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:

There are 181 surveys for this facility. Please select a date to view the survey results.

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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 a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and an Abbreviated survey in response to five complaints completed on September 3, 2026, it was determined that John J Kane Regional Center - Scott was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations

Plan of Correction:

483.10(f)(10(i)(ii) REQUIREMENT Protection/Management of Personal Funds:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.10(f)(10) The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds.
(i) The facility must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section.
(ii) Deposit of Funds.
(A) In general: Except as set out in paragraph (f)( l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund.
(B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund.

Observations:

Based on clinical record review, select facility policy, review of resident financial records, and resident and staff interviews, the facility failed to safeguard, manage, or accurately account for the resident's personal funds deposited with the facility for five of 38 residents sampled (Residents 21, R31, R246, R11, R46).

Findings include:

A review of the facility policy titled "Resident Rights" dated 2/1/26, with a previous review date of 11/24/25, indicated that upon written authorization of a resident, the facility must hold, safeguard, manage and account for personal funds of the resident deposited with the facility. Funds more than fifty dollars must be deposited in an interest-bearing account separate from the facility's operating account.

Review of the facility's Trial Balance Report dated from 4/1/26, through 6/30/26, listed multiple residents who had their funds deposited in the facility. The five residents randomly chosen identified the facility as the Rep Payee for their accounts were Residents R21, R31, R246, R11 and R46.

Review of Residents R21, R31, R246, R11 and R46 provided personal account information did not identify interest in each account for two of three quarters provided.

During an interview on 8/31/26, at approximately 2:00 p.m., the Business Office Manager (BOM) Employee E5 stated that his access to the accounts was limited and he had to reach out to the Revenue Manager.

During an interview on 9/126, at approximately 10:00 a.m., the Deputy Director of Kane Facilities confirmed that the facility had not applied the interest into each resident account for two of three quarters.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(2) Management.

28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 10/09/2026

Residents R21, R31, R246, R11, and R46 have all had the interest corrected to their accounts and received statements reflecting the correction.

The Accounting Manager/designee will conduct training for the Business Office staff on the requirements for providing quarterly resident trust fund statements and accurately managing resident personal funds. The training will cover documentation practices and the importance of timely communication with residents and their representatives (§483.10(f)(10)(iii)).

The Business office Manager or designee will conduct audits of 5 resident trust fund accounts monthly x4 months to ensure ongoing compliance with regulatory requirements. Findings will be reviewed during monthly QAPI/Quality Assurance meetings until substantial compliance is obtained.

483.10(f)(10)(iii) REQUIREMENT Accounting and Records of Personal Funds:

§483.10(f)(10)(iii) Accounting and Records.
(A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
(B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
(C)The individual financial record must be available to the resident through quarterly statements and upon request.

Observations:

Based on clinical record review, review of resident fund reports, and staff interviews, it was determined that the facility failed to provide accurate quarterly resident trust fund (resident funds account with current accounts open and holding resident monies) statements for five of 38 residents (Residents R21, R31, R246, R11 and R46).

Findings include:

Review of the facility policy "Resident Rights", dated 2/1/26, with a previous review date of 11/24/25, indicated that the facility must establish and maintain a system that assures a full and complete and separate according to generally accepted accounting principles of each resident's personal funds entrusted to the facility on the resident's behalf and assure that a fully accounting of a resident's personal funds is given in writing to the resident or responsible person at least quarterly.

During a review of the copy of the mailed "Savings Statement" provided to Residents R21, R31, R246, R11 and R46 did not include interest applied to each account for statements from the last two of three quarters indicating the statements accuracy of monies available.

During an interview on 8/31/26, at approximately 2:00 p.m., the Business Office Manager (BOM) Employee E5 stated that his access to the accounts was limited and he had to reach out to the Revenue Manager.

During an interview on 9/126, at approximately 10:00 a.m., the Deputy Director of Kane Facilities confirmed that the facility had not applied the interest into each resident account for two of three quarters.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(2) Management.
28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 10/09/2026

The Business Office Manager or designee will audit all current resident trust fund accounts ensuring latest quarterly statement was sent out and that all monthly payments have been properly deposited.

The Accounting Manager/designee will conduct training for the Business Office staff on the requirements for providing quarterly resident trust fund statements and accurately managing resident personal funds. The training will cover documentation practices and the importance of timely communication with residents and their representatives (§483.10(f)(10)(iii)).

The Business office Manager or designee will conduct audits of 5 resident trust fund accounts monthly x4 months to ensure ongoing compliance with regulatory requirements. Findings will be reviewed during monthly QAPI/Quality Assurance meetings until substantial compliance is obtained.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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.

