Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at John J Kane Regional Center-sc during CMS and state inspections, most recent first.
A resident with morbid obesity, heart failure, muscle weakness, and a documented need for substantial/maximal assistance and 2-person assist for bed mobility was being provided incontinence care by a single CNA, who partially rolled the resident and then left the bedside to obtain supplies, leaving the resident slightly turned on her side. While the CNA was away, the resident fell from the bed to the floor. The resident was found alert and oriented but later complained of head, neck, shoulder, and back pain, and had bleeding through bandages on a chronic wound. Facility records and the CNA’s statement confirmed that the resident’s care plan and assignment sheet requiring 2-person assist for bed mobility were not followed, and the facility determined this failure constituted neglect that resulted in the resident’s injury.
A resident with morbid obesity, heart failure, muscle weakness, and a documented need for substantial/maximal assistance with rolling had a care plan and assignment sheet specifying two-person assist for transfers and bed mobility. During incontinence care, a CNA partially turned the resident in bed and then left the bedside to obtain supplies, leaving the resident unattended in a slightly turned position. While the CNA was away, the resident fell from the bed to the floor, was found alert and oriented with bleeding from a pre-existing leg wound, and later complained of head pain. Facility investigation concluded that the CNA failed to follow the resident’s plan of care requiring two-person assist for bed mobility, leading to the fall.
A resident with Alzheimer's disease and a seizure disorder, known for wandering behaviors and identified as an elopement risk, was able to leave a secured unit during a planned power outage when maglocks on stairwell doors became disengaged. The resident accessed another floor before being safely returned by staff, with no injury or distress noted.
Two residents suffered injuries due to neglect in an LTC facility. One resident, with limited mobility, fell and fractured a femur when a nurse aide failed to follow the policy of rolling residents towards staff. Another resident, requiring two-person assistance, sustained a head laceration when a single aide attempted to reposition him, causing him to hit his head. Staff interviews confirmed the facility's failure to adhere to care policies, resulting in harm.
The facility failed to prevent falls and injuries for two residents. One resident with hemiplegia slid off the bed and fractured a femur when a nurse aide turned away during care, contrary to policy. Another resident with quadriplegia sustained a head laceration when a nurse aide attempted to adjust a sheet without required assistance. Staff interviews confirmed non-adherence to care policies, leading to these injuries.
A resident with complex medical needs, including quadriplegia and dementia, suffered a head injury when a nursing assistant attempted to reposition them without the required assistance. Despite documented care needs and staff awareness, the facility failed to investigate the incident as potential abuse or neglect, violating care policies.
The facility did not provide required training on abuse, neglect, and exploitation prevention for two staff members, a Unit Clerk and a Nurse Aide. This deficiency was confirmed by the Assistant DON and noted in the facility's training records.
The facility failed to provide mandatory QAPI training for two staff members, NA Employee E1 and NA Employee E2, as required. Employee E1, hired in 2014, and Employee E2, hired in 2002, did not receive the necessary in-service education within the specified time frames. This deficiency was confirmed by the Assistant Director of Nursing.
Failure to Follow Bed Mobility Care Plan Resulting in Resident Fall from Bed
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s care plan for bed mobility and by leaving the resident unattended in an unsafe position. The facility’s abuse/neglect policy defined neglect as the failure to provide goods and services necessary to avoid or that may result in physical harm, pain, mental anguish, or emotional distress. The resident involved had diagnoses including morbid obesity, heart failure, and muscle weakness, and the MDS indicated the resident required substantial/maximal assistance to roll left and right. The resident’s care plan and unit assignment sheet specified that the resident required assistance of two staff for transfers and bed mobility due to decreased mobility and generalized weakness and being at risk for injury related to falls. On the day of the incident, the resident experienced a fall from bed during care. A progress note documented that the ADON was called to the unit regarding a fall from bed and found the resident on the floor lying on her back, alert and oriented and able to answer questions. Another progress note recorded that the resident complained of pain in the head area, 911 was called, and the resident remained on the floor until paramedics arrived. The emergency department physician later documented that the resident presented after a fall out of bed with head injury and was complaining of pain in the head, neck, shoulder, and back, and had bleeding through the bandages on a chronic left wound. Facility documentation and staff statements showed that a nurse aide provided incontinence care alone, despite the care plan and assignment sheet indicating a two-person assist for bed mobility. The aide reported sliding and partially rolling the resident, then leaving the resident slightly turned on her side to go to the bathroom to obtain a washcloth and towel. While the aide was in the bathroom, the resident fell from the bed. The facility’s investigation concluded that the CNA failed to follow the resident’s plan of care requiring two-person assistance for bed mobility and walked away from the resident while she was slightly turned, which resulted in the resident falling out of bed and sustaining injury, including bleeding from a prior wound and complaints of neck pain.
