Health inspection·November 8, 2024

F 0582 Level of Harm - Minimal harm or potential for actual harm Coordinator (RNAC) Employee E1 confirmed Resident R203 did not receive the arbitration agreement, and confirmed the facility failed to ensure the NOMNC 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. 28 Pa. Code 201.14(a) Responsibility of Licensee. Residents Affected - Few 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a)(j) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 2 of 6 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 11/08/2024 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)

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based 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). Findings include: Review of the facility policy Discharge and Transfer dated 1/6/24, indicated a monthly list will be sent to the Ombudsman of residents who were facility-initiated transfer or discharged . Review of Title 42 Code of Federal Regulations §483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. During an interview on 11/7/24, at 2:30 p.m., the Director of Nursing confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division since 12/31/23. 28 Pa. Code 201.18(b)(3)(e)(2) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 3 of 6 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 11/08/2024 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)

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective October 2023, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of the clinical record indicated that Resident R40 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 9/25/24, included diagnoses of Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior) and neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). Review of a physician order dated 10/7/24, indicated Resident R40 was admitted to hospice care (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care). Review of Resident R40's MDS assessments revealed a MDS significant change was not completed to include hospice services. During an interview on 11/8/24, at 11:18 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that a Significant Change MDS was not completed for Resident R40. During an interview on 11/8/24, at approximately 2:30 p.m. the Nursing Home Administrator confirmed 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. 28 Pa. Code: 211.5(f) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 4 of 6 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 11/08/2024 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Some Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2023 indicated: -Section C, C0100, Brief Interview for Mental Status: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. -Section D, D0100, Resident Mood Interview: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's MDS dated [DATE], Section I: Active Diagnoses, Question 16100, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (paralysis on one side of the body). Review of the facility provided list of residents who receive hospice services included Resident R41. Review of Resident R41's MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs, Question O100K, indicated that Resident R39 did not receive hospice services while a resident at the facility. During an interview on 11/8/24, at 11:18 a.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to make certain that MDS assessments were completed accurately for two of 18 residents. -Resident R13 had an MDS completion date of 8/14/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R13 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R13 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R13 is rarely understood, and the Resident Mood Interview was not completed. -Resident R35 had an MDS completion date of 10/16/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R35 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. Review of Section D: Mood, Question D0100 indicated that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 5 of 6 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 11/08/2024 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)

F 0641 BIMS assessment should be completed; No further questions on the assessment were completed. Level of Harm - Minimal harm or potential for actual harm -Resident R41 had an MDS completion date of 7/31/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R41 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. Review of Section D: Mood, Question D0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. Residents Affected - Some -Resident R53 had an MDS completion date of 8/7/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R53 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. -Resident R169 had an MDS completion date of 10/11/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R169 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R169 is rarely understood, and the BIMS assessment was not completed. -Resident R174 had an MDS completion date of 8/26/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R174 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R76 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R174 is rarely understood, and the Resident Mood Interview was not completed. -Resident R190 had an MDS completion date of 8/17/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R105 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R190 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R190 is rarely understood, and the Resident Mood Interview was not completed. During an interview on 11/8/24, at 11:40 a.m. the Social Services Director Employee E2 confirmed that the facility failed to make certain that BIMS and/or PHQ-9 assessments were completed accurately for six of 12 residents. During an interview on 11/8/24, at approximately 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that comprehensive MDS assessments were completed accurately for two of 18 and failed to make certain that BIMS and/or PHQ-9 assessments were completed accurately for six of 12 residents. 28 Pa. Code: 211.5(f) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395640 If continuation sheet Page 6 of 6