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of five residents (Resident R94).

Findings include:

Review of facility's policy "Assessment-Comprehensive Person-Centered Care Planning" dated 2/1/26, indicated to assure documentation, development, and implementation of a comprehensive person-centered care plan for all residents to attain or maintain the highest practicable physical, mental and psychosocial well-being. Practitioner orders, medication administration records, treatment administration records, progress notes which include treatment plans, and skilled therapy treatment plans are part of the whole resident's comprehensive person-center care plan.

Review of the clinical record indicated Resident R94 was admitted to the facility on 2/19/26.

Review of Resident R94's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/3/26, indicated diagnoses of obstructive sleep apnea (muscles in the back of your throat relax and block your airway during sleep, your breathing repeatedly stops and starts), hypothyroidism (body doesn't make enough thyroid hormones), and diabetes (body does not use insulin effectively).

Review of Resident R94's physician orders dated 2/20/26, indicated Continuous Positive Airway Pressure machine (CPAP, helps sleep apnea patients breathe easily and safely while they sleep) to be worn at night.

Review of Resident 94's physician orders dated 3/5/26, indicated oxygen continuous 2-3 liters via nasal cannula, may titrate to keep oxygen saturation above 92%.

Review of Resident R94 's care plan started on 3/3/26 and last updated 8/24/26, did not reveal evidence of the oxygen or CPAP having been part of the resident's care planning.

Review of a providers' note on 8/11/26, indicated Resident R94 "using CPAP at night".

During an interview and observation on 8/31/26, at approximately 11:00 a.m. Resident R94 was asked by the surveyor if she uses oxygen and a CPAP and the resident replied yes. Resident 94 stated she uses the oxygen all the time and the CPAP every night, "I probably wouldn't be breathing if I didn't use my CPAP every night." CPAP was observed at resident's bedside and the resident was using oxygen.

During an interview on 9/3/26, at approximately 8:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed facility failed to develop care plans that included instructions to provide person centered care.

28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 10/09/2026

Resident R94's care plan was updated to include specific instructions for the use of the Continuous Positive Airway Pressure (CPAP) machine and oxygen therapy.
A review of care plans for all residents with CPAPs and Oxygen was conducted to identify whether they accurately reflect medical needs and preferences.
The DON or designee will provide training to nurses on the importance of developing comprehensive, person-centered care plans that include all necessary medical equipment and therapies.
The Director of Nursing or designee will conduct audits of care plans for residents with CPAPS and Oxygen weekly X 4 weeks ensuring that all necessary treatments and equipment are documented. Findings will be reviewed at the QAPI meeting.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:

§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to complete a restorative nursing program for one of four residents reviewed for ADLs (activities of daily living) concerns (Residents R7).

Findings include:

Review of the facility policy "Rehabilitative/Restorative Programs:" dated 2/1/26, indicated residents will receive rehabilitative services designed to improve or restore functioning.

During an interview on 9/1/26 at 2:50 p.m., Registered Nurse (RN) Unit Manager Employee E1 revealed that restorative activities are documented on the daily "Point of Care" electronic record.

Clinical record review for Resident R7 revealed a diagnoses list that included respiratory failure and lack of coordination and abnormalities of gait and mobility.

Review of the current care plan for Resident R7 revealed the resident requires assistance with walking and transferring. An intervention included maximum assistance with all ADLs.

Review of the physical therapy discharge summary dated 7/13/26, indicated highest practical level achieved.

Review of the current "After Therapy Care" status indicated Resident R7 will perform assisted range of motion exercises (hip, knee, and ankle exercises 3 sets of 15 repetitions) to the right and left lower extremities, and passive range of motion exercises (stretching to the thighs and calves 3 sets of 30-60 seconds hold each) to the right and left lower extremities.

Review of the daily "Point of Care" electronic record dated July through August 2026 did not include documentation that the restorative task was completed.

During an interview on 9/1/16 at 3:00 p.m., The Director of Nursing confirmed the above findings and that the facility failed to complete a restorative nursing program for ADLs concerns for Resident R7.

