [DATE REDACTED], with diagnoses including diabetes mellitus type two, peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), generalized muscle weakness, difficulty walking, hear failure and lymphedema (Swelling, most often in an arm or leg, caused by

a lymphatic system [a group of organs, vessels and tissues that protect you from infection and keep a healthy balance of fluids throughout your body] blockage).

A review of Resident 59's H&P, dated 6/13/24, indicated, the resident had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 A review of Resident 59's MDS dated [DATE REDACTED], indicated the resident required set up or clean-up assistance with eating, and required maximal assistance from staff for toileting, bathing, dressing and personal hygiene, Level of Harm - Minimal harm or bed mobility and transfers. potential for actual harm

During an interview with Resident 50 on 7/19/24 at 7:49 pm, the resident stated the call lights take a long Residents Affected - Few time to be answered. Sometimes she has to wait for longer than 45 minutes to get help. The resident further stated all shift are affected by long wait times to get help.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 43261 potential for actual harm Based on observation, interview and record review, the facility failed to post in a visible and prominent place Residents Affected - Few daily; the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for three of three sampled days (7/19/2024, 7/20/2024, and 7/21/2024).

This deficient practice had the potential to prevent residents and visitors from knowing the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) and had the potential to cause inadequate staffing.

Findings:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43261 Residents Affected - Some Based on interview and record review, the facility failed to ensure that two of five sampled residents (Residents 26 and 52) psychotropic (A drug or other substance that affects how the brain works and causes changes in mood) medication regimens were managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to:

1. Ensure implementation of the facility's pharmacy recommendation for Resident 26's Risperdal (anti-psychotic medication) use.

2. Ensure the informed consents were in placed timely for Resident 52's physician's order for psychotropic medications.

These deficient practices had the potential to place Resident 26 and 52 at risk of receiving unnecessary medications and/or overuse of medication and adverse consequences while using the medications.

Findings:

1. A review of Resident 26's Admission Record, indicated Resident 26 was admitted to the facility on [DATE REDACTED] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) and schizophrenia (a mental health problem that primarily affects a person's emotional state.

A review of Resident 26's Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 6/25/2024, indicated Resident 26's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and dependent from staff with activities of daily living (ADLs- eating, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene).

A review of Resident 26's Order Summary Report (OSR), dated 3/8/2024, indicated a physician order for a Risperdal 1 milligram (mg- unit of measurement) by mouth two times a day.

A review of facility's Pharmacy Note to Attending Physician/Prescriber (PNAPP), dated 6/7/2024, PNAPP indicated, the medication must undergo a psychotropic drug regimen review with evaluation for dose reduction unless contraindicated. The PNAPP also indicated that Resident 26's attending physician agreed, documented and signed PNAPP that a dose adjustment will be done with physician (MD) order to discontinue Risperdal.

During a concurrent interview and record review with the Director of Nursing (DON) on 7/21/2024 at 4:32 p.m. , Resident 26's progress notes and Medical Doctor (MD) order was reviewed, missing documentation and/or MD order to discontinue Risperdal medication. The DON stated that pharmacy recommendations must be checked and completed by the physician and nursing staff was supposed to verify and carry out physician's response.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 A review of facility's policy and procedures (P&P), titled, Medication Regimen Review, revised on 4/17/2024, indicated, the consultant pharmacist contacts the physician immediately to report and identified medication Level of Harm - Minimal harm or irregularities verbally and documents the notification and physician documents in the medical record that the potential for actual harm irregularity has been reviewed and what action was taken to address it.

Residents Affected - Some A review of facility's P&P, titled, Tapering Medications and Gradual Drug Dose Reduction, revised on 4/17/2024, indicated, residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

43454

2. A review of Resident 52's Admission Record, indicated Resident 26 was originally admitted to the facility

on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including dementia (loss of cognitive functioning-thinking, remembering, and reasoning) in other diseases, schizophrenia and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

A review of Resident 52's dated 4/8/2024, indicated Resident 52's cognitive skills for daily decision-making was severely impaired and required maximal assistance to total dependent from staff with ADLs- eating, oral hygiene, toileting hygiene, shower/bathe, and personal hygiene.

A review of Resident 52's OSR, dated 12/27/2023, indicated a physician order for the following:

i. Escitalopram oral tablet 20 milligram (mg - unit of measurement) - give one tablet for depression manifested by (m/b) verbalization of sadness verified informed consent obtained by physician (MD).

ii. Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) oral tablet 8.6 mg - give 1 tablet one tablet at bedtime for schizophrenia m/b outburst anger verified informed consent obtained by MD.

