John J Kane Regional Center-Ro

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff and family, it was determined that the facility failed to provide preventative interventions, and treatments which resulted in the development of avoidable pressure ulcers for two of two residents (Resident R5 and Resident R13), resulting in an infection for one of two residents (Resident R5). This failure resulted in an immediate jeopardy. Findings Include: Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, muscle wasting and atrophy (occurs when muscle fibers shrink due to disuse, aging, malnutrition, genetic factors, or nerve-related conditions), and Parkinson's Disease (a disorder of the nervous system that affects movement and gets worse over time). [...]

Inspectors wroteBased on clinical record review, review of resident fund reports, and staff and resident interviews, it was determined that the facility failed to provide quarterly resident trust fund (resident funds account with current accounts open and holding resident monies) statements for three of three residents (Residents R12, R23, and R48), and failed to accurately account for resident personal funds for one of three residents (Resident R48).

Inspectors wroteBased on a review of clinical records, and staff interviews, it was determined that the facility failed to develop and implement care plans that included instructions to provide person centered care for four of eight residents (Resident R1, R59, R61, and R123). Based on a review of facility policy, clinical records, and staff and resident interviews, it was determined that the facility failed to develop and implement care plans that included instructions to provide person centered care for four of eight residents (Resident R1, R59, R61, and R123).

Inspectors wroteBased on facility policy, clinical record review, resident and staff interview, it was determined that the facility failed to procure complete physician's orders for residents with an ostomy (an opening into the abdomen that removes waste) for one of three residents (Resident R7), and residents utilizing a bedside commode for two of two residents (Residents R7 and R126).

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing, and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of three nursing units (Three East), and two of five residents (Group Resident (GR)1, and GR2)

Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for three of five nurse aide (NA) personnel records (NA Employee E23, E25, and E26).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a medication pass, failed to follow Enhanced Barrier Precautions (EBP- infection control measures recommended by the Center for Disease Control (CDC) to reduce the transmission of multidrug-resistant organisms (MDROs) for one of three residents (Resident R7), failed to prevent cross contamination during a dressing change (Resident R13), and failed to conduct an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread for twelve of twelve months (April 2025 to April 2026).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to inform a resident or resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of five residents (Resident R103).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of three nursing stations (Third floor East) and failed to maintain the confidentiality of residents' medical information for one of five medication carts (Third floor medication cart ten).

Inspectors wroteBased on clinical record review, facility policy, and staff interviews, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for two of three residents (Resident R5 and R103).

Inspectors wroteBased on reviews of facility policy, facility documents, clinical records and staff interviews it was determined that the facility failed to implement written policies and procedures to ensure a complete, thorough and timely investigation was completed for one of two residents (Resident R72).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure the resident's representative was provided with written a notice of transfer for one of four residents (Resident R1), and notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of four resident hospital transfers (R103).

Inspectors wroteBased on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for one of six residents (Residents R1).

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received a copy of the baseline care plan and understood the baseline care plan for two of four residents (Resident R1 and R72).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for two of three residents (Residents R7 and R72).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Residents R12) reviewed.

Inspectors wroteBased on review of clinical records and staff interviews it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R61 and Resident R123). Findings Include: Review of the Oxygen Guideline policy last reviewed 5/28/26, indicated it is the facility policy to administer oxygen when prescribed to provide comfort and improve quality of life. Sets ups (cannulas, face masks, respiratory delivery, humidification bottles) should be changed at least every seven days and are labeled with date of change initiated by staff. Humidification bottles should be filled with distilled water and should be checked every shift and filled if needed. Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses of lymphedema, morbid obesity, and muscle wasting and atrophy. [...]

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice for one of two residents (Resident R103).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised care in a timely manner for one of 12 sampled residents. (Resident R5)

Inspectors wroteBased on clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility for two of six residents (Resident R48 and R72).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in two of three medication carts (9 East Medication Cart and 10 East Medication Cart) and in one of two medication rooms (3 East Medication Room).

Inspectors wroteBased on review of clinical records, select facility policy, payor source data, and resident and staff interview, it was determined the facility failed to ensure timely and necessary dental services for one resident who is a Medicaid recipient (Resident R5) out of three residents reviewed.

Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to prepare food in a form to meet physician ordered diets for one of eleven residents reviewed (Resident R25).

Inspectors wroteBased on review of job descriptions, 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 when it was determined that the facility had extensive noncompliance in multiple areas of pressure ulcer care, which resulted in the development of avoidable Stage III or Stage IV pressure ulcers for two of two residents (Resident R5 and Resident R13), resulting in an infection for one of two residents (Resident R5). This failure resulted in an immediate jeopardy.

Inspectors wroteBased on review of facility documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for one of eight staff members (nurse aide (NA) Employee E27).

Inspectors wroteBased on review of facility documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for one of eight staff members (nurse aide (NA) Employee E27).

Inspectors wroteBased on review of facility documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for one of one of eight staff members (nurse aide (NA) Employee E27).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post complete contact information for as required for the Office of the State Long-Term Care Ombudsman program, and Medicaid Fraud Unit, and failed to post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation on three of three floors (First, Second, and Third Floors).

Inspectors wroteBased on review of facility policy, resident clinical records, facility documents, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of verbal abuse for one of three sampled resident records (Resident R1).

Inspectors wroteBased on a review of facility policy and clinical record review, it was determined that the facility failed to protect residents from neglect due to lack of supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Closed Record Resident CR1).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation with a complete and thorough investigation of an incident involving an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Closed Record Resident CR1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to implement policies and procedures to report an incident of neglect for one of three residents (Closed Record Resident CR1).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to initiate a thorough investigation for incident of elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents reviewed (Closed Record CR1).

Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of three residents (Closed Record Resident CR1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs after an incident of elopement for one of three residents (Closed Record Resident CR1).

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 (Closed Record Resident CR1). This was identified as past non-compliance.

Inspectors wroteBased on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and staff interview it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of three residents (Resident R1).

Inspectors wroteBased on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to permit a readmission to the facility after hospitalization and failed to demonstrate in the clinical record that the discharge was appropriate and necessary for one of three sampled closed resident records (Closed Resident Record CR1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R2), which resulted in actual harm of a hematoma (a localized collection of blood outside the blood vessels, typically caused by blood vessel damage from trauma or injury) on residents left side of forehead, a laceration (cut) above the left eye, and a hematoma to right knee with pain for Resident R2.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, resident interviews, and staff interviews, it was determined that the facility failed to provide appropriate equipment to prevent an accident for one of two residents (Resident R1), which resulted in actual harm of bruising and a fracture of residents right foot for Resident R1, and failed to provide adequate supervision and assistance for one of two residents (Resident R2), which resulted in actual harm of a hematoma (localized collection of blood outside the blood vessels, typically caused by blood vessel damage from trauma or injury) on residents left side of forehead, a laceration (cut) above the left eye, and a hematoma to right knee with pain for Resident R2.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for two residents. This failure created an immediate jeopardy situation for two of 21 residents who were identified as at risk for elopement (Residents R6, and R111).

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly store, label. and date food and failed to monitor expiration dates of food products in the Main Kitchen which created the potential for food borne illness. Findings Include: Review of the facility policy Storing: Food and Equipment last reviewed 1/2/25, indicated that team members must store food in a manner that ensures quality, freshness, and safeguards against foodborne illness. All team members must follow food and temperature guidelines, labeling, use-by-dates, food storage chart, freezing, and leftover guidelines to ensure food and equipment criteria are met. Label food with name of product, date by which product should be used, and date thawed or frozen if applicable. Food should be discarded or used by the use-by-date. [...]

Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents requiring adequate supervision to prevent elopement.

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for four of four residents (Residents R7, R42, R66, and R219).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for three of four residents (Residents R35, R91, and R368).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of seven residents (Residents R5, R102, and R368).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of four crash carts and three of six Automated External Defibrillators (AED - a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to provide a dignified dining experience for one of three units observed (Three East) and failed to protect and value residents' private space for one of three units observed (Three East).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three resident areas (room [ROOM NUMBER]).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of four residents reviewed (Residents R35 and R68).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of decreased Capillary Blood Glucose (CBG) levels per physician orders and failed to implement the facility's hypoglycemia protocol for two of four residents (Residents R65 and R66).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of five residents (Residents R61 and R98).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of three medication carts (Three East Med Cart), and one of three medication rooms (Three [NAME] medication room).