Failure to Follow Two-Assist Bed Mobility Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement required fall-prevention interventions and provide adequate supervision during bed mobility for one resident. The resident had diagnoses including morbid obesity, heart failure, and muscle weakness, and the MDS documented a need for substantial/maximal assistance to roll left and right. The resident’s care plan, initiated earlier in the year, identified the resident as at risk for injury related to falls due to decreased mobility and generalized weakness and specified that two-person assistance was required for transfers and bed mobility. On the day of the incident, the resident was being provided incontinence care by a CNA. The CNA reported sliding the resident toward herself and then rolling the resident slightly toward the window, leaving the resident slightly turned onto her right side. At that point, the CNA left the bedside to go to the bathroom to obtain a washcloth, towel, and soap, leaving the resident unattended in a partially turned position. While the CNA was in the bathroom, the resident fell from the bed to the floor. Progress notes documented that the resident was found on the floor lying on her back, alert and oriented, with bleeding noted from a pre-existing left leg wound and later complaining of pain in the head area. The facility’s investigation determined that the CNA failed to follow the resident’s plan of care requiring two-person assistance for bed mobility and walked away from the resident while she was slightly turned, which resulted in the resident falling out of bed. The unit assignment sheet in use that day also indicated that the resident required two-person assistance for bed mobility, and in interview the CNA acknowledged receiving the assignment sheet but not recognizing the two-assist requirement for bed mobility, despite knowing the resident required two-person assistance for transfers.
Failure to Prevent Elopement During Power Outage
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with Alzheimer's disease and a seizure disorder who had a documented history of wandering behaviors. The resident was identified as being at risk for elopement through an evaluation and was ordered a security bracelet to alert staff when approaching monitored doors. The care plan specifically addressed the risk for elopement due to the resident's diagnosis and history. Progress notes documented repeated incidents of the resident testing door handles, keypads, and attempting to open windows, as well as sprinting toward open doors when noticed. During a scheduled facility power outage, the magnetic locks on the stairwell doors became disengaged, allowing the resident to leave the locked unit and access another floor via the stairwell. Security staff observed the resident on CCTV, and the nursing supervisor was notified and returned the resident to the unit. The resident did not sustain any injury or show signs of emotional distress. Staff interviews confirmed that the facility did not provide adequate supervision to prevent the elopement incident.
Neglect Leads to Injuries in Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from neglect, resulting in actual harm to two residents. Resident R91, who had right-sided hemiplegia and hemiparesis due to a stroke, was dependent on staff for bed mobility. During incontinence care, Nurse Aide Employee E9 turned away from Resident R91, who then slid off the bed and sustained a fractured left distal femur. The facility's policy required residents to be rolled towards staff, but Resident R91 was rolled away, contrary to the policy. Interviews confirmed that the bed was raised, and Resident R91 was unable to stop the slide, leading to the fall. Another incident involved Resident R3, who had anoxic brain injury, quadriplegia, and other conditions, requiring dependent care with two staff members for bed mobility. Despite this, NA Employee E8 attempted to readjust a sheet around Resident R3's waist without additional assistance, resulting in Resident R3 hitting his head on an overbed table and sustaining a laceration. The facility's policy and care sheets indicated the need for two staff members, but this was not followed, leading to the injury. Interviews with staff and the Director of Nursing confirmed the facility's failure to adhere to its policies, resulting in neglect and harm to the residents. The incidents highlighted the lack of compliance with the facility's procedures for resident care, specifically regarding the need for adequate staff assistance during care activities to prevent harm.
