Health inspection·November 3, 2023

F 0585 28 Pa. Code: 201.29(i) Resident Rights. Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 2 of 5 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 395640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Findings include: Review of the facility policy Abuse, last reviewed on 1/9/23, indicated that every complaint or allegation of resident abuse shall be promptly reported and an investigation initiated. The resident will be protected and definition of abuse can include injuries of unknown source and can be suspicious due to the extent of the injury. Failure to report abuse, cooperate with the investigation can result in disciplinary action. During an interview on 11/1/23, at 2:08 p.m., the Director of Nursing(DON) stated that the facility does not have a resident transfer policy. Review of the clinical record indicated that Resident R148 was admitted to the facility on [DATE], with diagnoses which included Myopathy(a disease that affects the muscles that control voluntary movement in the body), malnutrition, contracture of both knees(inability to straighten legs completely), difficulty walking, dementia, and anxiety during transfers. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 9/13/23, indicated the diagnoses remained current with additional diagnoses of right shoulder pain added on 9/1/23. Review of an Annual Assessment progress note dated 8/3/23, indicated Resident R148 screams when touched and is fearful, Resident R148 has a right leg contracture requiring a pillow between the knees and a six inch foam mattress and express comfort cushion while in the wheelchair. The documentation indicated that Resident R148 is an assistance of one for transfers with pivoting. Review of a progress note dated 8/3/23, indicated that Resident R148 developed a bruise under her right upper arm 8 centimeters (cm) x 7 cm. The documentation indicated the Nurse Aide believed it was the result of lifting Resident R148 under the arms. An incident report dated 8/3/23, indicated bruising from unknown etiology requiring xrays of right forearm , right humerus(upper arm) and right hand being completed; the xray of her right humerus indicated a possible fracture. A MRI and/or CT scan was recommended, however, the facility Medical Director stated Resident R148 would not be able to tolerate a MRI and she was to be evaluated by Ortho specialist. Review of a progress note dated 8/11/23, indicated the bruising worsened and now had covered the whole right side of Resident R148's body including the right arm and shoulder right side and torso, and Resident R148 grimaced in pain when touched. Xrays of the right humerus, right forearm, right hand, and thoracic spine were completed on 8/12/23, indicating no fractures. Hoyer lift transfers were now ordered. An Orthopedic specialist saw Resident R148 and declined to perform MRI or CT scan and reordered xray of Resident R148 shoulder and stated no fracture and put Resident R148 in a sling. During an interview on 11/1/23, at 2:08 p.m., the Director of Nursing confirmed that the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 3 of 5 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 395640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132 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)

F 0609 failed to report the injury of unknown source causing severe bruising to Resident R148 had not been identified as potential abuse/neglect and and reported to the State agency as required. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.14(a)(b)(c)(d) Responsibility of licensee. Residents Affected - Few 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 201.20(b) Staff Development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 4 of 5 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 395640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few Findings include: The facility Water Management Program last reviewed on 1/9/23, indicated that the plan is to minimize risk for Legionella associated with the building water systems at [NAME] McKeesport. Based on framework outlined in ASHRAE Standards. During a review of the annual testing dated 7/31/23, of the facility water systems indicated that Resident room [ROOM NUMBER] sink had a positive result for Legionella requiring treatment and re-testing which occurred on 9/2/23,. This result indicated Resident room [ROOM NUMBER] sink had no detection of Legionella. During review of Resident room [ROOM NUMBER] did not indicate the facility protected residents as the residents were not removed from the room once positive until a negative result was obtained. During an interview on 11/2/23, at 11:17 a.m., Maintenance Director Employee E4 and the Nursing Home Administrator confirmed that the facility did not remove residents from the positive room [ROOM NUMBER] and did not report the positive result to the appropriate agencies as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 5 of 5