Inspection Reports for
Kennedy Care Center

The facility failed to administer a prescribed nicotine patch to Resident 1, failed to label over-the-counter medications with opening dates, and failed to implement infection control protocols by not using protective gowns during high-contact care for Resident 2. These deficiencies posed potential risks of unmet care needs, medication safety issues, and infection transmission.

The facility was found deficient in protecting residents' dignity by failing to cover an indwelling urinary catheter privacy bag, maintaining confidentiality by sending resident information via personal cell phones, delayed treatment for urinary tract infection due to missed physician orders, and failure to follow infection control protocols including proper use of personal protective equipment (PPE) during care of residents on enhanced barrier precautions.

The facility was found deficient in multiple areas including failure to honor residents' rights to retain personal possessions, failure to conduct background checks on employees, failure to administer medications as ordered, late submission of resident assessments, delays in answering call lights, inadequate feeding tube administration, poor food palatability and preparation, unsafe food storage and handling, incomplete staff training and competency evaluations, and incomplete tuberculosis screening for staff. Despite some deficiencies, the facility generally provided adequate space and care.

The facility failed to ensure the call system was functional for one out of five sampled residents, resulting in potential delays in assistance that could lead to frustration, falls, and accidents. The call button for Resident 2 was found to be cracked and intermittently non-functional, posing a risk to resident safety.

The facility failed to maintain a homelike environment by not ensuring two shower rooms were clean and free from urine odor, resulting in a foul-smelling environment. Additionally, the facility failed to properly store and timely administer medications for several residents, increasing the risk of harm.

The complaint investigation focused on Resident 1's care deficiencies including failure to develop care plans, inadequate wound and foot care leading to serious infections and amputations, refusal of care and repositioning, unmanaged pain, and behavioral health needs. Substantiation status is not explicitly stated.

The facility failed to develop and implement individualized care plans addressing Resident 1's wounds, pain, refusal of care, and behavioral issues. Pressure ulcer assessments were inaccurate, and foot care was inadequate, leading to severe complications including amputation. Resident 1 was noncompliant with repositioning and exhibited behavioral disturbances that were not properly monitored or managed. Pain was not effectively assessed or treated. The facility also failed to provide necessary behavioral health care and services to manage Resident 1's aggressiveness.

The facility failed to provide preventive care consistent with professional standards to one resident at risk for pressure injuries by not properly setting the low air loss mattress according to physician orders and not monitoring and recording the resident's weight as per facility policy. These deficiencies placed the resident at risk for poor wound healing and potential development of new pressure injuries.

The facility failed to ensure that Resident 1's court-delegated general power of attorney was informed of the resident's health care decisions, placing the resident at risk for uninformed decisions. The Social Services Director confirmed that the facility did not obtain or update the POA documentation timely, violating facility policy and resident rights.

The facility failed to develop and implement a comprehensive care plan for a resident with a nephrostomy tube, failed to label and document peripheral IV catheter dressings properly, and did not have a Director of Nursing onsite for at least 8 consecutive hours daily from November 2024 to January 2025. These deficiencies posed potential risks to resident health and safety.

The facility failed to maintain resident dignity by allowing staff to stand over a resident while feeding, rather than sitting down, which could negatively impact the resident's self-esteem and comfort. The deficiency was observed during a meal and confirmed through staff interviews and policy review.

The complaint investigation found that Resident 1's legal representative was not notified of a change in condition on 8/6/2024, and the facility failed to provide requested medical records and the medical record release form to the legal representative despite multiple requests.

The facility failed to inform Resident 1's legal representative of a change in condition on 8/6/2024 and failed to provide timely access to Resident 1's medical records and the medical record release form upon request. These failures violated the resident's rights to notification and access to personal and medical records.

The complaint investigation found that Resident 1 left the facility without authorization on 7/3/2024. The facility did not report this unusual occurrence within 24 hours as required. Resident 1 was found by housekeeping at the facility entrance with belongings and stated he was leaving. The Director of Nursing confirmed Resident 1's unauthorized leave was later documented as leaving against medical advice, not an elopement. The facility's policies on unusual occurrences and wandering/elopement were reviewed and found to require timely reporting and supervision to prevent such incidents.

The facility failed to report Resident 1's unauthorized leave within the required 24-hour timeframe and failed to provide adequate monitoring and supervision to prevent Resident 1 from eloping. This placed Resident 1 at risk of exposure to environmental hazards and medical complications. Resident 1 left the facility without authorization but was later documented as leaving against medical advice.

The facility was found deficient in multiple areas including resident dignity and respect, informed consent for vaccinations, medication self-administration, call light accessibility and response times, care planning, pressure ulcer prevention, infection control, food palatability, staffing postings, and administrator oversight.

The facility failed to maintain infection control measures by not ensuring staff wore full PPE when providing care to a resident requiring enhanced barrier precautions, potentially risking the spread of infection to residents, visitors, and staff.

The facility failed to follow professional standards and facility policies in administering medications when a resident refused eyedrops, providing appropriate foot care and wound treatment, and ensuring medications were not left unattended at the bedside. These deficiencies posed potential risks of harm including complications from glaucoma, delayed wound healing, and infection.

The facility failed to ensure the discharge summary was documented by the physician for one sampled resident, resulting in incomplete records. Additionally, the facility did not post the actual direct care service hours per patient day daily, making this information inaccessible to residents and visitors.

