Pennsylvania Department of Health
KEARSLEY REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KEARSLEY REHABILITATION AND NURSING CENTER
Inspection Results For:

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KEARSLEY REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to two complaints and a facility reported event, completed on May 16, 2025, it was determined that Kearsley Rehabilitation And Nursing Center, was not in compliance with the 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 related to the health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of clinical documentation and staff interviews, it was determined the facility failed to ensure adequate supervision during care by ensuring two staff were available for one of two residents reviewed (Resident R56). This failure resulted in actual harm to Resident R56 who fell out of bed and sustained a compound fracture of the right femur (hip). This deficiency was identified as past non-compliance.

Findings include:

Review of Resident R56's clinical record revealed the resident was admitted to the facility on March 5, 2021, with diagnoses of cerebral infarction (area of brain tissue that has died), psychomotor deficit (slowing down of both thoughts and physical movements) following cerebral infarction, Hemiplegia and Hemiparesis (paralysis affecting only one side of the body) affecting the right dominant side, and need for assistance with personal care.

Review of Resident R56's quarterly MDS (Minimum Data Set, periodic assessment of resident care needs), section G, Functional Status, dated January 31, 2025, revealed the resident required extensive assistance of two or more staff members for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture).

Further review of of Resident R56's MDS assessment, Section C, Cognitive Patterns, revealed the resident was rarely understood, and a Staff Assessment for Mental Status concluded the resident had long and short term memory deficits and was unable to recall the current season, location of his/her room, names and faces of staff members, or that he/she was a resident in a nursing facility. As such, it was determined the resident was non-interviewable.

Review of Resident R56's care plan dated February 12, 2025 revealed the following intervention, "I am dependent on 2 staff and a sheet for turning and repositioning."

Review of Resident R56's bedside Kardex report (report of information available to nurse aides to alert them to resident care needs) revealed an intervention under the section "Bed Mobility/Positioning" which indicated "I am dependent on 2 staff and a sheet for turning and repositioning."

Review of the nursing notes for Resident R56 revealed a note written by Registered Nurse Supervisor, Employee E6, on April 20, 2025, at 6:17 a.m. The nursing note indicated, "Called by nurse to assess resident...related to fall. Resident was lying on floor to left side of [his/her] bed. Resident was noted bleeding from left knee from tiny laceration ....Resident transported to ER (emergency room) at 6:23 am."

Continued review of nursing notes revealed a note from Licensed Nurse, Employee E7, on April 20, 2025, at 8:19 a.m. which revealed, "@ 6am I heard a scream, then heard CNA (nurse aide) calling for me, I immediately ran to the room, observing the resident in a sitting position with right knee pulsating with blood, from a small laceration, large amount of blood observed."

Review of facility's incident report for Resident R56 revealed a fall occurred on April 20, 2025, at 6:00 a.m. The report indicated the fall was witnessed, and the resident lowered himself/herself to the ground. The report concluded the resident "slid from bed while receiving incontinent care. [Resident R56] is dependent on toileting, was being toileted as usual with [his/her] routine CNA (Nurse Aide, Employee E8). [The resident], while holding onto [his/her]right assist rail, [his/her] legs slid off the bed onto the floor ...[she/he] held onto the rail, preventing [his/her] top half from falling, the CNA safely lowered [him/her] to the floor." The report further revealed the resident was sent to the emergency department for evaluation. [Resident R56] was admitted to the hospital with a diagnosis of fractured femur (hip), and that he/she underwent surgical fracture repair.

Review of the hospital documentation signed by hospital physician, Employee E9, revealed Resident R56 had been admitted to the hospital with an "open fracture" (where the bone protrudes through the skin) of the right femur, which "will require operative fixation."

Telephone interview with Employees E6, E7, and E8 were conducted on May 16, 2025. Interview with RN Supervisor, Employee E6 at 2:38 p.m. revealed on the night of the fall, he was summoned to the room to assess the resident following the incident. He stated that staff was providing care to Resident R56 when he/she fell out of bed, and that upon his entry to the room, the only staff present were the charge nurse, Employee E7, and the nurse aide, Employee E8.