A review of Resident 52's medical record with the Medical Record Director (MRD) on 7/21/2024 at 8:30 p.m.,

the MRD stated and indicated, there was no Informed Consent on 12/27/2023 for physician's order of Resident 52's escitalopram and Seroquel medications.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43261 Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure Resident 29's Yupelri (Revefenacin-medication being given via inhalation [inhaling medication in the form of gas or vapor] used to help muscles around the airways of the lungs to relax) inhalation solution was stored properly per manufacturer's policy.

This deficient practice had the potential to compromise the safety and effectiveness of medication, resulting

in medication error when administered to Resident 29.

Findings:

A review of Resident 29's Admission Record, indicated Resident 29 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED], with diagnoses including asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and generalized muscle weakness.

A review of Resident 29's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 5/5/2024, indicated Resident 29 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring moderate assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).

A review of Resident 29's Order Summary Report (OSR), dated 4/1/2023, indicated an order for Yupelri inhalation solution 175 microgram (mcg - unit of measurement) per three milliliter (ml - unit of measurement), to inhale 1 vial via nebulizer (inhalation machine) one time a day.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252 potential for actual harm Based on observation, interview, and record review, the facility failed to provide palatable flood for two of six Residents Affected - Few residents sampled (Residents 59 and 84).

This failure resulted in bland, unpalatable food being served to the residents and surveyors.

Findings:

A review of Resident 59's Admission Record, dated 7/21/24, indicated Resident 59 was admitted to the facility on [DATE REDACTED], with diagnoses including diabetes mellitus type two, peripheral vascular disease (PVD - a disorder that involves the narrowing of peripheral blood vessels), generalized muscle weakness, difficulty walking, hear failure and lymphedema (tissue swelling).

A review of Resident 59's History and Physical (H&P), dated 6/13/24, indicated, the resident had the capacity to understand and make decisions.

A review of Resident 59's Minimum Data Set (MDS - A standardized assessment and care screening tool) dated 4/11/24, indicated the resident required set up or clean-up assistance with eating, and required maximal assistance from staff for toileting, bathing, dressing and personal hygiene, bed mobility and transfers.

A review of Resident 84's Admission Record, dated 7/21/24, indicated Resident 84 was admitted to the facility on [DATE REDACTED], with diagnoses including hypertension, generalized muscle weakness, anemia (low levels of healthy red blood cells to carry oxygen throughout your body), fibromyalgia (disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues) and abnormal posture.

A review of Resident 84's H&P, dated 6/14/24, indicated, the resident had the capacity to understand and make decisions.

A review of Resident 84's MDS dated [DATE REDACTED], indicated the resident required set up or clean-up assistance with eating, and was dependent on staff for bed mobility, toileting, bathing, dressing and personal hygiene.

During an interview on 7/19/24 at 8:04 pm with Resident 59, the resident stated overall the food could be better and there is no variety when she (Resident 59) asks for something different for the resident's sack lunch.

During an observation on 7/20/24 at 10:10 am, Morning [NAME] (AMC) was observed frying hamburger patties, and not seasoning them.

During a regular diet test tray evaluation on 7/20/24 at 12:35 pm by three surveyors, the test tray was noted to have a hamburger that was bland and had a soggy bottom bun, a peach pie that was smashed and potato salad that was also bland in taste.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During an interview on 7/21/24 at 7:47 pm with Resident 84, the resident stated the food was bland, and needed seasoning. States she regularly had to add salt and sometimes cannot find the packet on her tray. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedures titled Resident Food Preferences, reviewed 4/17/24, indicated, Individual food preferences will be assessed upon admission and communicated to the Residents Affected - Few interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. The resident has a right not to comply with therapeutic diets . if the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252

Residents Affected - Few Based on observation, interview, and record review, the facility failed implement appropriate sanitation and food handling practices by failing to discard expired food stored in the resident's nutrition refrigerators.

This deficient practice had the potential to result in unsafe food management.

Findings:

During an observation with concurrent interview on [DATE REDACTED] 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 [DATE REDACTED] and another with a brought in date of [DATE REDACTED]. 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 [DATE REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing Level of Harm - Potential for the facility. minimal harm 45455 Residents Affected - Some Based on observations, interviews, and record review the facility's governing body (individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454 potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Some a. Ensure one of five sampled residents (Resident 66) who was on a transmission-based isolation for extended spectrum beta-lactamase (ESBL - an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that doctors use to treat infections) was placed into a private single room.

b. Ensure staff wore appropriate Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to one of four sampled residents (Resident 192) who is on a transmission-based precaution room.

c. Ensure one of five sampled residents, (Resident 292), who had an active infection of Escherichia coli in urine (E. coli - bacteria that normally lives harmlessly in the human intestinal tract, but it can cause serious infections if it gets into the urinary tract) was placed into a contact precaution room according to facility's policy and procedures (P&P) and Centers of Disease Control and Prevention (CDC).

