Pennsylvania Department of Health
JOHN J KANE REGIONAL CENTER- SCOTT TOWNSHIP
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

JOHN J KANE REGIONAL CENTER- SCOTT TOWNSHIP
Inspection Results For:

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JOHN J KANE REGIONAL CENTER- SCOTT TOWNSHIP - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to three complaints, completed on June 16, 2026, it was determined that John J Kane Regional Center-Scott Township was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.аа

Plan of Correction:

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

з483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

з483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

з483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Observations: 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 Board of Nursing: A. Registered Nurses (RN), revealed the following: 21.11 General Functions (a)(4) Carries out nursing care and actions which promote, maintain and restore the well-being of individuals. (d)The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. 21.14 Administration of Drugs (a) A licensed registered nurse may administer a drug ordered for a patient in the dosage and manner prescribed. Review of the facility "Registered Nurse" job description "Duties and Responsibilities 28." Indicated the RN accurately carries out physician orders per facility nursing policies and procedures, transcribes and administers medications, treatments, and therapies. Review of facility personnel records on 6/16/26, indicated Registered Nurse (RN) Employee E1 is issued an active Pennsylvania State License in good standing. Review of Resident R1's clinical record indicated an admission date of 10/2/24, with diagnoses that included dementia, left hip replacement, high blood pressure, diabetes, asthma, and osteoporosis. Review of the Minimum Data Set (MDS) resident assessment and care screening dated 3/5/26, indicated Resident R1 is cognitively impaired with confusion at baseline. Review of nurse progress notes dated 5/22/26, indicated Resident R1 took another resident's medications v.s.s. (vital signs stable) no noted adverse effects at this time, however, will be sent to the hospital to be monitored. 911 called and transported. Review of a practitioner note dated 5/22/26, indicated able to review medications that patient grabbed and took with risk of hypotension (low blood pressure), hypoglycemia (low blood sugar), lethargy, delirium, bleeding. Will send to ER (emergency room) for evaluation and treatment. Review of a physician note dated 5/23/26, indicated Resident R1 was sent to the ER for evaluation after taking another patient's medication. Patient was clinically stable and had no complaints. The patient returned to facility after 24-hour review. Review of a facility "Event Report Medication Error" document dated 5/22/26, indicated Resident R1 took another resident's medication to include amlodipine (lowers blood pressure) 10 mg (milligrams), atenolol (lowers blood pressure and heart rate) 50 mg, Eliquis (blood thinner) 5 mg, Jardiance ( antidiabetic) 12.5 mg, Lisinopril (antihypertensive) 20 mg, olanzapine (antipsychotic) 2.5 mg, Lexapro (antidepressant) 10 mg, Ativan (anti-anxiety medication) 0.5 mg, metformin (anti diabetic) 500 mg, Certavite (a supplement) and Zyrtec (antihistamine). The RN put another resident's medications in a med cup on a breakfast tray. The breakfast tray was then put in front of Resident R1, and she took the other resident's medications. Review of RN Employee E1's witness statement dated 5/22/26, indicated "pulled patient 1's medication and placed it on a tray that is used to pass other trays. I went to assist another patient and when I returned the NA (nursing assistant) informed me that she (pt 2) (Resident R1) had taken the medication on the tray. Review of Resident R1's hospital "Service and Length of Stay" documentation dated 5/23/26, indicated the patient was admitted for accidental medication error. The resident was monitored and remained stable. Resident R1 returned to the facility on 5/23/26 in stable condition. During an interview on 6/16/26, at approximately 10:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that RN Employee E1 failed to follow nursing standards of practice for safe medication administration for Resident R1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 08/10/2026

1. Identified Resident was seen at the hospital with no adverse effects.
2. All residents receiving medications have the potential to be affected by this practice.
3. Nurses will be educated on PA Nurse Practice Act Staff by the Staff Development Coordinator/designee.
4. Random medication administration audits will be conducted for one nurse weekly on each shift for (2) weeks, then two nurses monthly for (3) months, then one nurse monthly on-going to ensure compliance with facility guidelines.
Audits' results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

з 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations: Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 10 residents during the day shift for 2 of 21 days (5/31/26 and 6/7/26) and one NA per 15 residents during the night shift for one of 21 days (5/27/26). Findings include: Review of the facility census data, nursing time schedules, and deployment sheets for the weeks of 5/26/26 to 6/15/26, revealed the following nurse aide staffing shortages: On 5/27/26 the census was 243, which required 16.20 NAs during the night shift. Review of the nursing time schedules revealed 16.00 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate for this deficiency. On 5/31/26 the census was 234, which required 23.40 NAs during the day shift. Review of the nursing time schedules revealed 21.33 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate for this deficiency. On 6/7/26 the census was 237, which required 23.70 NAs during the day shift. Review of the nursing time schedules revealed 23.47 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate for this deficiency. During an interview on 6/16/26, at 4:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift for 2 of 21 days and one nurse aide per 15 residents during the night shift for 1 of 21 days.

Plan of Correction - To be completed: 08/10/2026

1. The facility cannot retroactively correct this deficiency. No identified Residents were affected as a result of this deficiency. All Residents have the potential to be affected by this deficiency.
2. Education will be completed by the Nursing Home Administrator with the Nursing Staff Scheduler on staffing ratios.
3. Staffing meeting will be held up to five days per week with the NHA, DON, and Staff Scheduler, to ensure overall PPD and ratios are met. If not, actions will be implemented, including agency reach-out, and contacting staff currently working as well as those who are not currently in the facility.
4. The Department of Health staffing calculator tool will be used as an audit to monitor staffing ratios and PPD, weekly x4 and then monthly x3 by the Nursing Staff Scheduler or designee.
5. Results will be forwarded to the QAPI team for review and recommendation.

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