Interview with the charge nurse, Employee E7, at May 16, 2025 at 2:44 p.m., revealed, "I was outside [the room] and I heard a scream and the CNA (Employee E8) calling for help. I went in and saw the CNA holding the resident up. [He/she] was [rolled] on [his/her] right side, which is [his/her] weak side ... [Employee E8] said she had turned [resident], and [he/she] slipped off the bed. The bed was high because it was in position for the CNA." She further stated that this was the first fall for the resident "in the three years [he/she]'s been here," and the Nurse aide, Employee E8 was the only staff member present in the room at the time of the fall. She also stated the resident was "not on paired care." Charge nurse, Employee E7 had been unaware at the time of the resident's needed level of assistance for bed mobility and turning was a two or more person assist.

Interview with the Nurse Aide, Employee E8, on May 16, 2025 at 2:48 p.m., revealed during continence care, "I was changing [resident], and [he/she] was on [his/her] side. I don't even really know how [resident's] legs slipped off the bed ...it was just me. I rolled [him/her] side to side ... I was changing [resident], and [his/her] legs slipped off." Employee E8 revealed the resident had been rolled to the right side of the bed, holding the rail with [his/her] left arm. Employee E8 clarified that she had been standing on the left side of the bed at the time, and that the resident's legs had slid out of the right side of the bed, opposite of where she was standing. She said that she was able to assist the resident to the floor, and then called the charge nurse for help. She revealed that she was not aware at the time of the incident, the resident required assistance of two or more staff for bed mobility and repositioning.

On May 16, 2025, the Nursing Home Administrator (NHA), Employee E1, presented documentation indicating that the facility had initiated a plan of correction on April 21, 2025, related to ensuring nursing staff were made aware of the level of assistance required for care of residents and they verified ADL (Activities of Daily Living) care needs "including bed mobility and transfer status" prior to providing care.

Review of facility Action plan/Follow up documentation revealed the following information.

1. [Resident R56] care plan and Kardex have been updated to reflect current needs.
2. Sweep of current residents conducted to ensure ADL care needs reflect their current needs and are reflective in the care plan and Kardex.
3. Contracted Occupational Therapist educated on ensuring changes in care needs are reflective in the care plan and communicated to the resident's charge nurse. Also, it is vital to ensure current care needs are resolved or edited when a change is made [to] any previous bed mobility.
4. NHA or designee will conduct weekly audits to ensure care plan and Kardex clearly indicate the level of care needed. Results of the audits will be reviewed by the QAA (Quality Assurance) committee and the QAA committee will determine continuation of audits.

The facility alleged a date of compliance with this plan of correction of April 24, 2025.

Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of facility policy on assistance level verification for ADL care. Nursing staff and resident interviews were conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, interview or observation.

This deficiency was cited as past non-compliance.

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

28 Pa. Code 201.18(b)(1)(e)(1) Management.

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

Plan of Correction - To be completed: 06/02/2025

Past noncompliance: no plan of correction required.

483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:
Based on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to develop and implement a baseline care plan related to a pressure ulcer for one of two new admissions reviewed (Resident R47).

Findings Include:

Review of facility policy "Care Plans - Baseline" revealed a baseline plan of care to meet the resident's immediate health/safety needs is developed for each resident within 48 hours of admission.

Review of Resident R47's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 10, 2025, revealed the resident was admitted to the facility on April 4, 2025, and had diagnoses of muscle weakness, malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), and depression (mood disorder which causes persistent feelings of sadness of loss of interest).

Continued review of the MDS dated April 10, 2025, included a review of "Section M - Skin Conditions" which indicated Resident R47 was at risk of developing pressure ulcers/injuries and had an unhealed pressure ulcer/injury. Resident R47 was noted to have an unstageable deep tissue injury.

Review of facility wound report dated April 7, 2025, revealed Resident R47 had a left medial heel deep tissue injury that was present at the time of admission on April 4, 2025.

Review of Resident R47's clinical record and baseline care plan revealed no documented evidence a baseline care plan was created to include the interventions and treatments for the left heel deep tissue injury that was present at the time of admission.

Review of Resident R47's clinical record revealed a care plan for the left heel deep tissue injury was not developed and implemented until April 8, 2025.