Failure to Prevent Falls and Injuries in Residents
Penalty
Summary
The facility failed to provide appropriate assistance to prevent falls and injuries, resulting in actual harm to two residents. Resident R91, who had right-sided hemiplegia and hemiparesis due to a stroke, was dependent on staff for bed mobility. During incontinence care, Nurse Aide Employee E9 turned away from Resident R91, who then slid off the bed and sustained a fractured left distal femur. The facility's policy required residents to be rolled towards staff, but Employee E9 rolled Resident R91 away, contrary to the policy. Resident R3, who had anoxic brain injury, quadriplegia, and other conditions, required dependent care with rolling and assistance from two staff members. However, NA Employee E8 attempted to readjust a sheet around Resident R3's waist without additional assistance, resulting in Resident R3 hitting his head on the overbed table and sustaining a head laceration. The facility's policy and care sheets indicated that Resident R3 required assistance from two staff members due to his condition and behaviors. Interviews with staff and the Director of Nursing confirmed that the facility failed to adhere to its policies for providing care, which led to the injuries of Residents R91 and R3. The staff were aware of the care requirements and the availability of additional assistance, yet the necessary precautions were not taken, resulting in harm to the residents.
Failure to Investigate Potential Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate potential abuse and neglect for a resident, referred to as Resident R3, who was admitted with multiple diagnoses including anoxic brain injury, quadriplegia, schizoaffective disorder, contractures, anxiety, blindness, and dementia. The Minimum Data Set indicated that Resident R3 required dependent care with rolling, necessitating assistance from two staff members. Despite this, an incident occurred where a nursing assistant, NA Employee E8, attempted to readjust a sheet around Resident R3's waist without additional assistance, resulting in the resident's head hitting an overbed table and causing a laceration. Interviews with staff members, including NA Employee E5, E6, E7, and the Director of Nursing, confirmed that Resident R3 was known to be rigid and combative, requiring two staff members for care. The care needs were documented on care sheets and communicated during shift reports. However, the facility did not properly identify or investigate the incident as potential abuse or neglect, as confirmed by the Director of Nursing. This oversight was a violation of the facility's policy and state regulations regarding resident care and management.
Failure to Provide Abuse Prevention Training
Penalty
Summary
The facility failed to provide mandatory training on abuse, neglect, and exploitation prevention for two staff members, identified as Employee E3 and Employee E4. Employee E3, a Unit Clerk hired on 4/16/07, did not receive the required in-service education on these topics between 4/16/23 and 4/16/24. Similarly, Employee E4, a Nurse Aide hired on 5/19/14, lacked documented training on abuse, neglect, and exploitation prevention between 5/19/23 and 5/19/24. This deficiency was confirmed during an interview with the Assistant Director of Nursing on 9/26/24. The facility's failure to provide this essential training was noted in the review of facility documents and training records, which were supposed to include these topics as per the Facility Assessment reviewed on 7/12/24.
Failure to Provide QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) Program for two out of ten staff members, specifically Nurse Aide (NA) Employee E1 and NA Employee E2. Employee E1, hired on May 19, 2014, did not receive QAPI Program in-service education between May 19, 2023, and May 19, 2024. Similarly, Employee E2, hired on July 1, 2002, lacked documented QAPI Program training between July 1, 2023, and July 1, 2024. This deficiency was confirmed during an interview with the Assistant Director of Nursing on September 26, 2024, who acknowledged the facility's failure to provide the required training for these staff members.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Point Healthcare Residence | 0.3 mi | ★★★★★ | 0 | 0 |
| Concordia Of The South Hills | 0.6 mi | ★★★★★ | 0 | 0 |
| Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr | 1.5 mi | ★★★★★ | 21 | 0 |
| Asbury Health Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Carnegie Park Post Acute | 1.9 mi | ★★★★★ | 21 | 0 |
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