28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 10/09/2026

The restorative nursing program for R7 was implemented ensuring that all necessary range of motion exercises were completed and documented as per care plan.
A review of all residents receiving restorative nursing services was conducted to identify implementation of restorative measures.
The DON or designee will provide training to nursing staff on restorative care, including the importance of providing and documenting restorative nursing services.
The Director of Nursing or designee will conduct audits of residents receiving restorative nursing services weekly X 4 weeks. Findings will be reviewed at the QAPI meeting.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Plan of Correction - To be completed: 10/09/2026

Resident R9's dialysis communication forms were reviewed to ensure all missing documentation was completed as appropriate.
A review of dialysis communication forms for all residents' receiving dialysis was conducted to identify documentation issues.
The DON or designee will provide training to nurses on the importance of completed dialysis communication forms for residents receiving dialysis.
The Director of Nursing or designee will conduct audits of dialysis communication forms for residents receiving dialysis weekly X 4 weeks. Findings will be reviewed at the QAPI meeting.

§483.35(d)(7) REQUIREMENT Nurse Aide Perform Review – 12Hr/Year In- ser:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.35(d)(7) Regular in-service education.

The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on review of facility policy, personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations for five of five nursing staff (Nurse Aide (NA) Employees E7, E8, E9, E10 and E11).

Findings include:

Review of facility policy "Facility Assessment" dated 8/4/26, with a previous review date of 1/14/26, indicated that all personnel who provide services will have annual evaluations.

Review of NA Employee E7's personnel record indicated a hire date of 6/1/15. Review of NA Employee E7's current employee file failed to reveal an annual employee performance evaluation for 6/1/25, through 6/1/26.

Review of NA Employee E8's personnel record indicated a hire date of 5/20/24. Review of NA Employee E8's current employee file failed to reveal an annual employee performance evaluation for 5/20/25 and 5/20/26.

Review of NA Employee E9's personnel record indicated a hire date of 3/7/05. Review of NA Employee E9's current employee file failed to reveal an annual employee performance evaluation for 3/7/25, through 3/7/26.

Review of NA Employee E10's personnel record indicated a hire date of 2/23/15. Review of NA Employee E10's current employee file failed to reveal an annual employee performance evaluation for 2/23/25 and 2/23/26.

Review of NA Employee E11's personnel record indicated a hire date of 5/5/14. Review of NA Employee E11's current employee file failed to reveal an annual employee performance evaluation for 5/5/25 and 5/5/26.

During an interview 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations for five of five nursing staff personnel records (NA Employees E7, E8, E9, E10 and E11).

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.20(a)(d) Staff development.

Plan of Correction - To be completed: 10/09/2026

Employees E7, E8, E9, E10, and E11 received performance evaluations.
A review of nurse aide files was conducted to identify presence or absence of performance evaluations.
The Administrator or designee will provide training to the DON on the importance of conducting performance evaluations for nursing aides.
The Director of Nursing or designee will conduct audits of nurse aide performance evaluations monthly X 3 months. Findings will be reviewed at the QAPI meeting.

483.95(a) REQUIREMENT Communication Training:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.

Observations:

Based on review of facility policy, facility in-service documentation, personnel files, and staff interview, it was determined that the facility failed to provide annual training on Effective Communication for one of five staff members (Physical Therapist Employee E12).

Findings include:

Review of facility policy "Facility Assessment" last reviewed 8/4/26, with a previous review date of 1/14/26, indicated all personnel, including contracted staff will have annual trainings provided including content and competency and will be monitored by facility designated Managers/ Supervisors for attendance. Training requirements identified included Effective Communication as mandatory training for direct care staff including contracted staff.

Review of contracted Physical Therapy (PT) Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee E12's current personal file failed to reveal annual in-service training on Effective Communication 4/23/25 through 4/23/26.

During an interview completed on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide annual training on Effective Communication for one of five staff members (PT Employee E12).

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.20(a)(d) Staff development.

Plan of Correction - To be completed: 10/09/2026

Physical Therapist E12 received training on Effective Communication.
A review of direct care employee files was conducted to determine the presence or absence of annual Effective Communication training.
The Administrator will provide training to the DON and Director of Therapy on the importance of annual Effective Communication training.
The Administrator will conduct audits of direct care employees annual Effective Communications training monthly X 3 months. Findings will be reviewed at the QAPI meeting.

483.95(d) REQUIREMENT QAPI Training:

§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.

Observations:

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for one of five staff members (Physical Therapist (PT) Employee E12).

Findings include:

Review of facility policy "Facility Assessment" last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included QAPI.

Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee's current personal file failed to reveal annual in-service training on QAPI from 4/23/25, through 4/23/26.

During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for one of five staff members (contracted PT Employee E12).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.20(a)(d) Staff development.

Plan of Correction - To be completed: 10/09/2026

Physical Therapist E12 received training on QAPI.
A review of direct care employee files was conducted to determine the presence or absence of annual QAPI training.
The Administrator will provide training to the DON and Director of Therapy on the importance of annual QAPI training.
The Administrator will conduct audits of direct care employees annual QAPI training monthly X 3 months. Findings will be reviewed at the QAPI meeting.

