John J Kane Regional Center-Mc

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 30, 2026

  Based on review of facility policy, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of forty residents (Resident R1).Findings include: Review of the facility policy, Elopement: Missing Resident dated, 6/30/25, indicated It is the policy of the facility to provide each resident with adequate monitoring and interventions to maintain safety. If a resident is discovered to be missing, the center will immediately take all possible measures to assure the resident's safe return. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF689Oct 12, 2023

  Based on review of facility policy, clinical records, facility documents, resident interview, and staff interview, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). This failure created an immediate jeopardy situation for one out of 195 residents (Resident R1). Findings include: The facility Wanderer management program policy last reviewed on 1/9/23, indicated that the facility will provide safety measures for all residents who are deemed to be in need of additional safety measures including wander management. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. […]

• Actual harm, isolatedF689May 29, 2025

  Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy Accident Prevention, dated 1/6/25, indicated it is the facility's policy to prevent resident accidents and injuries. […]

• Actual harm, isolatedF600Sep 19, 2024

  Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, Abuse - Resident and Reasonable Suspicion of a Crime dated 1/16/24, defined neglect as the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. […]

• Actual harm, isolatedF689Sep 19, 2024

  Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, General Guidelines dated 1/16/24, indicated All care and services must be delivered as prescribed by the practitioner, and according to thre resident's person-centered plan of care. […]