The complaint involved allegations by Residents 3 and 4 that a Certified Nursing Assistant (CNA 5) was rough and rushed during care. The facility failed to investigate or monitor the allegations, failed to report to the state agency, and did not place the accused employee on leave. The Director of Nursing acknowledged the failure to investigate and report.

The facility failed to timely report and investigate allegations of abuse by staff towards Residents 3 and 4, resulting in delayed onsite inspection and potential risk of further abuse. Additionally, the facility failed to develop a comprehensive care plan for Resident 1's self-administration of medications, failed to manage Resident 1's pain appropriately by not ordering prescribed medications, failed to properly store Resident 1's medications, and failed to follow dietary menu instructions for multiple residents.

The complaint investigation found substantiated issues with call light response times and failure to accommodate resident allergies, specifically for Resident 5 who was allergic to chicken but was served chicken multiple times despite notifying staff.

The facility failed to timely answer call lights for 2 of 5 sampled residents, resulting in delayed assistance. Additionally, the facility failed to perform a dietary screening for one resident and repeatedly served food containing an allergen to which the resident was allergic, risking allergic reactions and nutritional issues.

The visit was complaint-related, triggered by allegations of failure to protect resident dignity, inadequate care planning, safety hazards related to smoking and oxygen use, respiratory care deficiencies, improper food temperature, and infection control lapses. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to cover urinary catheter bags compromising resident dignity, lack of comprehensive care plans for urinary catheter care, unsafe storage of cigarettes and oxygen posing fire hazards, inadequate respiratory care with unlabeled and improperly stored nasal cannula tubing, serving food at unsafe temperatures, and improper storage of clean Hoyer lift slings mixed with soiled linens increasing infection risk.

The facility failed to ensure proper transcription, documentation, and administration of wound care treatments for three of four sampled residents with wounds, potentially placing them at risk for infection and worsening conditions. Documentation gaps and missing treatment orders were noted despite some treatments likely being performed.

The complaint was substantiated as the nursing staff failed to promptly answer call lights, potentially delaying resident care and causing harm. The Director of Nursing confirmed the expectation for prompt response and acknowledged the potential for harm if calls are not answered timely.

The nursing staff failed to answer Resident 1's call bell promptly, which had the potential to delay necessary care and cause harm or injury. Observations, interviews, and record reviews confirmed the delay in response to the call light.

The facility failed to develop a care plan to address Resident 1's refusal of repositioning and perineal care, which had the potential to delay treatment, lead to inadequate care, and cause injury. Resident 1 was cognitively intact but refused care and became physical with staff during repositioning attempts. The nursing supervisor was aware, and the resident was educated about repositioning but refused the plan of care.

The complaint investigation found that Resident 1's wound care orders were not transcribed timely, wound care treatments were not documented for several days, and the care plan was delayed, increasing risk of infection or further skin breakdown. Interviews with Treatment Nurse 1, Director of Staff Development, Director of Nursing, and Certified Nursing Assistant confirmed these issues.

The facility failed to transcribe physician's orders, document and treat wound care from 8/25/2023 through 8/29/2023, and develop a care plan for Resident 1's left heel pressure sore for 18 days, potentially delaying necessary care and wound healing.

The facility failed to provide a privacy cover for the urinary drainage bag of one sampled resident, which posed an increased risk for loss of privacy and dignity. Interviews with staff confirmed the absence of a privacy cover and acknowledged the requirement for such covers to maintain resident dignity.

The facility failed to complete smoking assessments and initiate smoking care plans for two residents, placing them at risk for burns and injuries. Additionally, the facility failed to ensure one resident received a physician-ordered Registered Dietician consultation, resulting in inadequate delivery of necessary dietary care.

The complaint investigation focused on Resident 1's elevated blood sugar levels and missed diabetic medications. The investigation found the physician was not notified of high blood sugar readings (431 mg/dL and 421 mg/dL) and multiple medication doses were missed due to pharmacy delivery issues. Interviews with nursing staff and family members confirmed these findings.

The facility failed to ensure Resident 1 received treatment and care according to professional standards, including failure to notify the physician of elevated blood sugar levels above 400 mg/dL and missed doses of diabetic medications. These deficiencies increased the risk to Resident 1's health and delayed necessary interventions. The facility also experienced pharmacy delivery delays contributing to missed medication doses.

The visit was triggered by a COVID-19 outbreak complaint. The findings indicated failure to follow infection control screening protocols, increasing risk of COVID-19 spread.

The facility failed to ensure standard infection control practices to prevent the spread of COVID-19, including keeping the back door closed to ensure screening and screening all staff and family members at the reception area. Only 8 of 19 staff on shift were screened, posing a risk of infection spread.

The facility failed to ensure that nursing staff treated residents with respect and dignity by standing over a resident while feeding, which could negatively impact the resident's psychosocial well-being. The facility's policy supports dignified care, but staff did not consistently follow it.

The complaint investigation found that the facility did not provide Resident 1's medical records within the required two business days after the request was received on 3/14/2023. Records were only sent to the requestor on 3/21/2023, exceeding the facility policy timeframe. The deficiency was substantiated with potential harm due to delayed access.

The facility failed to provide Resident 1's medical records within the required two business days, delaying access to requested records. This deficient practice denied the resident or representative timely access to personal and medical records.

The facility was found deficient in multiple areas including resident dignity and privacy, call light accessibility, care plan development and implementation, medication administration and monitoring, infection control, medication storage and labeling, food safety and sanitation, pressure ulcer prevention, and room size compliance. Several residents were affected by these deficiencies, with potential risks for harm or delayed care.