Pennsylvania Department of Health
JOHN J KANE REGIONAL CENTER- MCKEESPORT
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on December 1, 2025, at John J. Kane Regional Center McKeesport, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 364702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 10, 2025 to December 1, 2025, it was determined that John J. Kane Regional Center McKeesport was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in three instances, affecting the entire facility.

Findings include:

1. Observation and interview on November 10, 2025, revealed the following emergency lighting deficiencies:

a) 8:40 a.m., the battery back-up light in Room A130 on the first floor, failed to illuminate when tested;
b) 8:50 a.m., the battery back-up light in the Generator Room, on the first floor, failed to function when tested;
c) 9:10 a.m., there was no battery back-up light in the automatic transfer switch room.

Interview with the Facility Maintenance Director on November 10, 2025, at 9:10 a.m. confirmed the battery back-up emergency lights were not working and missing.

Plan of Correction - To be completed: 12/17/2025

Service request was placed with contracted vendor Mare Solutions to replace the battery back-up light in Room A130, the Generator room, and add a new battery back-up light in the automatic transfer switch room

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in six instances, affecting 4 of 21 smoke compartments.

Findings include:

1. Observation on November 10, 2025, revealed the following deficiencies which would allow the passage of heat and smoke, and may affect operation of the automatic sprinkler system:

a) 8:40 a.m., there was a gap greater than 1/8 inch surrounding the escutcheon plate of a sprinkler head in Room B-116/ADL Room;
b) 8:55 a.m., there was a missing ceiling tile in Room B-147/ Medical Records File Room;
c) 9:00 a.m., there was a missing ceiling tile in Room B-396/Nourishment;
d) 9:05 a.m., a sprinkler head was missing an escutcheon plate in Room A-132;
e) 9:10 a.m., there were two missing ceiling tiles in Room A-140;
f) 9:20 a.m., there was a gap in the drywall surrounding electrical conduit in the ceiling in Room B-104 on the first floor.

Interview with the Maintenance Director on November 10, 2025, at 9:30 a.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 12/17/2025

Service requests were placed with Allegheny County Department of Facilities Management to remedy the gap surrounding the escutcheon plate in room B116. Replace missing ceiling tiles in rooms B147, B396, & A140, and to seal the gap in the drywall surrounding the electrical conduit in the ceiling in room B104. Work was completed on November 10, 2025.

Service requests will be placed with Allegheny County Department of Facilities Management to remedy the missing escutcheon in A132 and completed November 12, 2025.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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.

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of twenty one smoke compartments.

Findings include:

1. Observation on November 10, 2025, at 9:35 a.m., revealed there was a penetration sealed with an unapproved substance in the smoke barrier wall near Room A 132 on the first floor.

Interview with the Facility Maintenance Director on November 10, 2025, at 9:35 a.m., confirmed the penetration was sealed with an unapproved substance.

Plan of Correction - To be completed: 12/17/2025

Service request was placed with contracted vendor Mare Solutions to remove the unapproved substance in the smoke barrier wall near room A132 and replace it with a UL approved 3M fire barrier sealant CP 25WB+. Mare Solutions was educated on the proper type of UL Approved fire caulking that is approved in the facility and that no type of expandable foam is to be used. . Facility will make sure that any future venders will implement the regulated materials required to finish the contracted project.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923
Based on observation and interview, it was determined the facility failed to properly store oxygen cylinders in one instance, affecting one of twenty one smoke compartments.

Findings include:

1. Observation on November 10, 2025, at 9:00 a.m., revealed two unsecured oxygen cylinders stored in Medication Room A 247 on the second floor.

Interview with the Facility Maintenance Director on November 10, 2025, at 9:00 a.m., confirmed the oxygen storage deficiency.

Plan of Correction - To be completed: 12/17/2025

The two identified oxygen cylinders were immediately removed and secured properly.

Staff will be in-serviced on the proper storage of oxygen cylinders in the facility.

The Environmental Service Manager (ESM)/designee will randomly audit the Medication rooms for unsecured oxygen cylinders to assure compliance ensuring all oxygen cylinders are stored properly monthly x3. Any problems identified will be remedied immediately. The results of this audit will be reviewed and evaluated by the QAPI committee.

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