483.95(f)(1)(2) REQUIREMENT Compliance and Ethics Training:

§483.95(f) Compliance and ethics.
The operating organization for each facility must include as part of its compliance and ethics program, as set forth at §483.85-

§483.95(f)(1) An effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program.

§483.95(f)(2) Annual training if the operating organization operates five or more facilities.

Observations:

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for one of five employees (Physical Therapist (PT) Employee E12).

Findings include:

Review of facility policy "Facility Assessment" last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Corporate Compliance and Ethics.

Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee E12's current personal file failed to reveal annual in-service training on Corporate Compliance and Ethics from 4/23/25, through 4/23/26.
During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Corporate Compliance and Ethics for one of five staff members (PT Employee E12).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.20(a)(d) Staff development.

Plan of Correction - To be completed: 10/09/2026

Physical Therapist E12 received training on Compliance and Ethics.
A review of therapy employee files was conducted to determine the presence or absence of annual Compliance and Ethics training.
The Administrator will provide training to the DON and Director of Therapy on the importance of annual Compliance and Ethics training.
The Administrator will conduct audits of therapy employees annual Compliance and Ethics training monthly X 3 months. Findings will be reviewed at the QAPI meeting.

483.95(i) REQUIREMENT Behavioral Health Training:

§483.95(i) Behavioral health.
A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71.

Observations:

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for one of five employees (Employee E12).

Findings include:

Review of facility policy "Facility Assessment" last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Dementia and Psychosocial Needs.

Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee's current personal file failed to reveal annual in-service training on Dementia and Psychosocial Needs from 4/23/25, through 4/23/26.

During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Dementia and Psychosocial Needs for one of five staff members (contracted PT Employee E12).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.20(a)(d) Staff development.

Plan of Correction - To be completed: 10/09/2026

Physical Therapist E12 received training on Behavioral Health.
A review of therapy employee files was conducted to determine the presence or absence of annual Behavioral training.
The Administrator will provide training to the DON and Director of Therapy on the importance of annual Behavioral Health training.
The Administrator will conduct audits of therapy employees annual Behavioral Health training monthly X 3 months. Findings wil
l be reviewed at the QAPI meeting.

§ 201.20(a)(2) LICENSURE Staff development.:

(2) Restorative nursing techniques.

Observations:

Based on a review of employee education records and staff interviews, it was determined that the facility failed to ensure that employees completed the required annual restorative nursing techniques education for seven of 10 employees reviewed (Nurse Aide (NA) Employees E7, E8, E9, E10 and E11 and Physical Therapist(PT) Employee E12, Registered Nurse(RN) Employee E13).

Findings include:

Review of facility policy "Facility Assessment" last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The additional mandatory training program for nursing staff included Restorative Nursing.

Review of facility provided documents and training record for E7, E8, E9, E10, E11, E12 and E13 revealed the following staff members did not have documented training on restorative nursing techniques.

Nurse Aide (NA) Employee E7 had a hire date of 6/1/15, failed to have restorative nursing techniques in-service education between 6/1/25 and 6/1/26.

NA Employee E8 had a hire date of 5/20/24, failed to have effective restorative nursing techniques in-service education between 5/20/25 and 5/20/26.

NA Employee E9 had a hire date of 3/7/05, failed to have effective restorative nursing techniques in-service education between 3/7/25 and 3/7/26.

NA Employee E10 had a hire date of 2/23/15, failed to have effective restorative nursing techniques in-service education between 2/23/25 and 2/23/26.

NA Employee E11 had a hire date of 5/5/14, failed to have effective restorative nursing techniques in-service education between 5/5/25 and 5/5/26.

PT Employee E12 had a hire date of 4/23/18, failed to have effective restorative nursing techniques in-service education between 4/23/25 and 4/23/26.

RN Employee E13 had a hire date of 3/20/17, failed to have effective restorative nursing techniques in-service education between 3/20/25 and 3/20/26.

During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to ensure that employees completed the required annual restorative nursing techniques education for seven of 10 employees reviewed.

Plan of Correction - To be completed: 10/09/2026

Employees E7, E8, E9, E10, E11, E12, and E13 received training on restorative nursing techniques.
A review of direct care employee files was conducted to determine the presence or absence of annual Restorative Nursing training.
The Administrator will provide training to the DON and Director of Therapy on the importance of annual Restorative Nursing training.
The Administrator will conduct audits of direct care employees annual Restorative Nursing training monthly X 3 months. Findings will be reviewed at the QAPI meeting.