These deficient practices placed increased the risk of acquiring and transmitting infections to other residents, staff and visitors in the facility.

Findings:

A review of facility's license, effective date 11/1/2023 indicated, the facility has a licensed bed capacity of 97 residents.

1a. A review of Resident 66's Admission Record indicated the resident was originally admitted to the facility

on [DATE REDACTED] and was readmitted on [DATE REDACTED], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function), and dysphagia (difficulty swallowing food or liquid).

A review of Resident 66's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 7/3/2024, indicated Resident 66 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required total dependence from staff for activities of daily living (ADL-eating, oral hygiene, toileting hygiene, personal hygiene).

A review of Resident 1's Physician Order Summary dated 7/13/2024, indicated a physician ordered, Contact Isolation (residents with known or suspected infections that represent an increased risk for contact transmission) every shift for ESBL in the urine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 1b. A review of Resident 192's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnosis including malignant neoplasm of rectum (rectal cancer - a type of cancer that forms in Level of Harm - Minimal harm or the tissues of the rectum), chronic kidney disease and respiratory disorders (a type of disease that affects potential for actual harm the lungs and other parts of the respiratory system [nose, mouth, throat, voice box, windpipe and lungs]).

Residents Affected - Some A review of Resident 192's MDS dated [DATE REDACTED], 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 Order Summary Report as of 7/21/2024 indicated, there are no physician's order for transmission-based precaution.

A review of facility's census indicated indicated that:

On 7/19/2024, the facility had 85 residents with 12 empty beds,

On 7/20/2024, the facility had 85 residents with 12 empty beds; and

On 7/21/2024, the facility had 87 residents with 10 empty beds.

During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 7/19/2024 at 7:49 p.m., LVN 2 stated and confirmed Resident 66 was on contact isolation for ESBL and that Resident 66 sahred the same room with Resident 192. LVN 2 stated Resident 66 and Resident 192 were not on any contact isolation.

During an observation on 7/19/2024, 7/20/2024, and 7/21/2024, Resident 66, who was on contact precaution isolation, was placed in a room shared with one other resident, Resident 192.

During an interview with the Infection Preventionist Nurse (IPN) on 7/21/2024 at 3:38 p.m., the IPN stated, residents who are on contact precaution should be placed in a private room if there are room available in the facility. The IPN stated, the facility had empty rooms available on 7/19/2024, 7/20/2024, and 7/21/2024. The IPN stated, this place other residents at risk of contacting the infection.

During an interview with the Director of Nursing (DON) on 7/21/2024 at 9:10 p.m., the DON stated residents

on contact isolation should be placed in a private single room if the facility is able to accommodate them. The DON further stated, the facility had empty rooms available. The DON further stated, Resident 192, is being co-horted (share) with [Resident 66] who is on contact precaution isolation.

A review of the facility's policy and procedures titled Isolation - Transmission-Based Precautions and Enhanced Barrier Precautions, reviewed on 4/17/2024 indicated, The individual on contact precautions is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. A review of Resident 192's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses including malignant neoplasm of rectum, chronic kidney disease and respiratory Level of Harm - Minimal harm or disorders potential for actual harm

A review of Resident 192's MDS dated [DATE REDACTED], indicated Resident 192 had severely impaired cognition for Residents Affected - Some 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.

During an observation of Resident 192 on 7/19/2024 at 6:25 p.m., Resident 192's room was observed with a signage of contact isolation room. Certified Nursing Assistant 4 (CNA 4) was observed feeding Resident 192 inside Resident 192's room and was not wearing any appropriate PPE.

During an interview with CNA 4 on 7/19/2024 at 6:40 p.m., CNA 4 stated, she does not need to wear full PPE while assisting Resident 192 and/or going inside Resident 192. CNA 4 further stated, Resident 192's roommate (Resident 66), is the one with a contact precaution isolation order and I was told that I did not need to wear full PPE by other CNAs (unidentified) during hand-off reports.

During an interview with LVN 2 on 7/19/2024 at 7:49 p.m., LVN 2 stated, staff need to wear full PPE before entering Resident 192 and Resident 66's room, because the whole room is a contact isolation room.

During an interview with the IPN on 7/21/2024 at 3:38 p.m., the IPN stated, all staff should wear full PPE

before entering a contact isolation room. The IPN stated, if they don't wear full PPE, if places risk of transmitting the infection to other residents, staff and visitors in the facility.

3. A review of Resident 292's Admission Record indicated resident was admitted to the facility on [DATE REDACTED] with diagnoses including DM, respiratory disorders in diseases, and malignant neoplasm of prostate (prostate cancer - a disease in which malignant (cancer) cells form in the tissues of the prostate).

A review of Resident 292'2 MDS dated [DATE REDACTED], indicated Resident 292's cognitive skills for daily decision-making mildly impaired.

