John J Kane Regional Center-Gl

In the surveyor’s words

From the most serious findings on record at John J Kane Regional Center-Gl, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 9, 2026

  Based on review of facility policies, facility provided documents and clinical records, and staff interviews, it was determined that the facility failed to protect residents from abuse and neglect which resulted in actual harm of a fracture of the right tibia (lower leg bone) for one of four residents (Resident R86). This deficiency is cited as past non-compliance.Findings include: Review of the facility policy, Abuse-Resident and Reasonable Suspicion of a Crime dated 6/13/26, and previously reviewed 6/30/25, indicated the facility is to treat every resident with consideration, respect and full recognition of his/her dignity and individuality. […]

• Actual harm, isolatedF686May 26, 2026

  Based on the review of professional standards of practice, facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of pressure ulcers that resulted in hospitalization for the treatment of wounds. This resulted in actual harm for two of three residents with facility-acquired pressure ulcers. (Resident R15 and Resident R2).Findings include: Review of the US Department of Health and Human Services, Agency for Healthcare Research &; Quality, the Pressure Ulcer Best Practice Bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment,… […]

• Actual harm, isolatedF689Apr 6, 2026

  Based on review of facility policy, clinical record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of thirteen residents (Resident R1). Findings include: Review of facility policy Abuse-Resident and Reasonable Suspicion of a Crime dated 1/22/26, indicated every resident will be treated with consideration, respect and full recognition of his/her dignity and individuality by preventing abuse, neglect, exploitation of residents, and misappropriation of resident property program. […]

• Actual harm, isolatedF686Aug 3, 2021

  Based on observation, review of facility policies, review of clinical records and staff and resident interviews, it was determined that the facility failed to timely provide adequate preventative treatment and services to prevent new pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development associated with use of an orthopedic brace (immobilizer), which resulted in harm in the development of two pressure ulcers for one of four residents (Resident R1) reviewed. Findings include: The facility policy entitled Pressure Ulcer Prevention dated 1/5/21, indicated that the facility will consider all residents to be at risk and therefore will provide defined prevention interventions via written protocols. […]

• No harm, potential for more than minimal, widespreadF801Jul 9, 2026

  Based on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months (June 2025 through July 2026). Findings include:During an interview on 7/6/26, at approximately 9:46 a.m., the Dietary Supervisor Employee E12 stated that he was the manager and was not certified.During an interview on 7/6/26, at 9:50 a.m., Registered Dietician Employee E13 stated that she works 4 days a week and is clinical only does not manage the dietary department.During an interview on 7/6/26, at approximately 9:50 a.m., the Nursing Home Administrator confirmed that the facility currently does not have a Certified Dietary Manager failed to provide documented evidence that any staff met the… […]