§ 201.20(a)(3) LICENSURE Staff development.:

(3) Emergency preparedness in accordance with 42 CFR 483.73(d) (relating to emergency preparedness).

Observations:

Based on a review of employee education records and staff interviews, it was determined that the facility failed to ensure that employees completed the required annual emergency preparedness education for one of ten employees reviewed (Physical Therapist Employee E12).

Findings include:

Review of facility policy "Facility Assessment" last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Fire, Safety and Emergency Preparedness.

PT Employee E12 had a hire date of 4/23/18, failed to have emergency preparedness in-service education between 4/23/25 and 4/23/26.

During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to ensure that employees completed the required annual emergency preparedness education for one of 10 employees reviewed.

Plan of Correction - To be completed: 10/09/2026

Employees E7, E8, E9, E10, E11, E12, and E13 received training on Emergency Preparedness.
A review of direct care employee files was conducted to determine the presence or absence of annual Emergency Preparedness training.
The Administrator will provide training to the DON and Director of Therapy on the importance of annual Emergency Preparedness training.
The Administrator will conduct audits of direct care employees annual Emergency Preparedness training monthly X 3 months. Findings will be reviewed at the QAPI meeting.

§ 201.20(a)(4) LICENSURE Staff development.:

(4) Fire prevention and safety in accordance with 42 CFR 483.90 (relating to physical environment).

Observations:

Based on a review of employee education records and staff interview, it was determined that the facility failed to ensure that employees completed the required annual fire prevention and safety education for one of 10 employees reviewed (Physical Therapist (PT) Employee E12).

Findings include:

Review of facility policy "Facility Assessment" last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Fire, Safety and Emergency Preparedness.

PT Employee E12 had a hire date of 4/23/18, failed to have fire prevention in-service education between 4/23/25 and 4/23/26.

During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to ensure that employees completed the required annual fire prevention education for one of 10 employees reviewed.

Plan of Correction - To be completed: 10/09/2026

Employees E7, E8, E9, E10, E11, E12, and E13 received training on Fire Prevention.
A review of direct care employee files was conducted to determine the presence or absence of annual Fire Prevention training.
The Administrator will provide training to the DON and Director of Therapy on the importance of annual Fire Prevention training.
The Administrator will conduct audits of direct care employees annual Fire Prevention training monthly X 3 months. Findings will be reviewed at the QAPI meeting.

§ 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 per 10 residents during the day shifts, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift, on two of 28 days (8/23/26 and 8/24/26).

Findings include:

Review of the nursing schedules and census information for 8/9/26, through 8/29/26, revealed that the facility failed to meet the following:

8/23/26: Day shift required 177.00 hours of nurse aide care, facility provided 152.00.
8/24/26: Day shift required 177.00 hours of nurse aide care, facility provided 176.00.

During an interview on 9/3/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of one nurse aide per 10 residents during the day shifts, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift, on two of 28 days.

Plan of Correction - To be completed: 10/09/2026

The facility cannot retroactively correct this deficiency. No identified residents were affected as a result of the deficiency. All residents have the potential to be affected by this deficiency.
Education will be completed by the nursing home administrator or designee with the nursing staff scheduler and off shift supervisors on ratios, PPD, and proactive reporting of potential problem shifts.
Staffing meeting will be held five days per week excluding holidays with nursing home administrator, Director of nursing, and nursing staff scheduler, to review overall PPD and ratio requirements are met. If not, actions will be implemented , including agency reach out, reaching out to staff currently working as well as those that are not in the facility.
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.
Results will be forwarded to QAPI for review and recommendation.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 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 licensed practical nurse (LPN) per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the night shift on one of 21 days (8/25/26).

Findings include:

Review of the nursing schedules and census information for 8/9/26, through 8/29/26, revealed that the facility failed to meet the following:

08/25/26: Night shift required 44.25 hours of LPN care, facility provided 40.00.

During an interview on 9/3/26, at 10:30 a.m., the Director of Nursing confirmed that the facility administrative staff failed to provide a minimum of one LPN per 12 residents during the day and/or evening shifts, and one LPN per 20 residents during the night shift on one of 21 days.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on three of 21 days (8/23/26, 8/24/26, and 8/25/26).

Findings include:

Review of the nursing schedules and census information for 8/9/26, through 8/29/26, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:

-8/23/26, Census 236. PPD 2.92.
-8/24/26, Census 236. PPD 2.98.
-8/25/26, Census 236. PPD 3.14.

During an interview on 9/3/26, at 10:30 a.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on three of 21 days.

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