John J Kane Regional Center-Mc

Inspectors wroteBased on review of facility policy, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of forty residents (Resident R1).

Inspectors wroteBased on review of job descriptions, facility documents, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of forty residents (Resident R1).

Inspectors wroteBased on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of five residents (Resident R1)A review of the facility policy Notification of Changes in Resident Condition and Treatment Changes dated 6/30/25, indicated to notify physician of changes, accidents, and injuries; and assessment findings and secures treatment and diagnostic direction and orders from physician. Also indicated to, document findings and notifications in the nurses' notes. [...]

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance.

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R1). This was identified as past non-compliance.

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed accurately for two of 18 residents (Resident R41 and R45) and failed to make certain that BIMS and/or PHQ-9 assessments were completed accurately for six of 12 residents (R13, R35, R41, R169, R174, and R190).

Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC - a form that providers must deliver to a patient covered under a Medicare when services are terminating. The NOMNC informs beneficiaries of their right to request a review of the discharge) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R203).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R40).

Inspectors wroteBased on a review of facility policy, federal regulation and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eight of 10 months (December 2023 and January, February, March, April, May, June, July, and August 2024).

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents (Residents R2).

Inspectors wroteBased on review of facility policy, clinical records, facility documents and staff interview, it was determined that the facility failed to make certain a resident was free from a physical restraint for one of five residents reviewed (Resident R1). This was identified as past non-compliance.

Inspectors wroteBased on review of facility policy, resident clinical record, investigation documentations and staff interview, it was determined that the facility failed to report an injury of unknown source which caused severe bruising and required xrays for one of three residents (Resident R148).

Inspectors wroteBased on review of facility policies, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia).

Inspectors wroteBased on a review of facility policy, observations, resident and staff interviews, it was determined the facility failed to provide grievance forms for filing anonymous grievances on three of three units (second floor unit, third floor unit and fourth floor unit).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident interview, and staff interview, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). This failure created an immediate jeopardy situation for one out of 195 residents (Resident R1).

Inspectors wroteBased on facility policy, observations, staff interviews it was determined that the facility failed to ensure that garbage and refuse was disposed of properly in the Food Service Department's refuse area (Main trash compactor).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview it was determined that the facility failed to implement a care plan for to monitor for signs and symptoms of hypo/hyperglycemia (high/low blood sugars) for one of three residents (Resident R251).

Inspectors wroteBased on review of literature from Poison Control, clinical record review, and staff interview, it was determined that the facility failed to assess a resident for signs and symptoms of toxicity and provide appropriate follow up care after a resident ingested a non-food substance for one of four dementia residents (Resident R151) and failed to asses and provide care for one of three resident experiencing hypoglycemia.

Inspectors wroteBased on review of facility documentation and resident interviews it was determined that the facility failed to assist the residents to meet or organize for three of 11 Months (May 2022, August 2022, and November 2022).