Health inspection·December 30, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Findings include: Review of facility policy All Policy and Procedures : General Guidelines dated 1/3/24, indicated Staff must document all care and services provided to the resident. Documentation should - d. Include identification, evaluation, intervention, and attempts to made to implement and revise the plan of care to address the changing needs of the resident. Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record MDS ( minimum data set - a periodic assessment of resident needs) dated 10/23/24, indicated diagnosis of unspecified dementia ( a general term for memory, language, problem -solving, and other thinking abilities that are sever enough to interfere with daily living) hypertension ( is when the pressure in your blood vessels is too high), and renal insufficiency (kidneys functioning poorly). Review of facility documentation dated 12/8/24, submitted to the State Regional Office indicated that Resident R1 was sent to the ER this morning with elevated blood pressure, increased pulse, heme test positive emesis . Review of Resident R1 clinical record indicated the following: Physician order: Clonidine patch weekly; 0.3mg/24hr Amount to administer:1 patch; transdermal. Review of Resident R1 November MAR (medication administration record - a record documenting residents medication) indicated the following: November 8, 2024 patch applied to lua. November 15, 2024 patch applied to right shoulder. November 22nd and 29th 2024, both blank with indication resident refused. Review of Resident R1 December MAR indicated the following: (continued on next page) 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 Page 1 of 5 Event ID: 395606 Printed: 05/15/2026 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 395606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237 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)