Health inspection·March 26, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings include: A review of the facility policy, Restraint, Physical last reviewd, 2/07/23, defined a restraint as anything that restricted freedom from movement, and limited one's sense of control and independence. Review of the clinical record indicated that Resident R1 was admitted to the facility 10/6/23. The Minimum Data Set (MDS - periodic assessment of care needs) dated 3/7/24, included diagnoses of unspecified dementia, muscle wasting, diabetes and adult failure to thrive. The Brief Interview of Mental Status (BIMS a screening too to determine cognition) recorded a score of 5, indicating the resident is cognitively impaired. Review of facility provided documents dated 3/13/24, indicated Resident R1 was found by the 7-3 shift with the sheet tied behind the lower back and corners of the lower gown tied behind the resident's thighs. Review of facility provided documents dated 3/13/24, revealed that Nurse Aide (NA) Employee E1, was identied as the individual that tied the sheet behind the resident and the gown behind the thighs. Review of a written statement from NA Employee E1 dated 3/13/24, indicated, Resident was very active all night, could not rest, kept tying her gown herself, I changed her and had a gown on her the right way, I cleaned BM (feces) off her hands and face. Review of a written state from NA Employee E2 dated 3/13/24 (worked the on-coming 7 a.m. shift) indicated, When I went in to see Resident R1, I tried to pull down her sheet to pull her up in bed but it wouldn't come out so I turned her over to see why and found the sheet was tied under her, I reported this, when we went in to pull up in bed, we seen her gown was was tied around her legs as well. Review of NA Employee E1's employee file indicated that on 4/4/23 she had a previous verbal warning for abuse and neglect and was re-educated at that time. Further review indicated that NA Employee E1 was suspended on 3/13/24 and employment was terminated on 3/20/24. Review of Resident R1's clinical record indicated a physician note dated 3/16/24, that the facility made him aware of the incident on the date it occurred. (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 2 Event ID: 395640 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 03/26/2024 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)