Inspectors wroteBased on the review of clinical records, and staff interviews, it was determined that the facility failed to maintain and complete accurate, and appropriate documentation for two of eight residents (Resident R20, and R41).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of four residents (Residents R91).

Inspectors wroteBased on review of facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for two of eight staff members (Employee E12, and E13).

Inspectors wroteBased on a review of facility policy, observation, and staff interview, it was determined that the facility failed to properly reheat food items in the unit pantries creating the potential for cross contamination and food-borne illness for two of three units (2 East Pantry and 3 East Pantry).

Inspectors wroteBased on facility policy review, facility documents, and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications and ensure medication cart keys were provided to staff in accordance with professional standards during a shift to shift change on one out of six medication carts (3-West low hall ).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications securely in one out of six medications carts (3-West Low hall medication cart).

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for Respiratory Precautions for one of three residents (Resident R1), failed to prevent cross contamination by having dirty linens on the floor for one of eight residents (Resident R1), failed to maintain sanitary commodes in bathrooms for three of eight residents (Residents R2, R3, and R5), and failed to ensure floor mats were clean for four of eight residents (Residents R4, R6, R7, and R8).

Inspectors wroteBased on review of facility documentation, clinical record review and staff interview it was determined that the facility failed to follow a care plan and failed to develop a care plan for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record, family and staff interview, it was determined that the facility failed to follow the physician order, with missed medication, resulting in a hospitalization for one of four residents (Resident R1).

Inspectors wroteBased on clinical record reviews, observations and staff interviews, it was determined that the facility failed to prepare food in an appropriate consistency to meet the resident's needs for one of seven residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for one of three residents (Resident R52) who had two choking episodes, which resulted in actual harm during the second choking episode that required the Heimlich maneuver (abdominal thrusts that elevate the diaphragm and increase airway pressure, forcing air from the lungs; used to expel a foreign body from the airway).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined the facility failed to properly date and store food products in a manner to prevent foodborne illness in the Main Kitchen.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four out of four residents sampled with facility-initiated transfers (Residents R2, R41, R81, and R118).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of four residents (Resident R2, R41, and R81).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of four resident hospital transfers (Resident R2, R41, R81, and R118). Findings Include: Review of facility policy Bed Hold Notice and Procedures dated 1/3/24, indicated written notice of the bed hold policy will be provided to the resident or legal representative upon admission, upon hospital transfer, or at day two or three when resident is admitted to the hospital, and upon therapeutic leave of absences lasting over 24 hours. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident and a resident's representative was provided a summary of their completed baseline care plan for three of six residents (Resident R41, R71, and R82).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of three residents (Resident R83, R88, and R99).

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain a diagnosis for hospice services for four of four residents (Residents R70, R71, R81, and R98) and failed to have a completed hospice communication binder for one of four residents (Resident R71).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of three residents (Resident R52) involving a choking incident.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of a choking incident to rule out neglect for one of three residents (Resident R52).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels, failed to assess a resident for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) for one of three residents (Resident R73), and failed to obtain physician orders for one of ten residents (Resident R369).

Inspectors wroteBased on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for two of four residents (Resident R2 and R82).

Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of three residents reviewed (Resident R41).

Inspectors wroteBased on review of facility policy, observations, clinical record review, and staff interviews, it was determined that the facility failed to follow Enhanced Barrier Precautions (EBP) for two of four residents (Residents R1 and R65) and failed to track active infections for one out of three residents (R369).

Inspectors wroteBased on review of facility policy, clinical records, security footage, facility documents, and staff interviews, 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) for one out of four sampled residents (Resident R1). This deficiency is cited as past non-compliance.

Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to ensure that appropriate treatment and services were provided for six of six residents with an indwelling urinary catheter (Residents R1, R2, R3, R4, R5, and R6).

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to notify the resident's representative of a change in prescribed medication for Resident R1.

Inspectors wroteBased on review of facility policy, resident record, investigation documents and staff interview, it was determined that the facility failed to report an allegation of neglect within 24-hours for one of six sampled residents (Resident R1).

Inspectors wroteBased on facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for medication administration for one of eight residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of eight residents (Resident R1).