A review of Resident 292's Lab Results Report, collected on 7/12/2024 indicated, Resident 292's urine culture (a test healthcare providers use to check for a UTI by seeing if bacteria or fungi can grow from a sample of urine) tested positive for e-coli.

A review of Resident 292's Order Summary Report dated 7/15/2024 indicated, a physician ordered, macrobid (medication used to treat and prevent urinary tract infections) 100 milligrams (mg - unit of measurement) by mouth twice daily for Urinary Tract Infection (UTI). The Order Summary Report did not indicate Resident 292 had an order for contact isolation.

During an observation of Resident 292 on 7/21/2024 at 4:05 p.m., Resident 292 was placed in a room shared with two other residents and Resident 292. There was no signage for contact precaution isolation posted outside the door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview with the IPN on 7/21/2024 at 5:33 p.m., the IPN stated, Resident 292, is on enhanced precaution room and not on any contact precaution room. The IPN stated, Resident 292 has an indwelling Level of Harm - Minimal harm or catheter (a device that drains urine (pee) from urinary bladder into a collection bag outside of the body when potential for actual harm a person can't pass urine on their own or for various medical reasons) and incontinent for bowel and bladder.

The IPN stated, there is difference between enhanced precaution room and contact precaution isolation. Residents Affected - Some

During an interview with DON on 7/21/2024 at 9:12 p.m., DON stated resident who have e-coli in urine does not need to be placed in a contact precaution room according to their policy. DON further stated, they have empty beds available in the facility.

A review of the facility's policy and procedures titled Isolation - Transmission-Based Precautions and Enhanced Barrier Precautions, reviewed on 4/17/2024 indicated, Contact precautions are implemented for residents knows or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45455

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in one of 35 multiple resident bedrooms (room [ROOM NUMBER])

This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Findings:

A review of the facility's Request for Room Size Waiver letter, dated 4/19/2024, submitted by the Administrator, indicated there is 1 room not meeting the 80 square feet requirement per resident according to federal regulation. The letter indicated that the the room size (room [ROOM NUMBER]) does not adversely affect any residents or any resident's special needs. The letter also indicated both ambulatory and non-ambulatory residents can freely move in the rooms without harm or impediment and there have been no grievances from residents, family members or staff regarding he room size of the room in question.

A review of the undated Client Accommodations Analysis submitted by the facility indicated the following rooms with their corresponding measurements:

Rooms # Total Sq. Ft Resident # Beds Floor Area Sq. Ft/Resident.

room [ROOM NUMBER] 154 square feet 2 beds occupancy 77 square feet per resident

The minimum square footage for a 2-bed room should be 160 sq. ft. per federal regulation.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 055977

F-F686

Findings:

A review of Resident 16's Admission Record indicated the resident was originally admitted on [DATE REDACTED] and was readmitted on [DATE REDACTED] 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), type two diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).

A review of Resident 16's Miimum Data Set (MDS- a standardized assessment and care screening tool) dated 6/28/2024, 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. The MDS also indicated Resident 16 was at risk of developing pressure ulcers/injuries and was on a pressure reducing device for bed.

A review of Resident 16's CP 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 Order Summary Report (OSR), dated 9/8/2022 indicated a physician ordered, Low-air- for skin management. Monitor for proper functioning and settings per resident's weight.

A review of Resident 16's Weight Summary Report, dated 7/16/2024 indicated, Resident 1's weighed 98 pounds (lbs. - unit of measurement).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 7/20/2024 at 6:50 p.m., Resident 16's LAL mattress was observed with a setting of 130. LVN 2 stated, the knob setting Level of Harm - Minimal harm or indicated the weight in lbs. and that the current LAL mattress setting for Resident 16's LAL mattress was potential for actual harm incorrect. LVN 2 stated, the setting should be close to 98 lbs. which was Resident 16's current weight.

Residents Affected - Few A review of facility's policy and procedures (P&P), titled, Care Plans, Comprehensive Person-Centered reviewed on 4/17/2024 indicated, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 35 055977 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45455 potential for actual harm Based on observation, interview, and record review, the facility failed to provide preventive care consistent Residents Affected - Some with professional standards of practice to three of three sampled residents (Residents 1, 16, and 292), who was at risk for developing of pressure injuries (Damage to an area of the skin caused by constant pressure

on the area for a long time), by failing to:

1. Ensure Resident 292 had bilateral heel protectors (devices that include foam or gel that are used to help prevent heel pressure ulcers) placed while in bed per physician's order (MD order).

2. Ensure the appropriate settings for the low air loss mattress (LALM-a mattress designed to prevent and treat pressure wounds) for Residents 1 and 16 according to MD's order and/or the facility's policy.

These deficient practices placed Residents 1, 16, and 292 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and development of new pressure injury/ies.

Cross Reference