John J Kane Regional Center-Sc

Based on review of facility policy, Pennsylvania Code Title 49. Professional and Vocational Standards, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to follow nursing standards of practice for safe medication administration for one of eight residents reviewed for medication administration (Resident R1). Findings include: Review of the Facility Policy, Medication Administration General Guidelines dated 2/1/26, indicated it is the policy to safely administer medications to residents as prescribed by the practitioner and in accordance with current standards of practice and regulatory requirements. Review of the facility policy Medication Error Reporting, Analysis and Correction (MERF) indicates a medication error is observed or identified preparation or administration of medication or biological which is not in accordance with practitioner orders, manufactures specification, and accepted professional standards and principles. Review of the Pennsylvania Code Title 49. Professional and Vocational Standards Chapter 21, State…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 for one of four residents (Resident R1). This was identified as past non-compliance.Findings include: Review of the facility policy, Abuse - Resident and Reasonable Suspicion of a Crime dated 11/24/25, 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]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/28/25, included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), heart failure (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls for one of four residents (Resident R1). This was identified as past non-compliance.Findings include: Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the facility policy, Resident Falls dated 11/24/25, indicated it is the policy of the facility to take all precautions to minimize the risk of falling for all residents and if a fall does occur, to implement appropriate measures to prevent reoccurrence. Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/28/25, included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility document review and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition on five of five nursing units (2A, 3A, 3B, 4A, and 4B).Review of facility submitted information dated 7/16/25, indicated that on 7/15/25, At 7:11pm, During a scheduled facility power outage, the maglock (electrified magnetic locking mechanism) door batteries became disengaged. While monitoring CCTV (closed-circuit television, a type of video surveillance system), Security saw resident enter the stairwell on unit 4A. Resident was identified as [Resident R1]. Security witnessed on camera her carefully safely walk down the stairwell and exit on unit 2A. Total Time 2 mins and 20 seconds. Nursing Supervisor immediately notified by Security and met resident on unit 2A. Resident returned to the unit safely. Resident had no injury. No emotional distress noted. MD (Doctor of Medicine) and NOK (next of kin) notified. Review of an employee statement dated 7/15/25, written by Security Employee E1, indicated, While reviewing CCTV I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, 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 for one of 41 residents (Resident R1). Review of the facility policy Elopement - Missing Resident dated 1/8/25, indicated the facility will provide to each resident adequate monitoring and interventions to maintain safety. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/30/25, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and a seizure disorder. Review of Section E: Behavior indicated Resident R1 had displayed wandering behaviors. Review of an Elopement Evaluation completed on 6/18/25, indicated Resident R1 was at risk for elopement. Review of the physician's order dated 6/18/25, indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility incident/accident reports, clinical records, and staff interviews, it was determined that the facility failed to identify and/or investigate potential abuse and/or neglect for one of three residents (Resident R3). Findings include: Review of the facility policy Abuse- Resident last reviewed on 1/5/24, indicated that the facility treat every resident with respect and dignity. The failure of the facility to provide goods and services to a resident that are necessary to avoid or may result in physical harm is identified as neglect. All complaints/allegations of resident abuse/neglect shall be promptly reported to the administration and investigated. Alleged violations whether or not confirmed, must be reported. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included anoxic brain injury, quadriplegia, schizoaffective disorder, contractures, anxiety, blindness and dementia. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven Residents (Residents R53, R64, R71, and R76). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 R20). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective 10/1/2019, 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. A review of the clinical record indicated that Resident R20 was admitted to the facility on [DATE], with diagnoses which included dementia (group of symptoms that affects memory, thinking and interferes with daily life), and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, employee personnel records, grievance and abuse investigation documents, reports submitted to the State field office, resident interview and staff interview it was determined that the facility failed to make certain that all allegations of verbal abuse are reported to the State Agency as required for one of five residents (Resident R96). Findings include: The facility Abuse: protection from abuse policy dated [DATE], indicated that the facility every resident with consideration, respect and full recognition of his/her dignity and individuality. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance. Alleged violations, whether or not confirmed, must be reported to the Administrator, PA Department of Health, the Area Agency on Aging, Compliance Officer, and to the Executive Director. Review of Resident R96's admission record indicated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.