28 Pa. Code 211.10 (d) Resident care policies.

Plan of Correction - To be completed: 06/19/2025

1. R47 care plan has been updated to accurately reflect his care needs.

2. Current residents with alterations in skin will be checked to ensure alterations in skin are care planned.

3. Licensed nursing staff will be in-serviced on ensuring that resident have baseline care plans developed and implemented within 48 hours of admission.

4. NHA or designee will conduct weekly audits of new admissions to ensure baseline care plans are in place. Results of the audits will be reviewed by the QAA committee and the QAA committee will determine the continuation of audits.

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

§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 observations and clinical record review, it was determined that the facility did not ensure the comprehensive care plan was implemented related to communication for one of 18 residents reviewed (Resident R46).

Finding include:

Review of Resident R46 's clinical record revealed that Resident R46 was admitted to the facility on January 27, 2021 with diagnoses of, but not limited to, Chronic Respiratory Failure, Cerebrovascular Accident (also known as a stroke), cognitive impairment.

Review of Resident R46's care plan revised on October 1, 2024 revealed that Resident R46 has a communication deficit related to Aphasia. Intervention implemented on December 12, 2022 that Resident R46 is able to communicate by: lip reading, writing, communication board, gestures, sign language, translator.

Further review of Resident R46's care plan revised on February 1, 2021 revealed that Resident R46 is dependent on staff for activities, cognitive stimulation, social interaction related to immobility, physical limitations. Interventions implemented on February 1, 2021 for all staff to converse with resident while providing care.

Observation on May 13, 2025 at 11:45am revealed Licensed Practical Nurse, Employee E3, providing care to Resident R46. Resident R46 appearing agitated and confused, stating "I'm scared". Employee E3 preformed care without speaking or addressing the resident, no reassurance or directions provided to the resident.

Plan of Correction - To be completed: 06/19/2025

1.R46's careplan has been reviewed with caregivers and is being followed. Employee E3 has been educated on following care planned needs.

2. Current Residents who have communication deficits will be checked to ensure they have care plans in place and interventions are being implemented by nursing staff.

3. Nursing staff will be in-serviced on ensuring that resident comprehensive care plans developed, reviewed quarterly, and interventions are appropriate for resident care needs.

4. NHA or designee will conduct random weekly audits current residents to ensure care plans are in place for those with communication deficits are being followed and have appropriate interventions. Results of the audits will be reviewed by the QAA committee and the QAA committee will determine the continuation of audits.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Plan of Correction - To be completed: 06/19/2025

1. R29 no longer resides in the facility. R23 was reweighed and is being followed by Registered Dietician.

2. Current residents will be checked to ensure weights and any necessary reweight is obtained timely.

3. DON. ADON, and dietician will be in-serviced on ensuring weights, re-weights and RD consults are completed timely.

4. NHA or designee will conduct weekly audits of current resident to ensure weights, re-weights and RD consult are completed timely. Results of the audits will be reviewed by the QAA committee and the QAA committee will determine the continuation of audits.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;

Plan of Correction - To be completed: 06/19/2025

1. R6 is receiving medications according to physician orders.

2. Current residents will be checked to ensure they are receiving medications timely.

3.Employee E3 and Licensed nursing staff will be educated on ensuring medications are administered as ordered and ensuring physicians are notified of any changes in medication administration.

4. NHA or designee will conduct weekly to ensure residents are receiving medications according to physicians order. Results of the audits will be reviewed by the QAA committee and the QAA committee will determine the continuation of audits.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to be free of significant medication error for one of three residents (Residents R6).

Findings include:

Review of facility policy, "Administering Medications" revised April 2019, revealed, "Medications are administered withing one hour of their prescribed time, unless otherwise specified."

Review of Resident R6's clinical record revealed Resident R6 was admitted on May 22, 2024 with diagnosis of, but not limited to COPD (Chronic Obstructive Pulmonary Disease), Diabetes, Hypertension (high blood pressure).

Review of Resident R6' s MDS (Minimum Data Set) dated April 9, 2025, revealed that resident has a BIMS (Brief interview for mental status) of 15, indicating resident is cognitively intact.

