Pennsylvania Department of Health
JOHN J KANE REGIONAL CENTER- SCOTT TOWNSHIP
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- SCOTT TOWNSHIP - 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 September 8-9, 2025, at John J. Kane Regional Center-Scott Township, 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# 364902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 8-9, 2025, it was determined that John J. Kane Regional Center-Scott Township 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 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 four instances, affecting four of seventeen smoke compartments.

Findings include:

1. Observation on September 8, 2025, revealed the following deficiencies that may affect operation of the automatic sprinkler system:

a) 9:35 a.m., there was a gap in the ceiling tile, greater than 1/8 inch in the Kitchen storage room;
b) 9:45 a.m., there were missing ceiling tiles in Visiting Rooms 1 and 2 (Room 111);
c) 9:55 a.m., there was a a large piece of ceiling tile missing in Room 294/Soiled linen;
d) 10:05 a.m., a ceiling tile was missing a large piece at the corner of the tile
in Room 499.

Interview with the Facility Administrator, Maintenance Director, and Chief of Security on September 9, 2025, at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 10/13/2025

This plan of correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by state and federal law.
It is the policy of the Regional Center to provide the necessary care and services to attain and maintain the highest practicable well-being of our residents in accordance with state and federal regulations.

ESM/designee will randomly inspect ceiling tile areas to ensure the appropriate placement of the ceiling tiles as to not affect operation of the automatic sprinkler system.

Audit weekly for 4 weeks, then monthly for 2 months verifying appropriate ceiling tile placement.

Results will be reported to the Quality Improvement Committee for review and recommendations.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in three instances, affecting three of seventeen smoke compartments.

Findings include:

1.Observation on September 8, 2025, revealed the following:

a) 10:20 a.m., the door to Oxygen Storage did not close and latch, when tested;
b) 10:35 a.m., the door to the Kitchen Janitor's closet did not close and latch, when tested;
c) 11:05 a.m., the door to Resident room 287 would not close and latch, when tested.

Interview with the Facility Administrator, Maintenance Director, and Chief of Police on September 9, 2025, at 1:30 p.m., confirmed the corridor door deficiencies.

Plan of Correction - To be completed: 10/13/2025

Facility carpenter is adjusting/aligning the three doors listed to ensure doors closed and latch properly/positive latch.

ESM/designee will randomly inspect door latches to ensure facility doors have a positive latch.

Audit weekly for 4 weeks, then monthly for 2 months verifying doors have a latch
Results will be reported to the Quality Improvement Committee for review and recommendations.

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