John J Kane Regional Center-Ro

In the surveyor’s words

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

• Immediate jeopardy, patternF686Jul 18, 2026

  Based on review of facility policy, clinical records, observation, and interviews with staff and family, it was determined that the facility failed to provide preventative interventions, and treatments which resulted in the development of avoidable pressure ulcers for two of two residents (Resident R5 and Resident R13), resulting in an infection for one of two residents (Resident R5). This failure resulted in an immediate jeopardy. Findings Include: Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, muscle wasting and atrophy (occurs when muscle fibers shrink due to disuse, aging, malnutrition, genetic factors, or nerve-related conditions), and Parkinson's Disease (a disorder of the… […]

• Immediate jeopardy, isolatedF689Apr 11, 2025

  Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for two residents. This failure created an immediate jeopardy situation for two of 21 residents who were identified as at risk for elopement (Residents R6, and R111). […]

• Actual harm, isolatedF600Jul 7, 2025

  Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R2), which resulted in actual harm of a hematoma (a localized collection of blood outside the blood vessels, typically caused by blood vessel damage from trauma or injury) on residents left side of forehead, a laceration (cut) above the left eye, and a hematoma to right knee with pain for Resident R2. […]

• Actual harm, isolatedF689Jul 7, 2025

  Based on review of facility documents, facility policy, clinical records, resident interviews, and staff interviews, it was determined that the facility failed to provide appropriate equipment to prevent an accident for one of two residents (Resident R1), which resulted in actual harm of bruising and a fracture of residents right foot for Resident R1, and failed to provide adequate supervision and assistance for one of two residents (Resident R2), which resulted in actual harm of a hematoma (localized collection of blood outside the blood vessels, typically caused by blood vessel damage from trauma or injury) on residents left side of forehead, a laceration (cut) above the left eye, and a hematoma to right knee with pain for Resident R2. […]

• Actual harm, isolatedF689Jun 28, 2024

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for one of three residents (Resident R52) who had two choking episodes, which resulted in actual harm during the second choking episode that required the Heimlich maneuver (abdominal thrusts that elevate the diaphragm and increase airway pressure, forcing air from the lungs; used to expel a foreign body from the airway). Findings include: Review of facility policy Accident Prevention dated 1/3/24, indicated the interdisciplinary team (IDT) is to assess, observe, and identify environmental and resident risks/hazards. […]