Review of Resident R6's physician orders revealed order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% 1 inhalation inhale orally via nebulizer four times a day, administration time ordered for May 13, 2025, at 9:00am. Further review revealed physician order for Budesonide Inhalation Suspension 0.5 MG/2ML 2 ml inhale orally two times a day for Wheezing/Shortness of breath, administration time ordered for May 13, 2025, at 9:00am.

Interview with Resident R6 on May 13, 2025 at 11:30am revealed that resident had not received her morning medications on May 13, 2025 and she was most concerned with her breathing treatments "because they help me breathe better, I really need them on time".

Observation of Medication Pass on May 13, 2025 at 12:05 p.m. revealed Licensed Practical Nurse, Employee E3 administering Albuterol and Budesonide.

Interview with Licensed Practical Nurse, Employee E3 confirmed medications being administered are ordered for May 13, 2025 at 09:00am.

Further review of Resident R6's clinical record revealed no documented evidence that physician was notified prior to administering medications related to late administration of medications causing significant medication errors.

Review of Medication Administration Records (MARs) for Resident R6, further revealed incorrect documentation for administration times for ten of ten medications passed during observation of medication pass on May 13, 2025, at 12:05pm. Per documentation entered by Licensed Practical Nurse, Employee E3, all medications were administered to Resident R6 on May 13, 2025 between 10:24am and 10:30am.

Interview with Licensed Practical Nurse, Employee E3 on May 14, 2025, at 11:45am revealed that medications were not properly signed out at time of administration, "I write it all down on paper and go back to document later".

28 Pa. Code 211.12(d)(1) Nursing services

28 Pa. Code 211.12(d)(3) Nursing services

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

Plan of Correction - To be completed: 06/19/2025

1. R6 is receiving insulin and albuterol sulfate inhalation nebulizer according to physician order.

2. Current residents who receive routine insulin and albuterol sulfate inhalation nebulizers will be checked to ensure they are receiving medications according to physician order.

3. Employee E3 and Licensed nursing staff will be educated on ensuring medications are administered as ordered and ensuring physicians are notified of any changes in medication administration.

4. NHA or designee will conduct weekly to ensure residents are receiving medications according to physicians order. Results of the audits will be reviewed by the QAA committee and the QAA committee will determine the continuation of audits.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based observations and staff interviews, it was determined that facility did not ensure that opened medications were properly labeled with the date that the medication was opened for two of three medication carts reviewed and one of one medication room reviewed. (Upper Level Med room, Lower Level South Med Cart, Lower Level North Med Cart).

Findings include:

Observation of Medication cart on Lower-Level South Med Cart on May 14, 2025 at 10:05 a.m. revealed one opened bottle of medication, including Geri-tussin 200ml/10ml Solution, not labeled with an open date.

Interview with Licensed nurse, Employee E4 on May 14, 2025 at 10:05am confirmed one opened bottles of medication not labeled with an open date.

Observation of Medication cart on Lower-Level North Med Cart on May 13, 2025 at 11:45 am revealed two open packages, Albuterol Sulfate 0.083% nebulizer treatment and
Budosemide 0.5mg/2ml nebulizer treatment, not labeled with an open date.

Interview with Licensed nurse, Employee E3 on May 13, 2025 at 11:45am confirmed two opened packages of medication not labeled with an open date.

Observation in Upper Level Med Room on May 14, 2025 at 11:12am revealed two open bottles including Vancomycin 50mg/ml oral solution and Tuberculin 5tu-0.1ml injectable, not labeled with open date.

Interview with Employee E5 on May 14, 2025 at 11:12 a.m. confirmed two open bottles with no open date.

28 Pa. Code 211.12 (d)(1) Nursing services.

Plan of Correction - To be completed: 06/19/2025

1. Medications that were not labeled appropriately have been discarded, and replaced.

2. Medications requiring an open date have been checked to ensure they are labeled appropriately. Any medications not labeled will be discarded, and replaced.

3. Licensed nursing staff will be in serviced on ensuring medications requiring an open date are labeled with the date the bottle was opened.

4. NHA or designee will conduct weekly to ensure medications requiring an open date are labeled correctly. Results of the audits will be reviewed by the QAA committee and the QAA committee will determine the continuation of audits.

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