Kennedy Care Center

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review the facility failed to follow physician order to administer medication based on professional standards of clinical practice for one of five sampled residents (Resident 1). For Resident 1, the facility failed to administer the Nicotine (an addictive poisonous chemical found in tobacco) Patch (medication used to help stop smoking cigarettes)14 milligrams (mg- unit of measurement) per 24hours (14mg/24hrs) for smoking cessation. This failure had the potential to result in unmet care needs, ineffective management of smoking cessation and compromise Resident 1's health.During a review of the admission Record indicated the facility admitted Resident 1 on 12/3/25 with diagnoses including tobacco use and generalized muscle weakness. During a review of Resident 1's Physician Order dated 12/5/25 at 9:15 a.m., indicated an order for Nicotine Patch 14mg./24 hours apply one patch transdermal (application of medication through the skin) one time a day for smoking cessation for six weeks and remove per schedule. During a review of the Minimum Data Set (MDS- resident assessment tool), dated 12/10/25, indicated Resident 1 was cognitively intact. Resident 1needed substantial assistance (helper does more than half the effort) for toileting hygiene, shower/bathe, lower body dressing and putting on/taking off footwear. Resident 1 needed moderate assistance (helper does less than half the effort) with upper body dressing and supervision with eating and oral hygiene. During observation of medication administration and concurrent interview on 12/30/25 at 8:11 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 1's Nicotine Patch was not available. During follow-up interview on 12/30/25 at 10:15 a.m., LVN 1 stated Resident 1's physician needs to be notified that the Nicotine Patch was not available. LVN 1 stated Resident 1 can have withdrawals or side effects if the nicotine patch is not administered. During an interview on 12/30/25 at 1:07 p.m., the director of nursing (DON) stated the Nicotine Patch was a house supply and was available for administration to Resident 1. DON stated LVN 1 should have obtained the nicotine patch from

the medication room. During a review of the facility's policy and procedure (P&P) titled Administering Medications reviewed on 4/25 indicated medications are administered in a safe and timely manner and as prescribed. The same Policy indicated the medications are administered in accordance with prescriber orders, including any required timeframe.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure over the counter medications (OTC) were labelled with the date when the containers were first opened for one of one medication cart reviewed.

During observation on 12/30/25 at 9:56 a.m., one container of acetaminophen (medication for short term relief of minor aches and pain) and one container of docusate sodium liquid (DSS, medication to relieve constipation) had no date indicating when they were first opened. This deficient practice had the potential to administer the medications to residents beyond the recommended days of use after opening the container.

During observation and concurrent interview on 12/30/25 at 9:56 a.m. with Licensed Vocational Nurse (LVN 2), the acetaminophen and DSS containers were found in the medication cart that had no dates indicating when they were initially opened. During concurrent interview, LVN 2 stated the acetaminophen and the DSS did not have a date when it was opened. LVN 2 stated the acetaminophen and the DSS should have a date written on the containers when it was first opened .so we know how long we can use it for. During an

interview on 12/30/25 at 1:07 p.m., the director of nursing (DON) stated the acetaminophen and the DSS containers should have the dates when it was initially opened written on the container to know how long .it is safe to administer the medications. During review of the facility's policy and procedure (P&P) titled Medication Labelling and Storage reviewed on 4/25, the P&P indicated labelling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. [NAME]-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

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 potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to implement their infection control policy for one of five sampled residents (Resident 2). Resident 2, who was on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, microorganisms resistant to most antibiotics]), the facility failed to ensure protective gown was used when Resident 2 was repositioned in bed on 12/30/25 at 8:39 a.m.This deficient practice had the potential to spread infection to other residents and staff.During a review of admission Record indicated the facility admitted Resident 2 on 11/13/25 and re-admitted on [DATE REDACTED] with diagnoses including cerebrovascular (CVA, loss of blood flow to a part of the brain) with left side weakness, reduced mobility and generalized muscle weakness. During a review of Resident 2's Care Plan initiated on 11/16/25 indicated Resident 2 required EBP during high-contact care activities due to the presence of chronic wounds. The Care Plan goal indicated EBP will be appropriately utilized to reduce the risk of transmission of MDRO. The care plan interventions included utilizing the use of Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) by using including gowns and gloves during high contact resident care activities.During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 12/29/25 indicated Resident 2 had moderately impaired cognitive skills. The MDS indicated Resident 2 was dependent (helper does all of the efforts) on staff for toileting hygiene, shower/bathe, upper/lower body dressing and putting on/taking off footwear.

Resident 2 needed substantial assistance (helper does more than half the effort) for oral hygiene and set-up assistance with eating. During an observation on 12/30/25 at 8:39 a.m., Resident 2 was lying in bed with a breakfast tray at his bedside. Certified Nurse Assistant 1 (CNA1) entered Resident 2's room. CNA 1 was wearing gloves but had no protective gown. CNA 1, using Resident 2's bed linens, pulled up and repositioned Resident 2 so that Resident 2 can eat breakfast.During a follow-up interview on 12/30/25 at 8:46 a.m. CNA 2 stated he did not wear a protective gown while repositioning Resident 2 because he did not know Resident 2 was on EBP. During an interview on 12/30/25 at 8:47 a.m. Director of Staff Development (DSD) stated Resident 2 was on EBP due to multiple wounds. DSD stated Resident 2's name posted outside his room had an orange circle next to Resident 2's name to indicate that Resident 2 was on EBP. DSD stated CNA 1 should wear protective gown and gloves when performing high contact care activities like repositioning or changing Resident 2 to prevent the transmission of infections. During a review of the facility's policy and procedure (P&P) titled Enhanced Barrier Protections, reviewed on 4/25, the P&P indicated EBPs are utilized to prevent the spread of MDROs to residents. The same Policy indicated EBP refers to infection prevention and control interventions designed to reduce the transmission of MDROs

during high contact resident care. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high contact resident care activities requiring the use of gowns and gloves for EBPs included dressing, transferring and providing bed mobility.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet