Kennedy Care Center

In the surveyor’s words

From the most serious findings on record at Kennedy Care Center, in the surveyor’s own words.

• Actual harm, isolatedF687Mar 20, 2025

  Based on interview and record review, the facility failed to provide foot care consistent with professional standards to maintain skin integrity for one of four sampled residents (Resident 1) by failing to: 1.Ensure that the Magnetic Resonance Imaging (MRI - uses a strong magnetic field and radio waves to create detailed images of the inside of the body, aiding in the diagnosis and monitoring of various conditions) recommended by the Wound Physician Specialist (WPS) to rule out (R/O) osteomyelitis (a bone infection that can occur when bacteria spread to the bone, causing pain, swelling, and potentially leading to serious complications if left untreated) on 2/12/2025 after Resident 1's left plantar foot (located on the bottom of the foot) wound has reopened. […]

• Actual harm, isolatedF880Nov 15, 2022

  Based on observation, interview, and record review, the facility failed to maintain a system to prevent and control the transmission of COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) infection for eight of eight sampled residents (Resident 1, 2, 3, 4, 5, 6, 7 and 8) by failing to ensure seven staff: -Housekeeper [HK] 1, -Occupational Therapy Aide [OTA], -Maintenance Director, -Laundry Worker [LW] 1, Licensed Vocational Nurse [LVN] 1, Certified Nursing Assistant [CNA] 1 and CNA 2) were fit tested (a test to verify that a respirator is both comfortable and provides the wearer with the expected protection)… […]

• No harm, potential for more than minimal, widespreadF921Feb 17, 2026

  Based on interview, observation and record review, the facility failed to maintain a safe, and functional environment for residents, staff and visitors by failing to ensure one of two entry doors in the facility was free from mechanical and/or electrical failure and in a safe operating condition.This deficient practice resulted to the theft of Resident 1's mobile phone by an unhoused individual (HL 1) who entered the facility without staff awareness on 1/9/2026, placing all residents, staff, and visitors at risk of avoidable abuse and misappropriation of property.Findings:During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control… […]

• No harm, potential for more than minimal, widespreadF812Aug 8, 2025

  Based on observation, interviews, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 76 of 76 residents when: Improper Storage of Fooda. Improper Storage and labeling of Food b. Prepared leftover tuna stored in the refrigerator c. Dietary staff did not follow cool down methodd. Multiple food items with expiration datese. Dietary Cooks did not follow the thawing process 2. Equipment Cleanliness/Cross-contaminationa. The stove was dirtyb. The floor in front of the stove was dirtyc. Multiple large silver pans were dirty 3. […]

• No harm, potential for more than minimal, patternF684Feb 17, 2026

  Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of four sampled residents, (Resident 1) by failing to: Ensure Resident 1 was assessed and evaluated after an incident of theft and misappropriation of property by an unhoused individual (HL 1) who gained access to the facility without consent on 1/9/2026.Ensure a complete documentation of the incident was completed and documented according to facility's policy and procedure (P&P) titled, Charting and Documentation, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program.These deficient practices placed Resident 1 in delayed intervention to provide treatment and care and to ensure safety of Resident 1 and… […]