John J Kane Regional Center-Gl

Inspectors wroteBased on review of facility documents, the Pennsylvania Nursing Practice Act, incidents submitted to the local State Agency, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for ten of 43 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).

Inspectors wroteBased on review of facility policies, facility provided documents and clinical records, and staff interviews, it was determined that the facility failed to protect residents from abuse and neglect which resulted in actual harm of a fracture of the right tibia (lower leg bone) for one of four residents (Resident R86). This deficiency is cited as past non-compliance.

Inspectors wroteBased on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months (June 2025 through July 2026).

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpster to prevent the potential for rodent and insect infestation.

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to provide a dignified dining experience for two of four residents (Resident R16 and R118).

Inspectors wroteBased on review of facility policy, clinical records, review of facility provided documents and staff interview, it was determined that the facility failed to conduct a thorough investigation to rule out the potential for abuse/neglect for one of four residents (Resident R197).

Inspectors wroteBased on review of facility policy and clinical records it was determined that the facility failed to notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) and for change in physical assessment for three of 14 residents (Resident R 3, R11, R137).

Inspectors wroteBased on review of facility policies, clinical records, and staff interview it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a condom urinary catheter (a condom placed over the penis to drain urine) for one of four residents using catheters (Resident R197).

Inspectors wroteBased on resident observation and staff interview it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of three residents (Resident R239).

Inspectors wroteBased on the review of professional standards of practice, facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of pressure ulcers that resulted in hospitalization for the treatment of wounds. This resulted in actual harm for two of three residents with facility-acquired pressure ulcers. (Resident R15 and Resident R2).

Inspectors wroteBased on a review of facility documents, observations, and staff interview, it was determined that the facility failed to maintain an effective call system for 15 of 17 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).

Inspectors wroteBased on review of facility policy, clinical record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of thirteen residents (Resident R1).

Inspectors wroteBased on review of facility policy, documents, clinical record and staff interviews, it was determined that the facility failed to make certain a resident was free from the use of physical restraints without a physical restraint order for one of eight residents reviewed. (Resident R2).

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in a laceration (deep cut) for one of eight residents (Resident R1).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly restrain hair to prevent the potential for cross contamination in the Main Kitchen.

Inspectors wroteBased on a review of scheduled activities, observations, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents on one of five nursing units (Nursing Unit 3B).

Inspectors wroteBased on review of facility assessment, personnel file reviews, and staff interviews, it was determined that the facility failed to implement, and maintain an effective training program for individuals providing services under contractual arrangement, consistent with their expected roles.

Inspectors wroteBased on review of facility policy and documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for two of ten residents (Resident R17 and R400).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for three of nine residents reviewed (Residents R8, R45, and R154), and the facility failed to appropriately respond to a resident's change in condition for one of four residents (Resident R146).

Inspectors wroteBased on review of facility documents, clinical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a resident from falling from the wheelchair, for one of three residents (Resident R32).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eleven of nineteen residents reviewed (Resident R3, R21, R38, R43, R89, R100, R105, R117, R147 ,R187, R214). Findings Include: A review of the facility policy Advanced Directives: Patient Self Determination Act and PA Act 169 dated 1/2/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. [...]

Inspectors wroteBased 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 12 residents reviewed (Residents R13, R89, R147, and R198).

Inspectors wroteBased on review of facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for four of ten staff members (Employees E2, E3, E4, and E5).