Pennsylvania Department of Health
 KEARSLEY REHABILITATION AND NURSING CENTER
Building Inspection Results

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KEARSLEY REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  41 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
KEARSLEY REHABILITATION AND NURSING CENTER - 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 May 19, 2025, at Kearsley Rehabilitation and Nursing Center, 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 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0000


Facility ID #032502
Component 01
Long Term Care Building

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2025, it was determined that Kearsley Rehabilitation And Nursing Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 two-story, Type II (222), fire resistive building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to maintain carbon monoxide alarms in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

Document review on May 19, 2025, at 8:00 a.m., revealed the facility failed to adhere to the Care Facility Carbon Monoxide Alarms Standards Act in the following way:

a. No documentation of testing/cleaning carbon monoxide detectors was available.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the lack of documentation.






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

1. Carbon monoxide detectors have been tested and cleaned by an approved vendor.

2. Documentation of testing and cleaning will be maintained in the facilities Life Safety Binder.

3.Carbon Monoxide detectors will be monitored by Maintenance Director to ensure carbon monoxide detectors are tested and cleaned in compliance with Approved American National Standard for single carbon monoxide detectors.

NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting one of two levels in the facility.

Findings include:

Observation on May 19, 2025, at 10:26 a.m., revealed on the upper level, the staff did not know the code to unlock the exit stair door near resident room 30.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the staff did not know the unlock code.




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

1. Facility staff have been educated on door alarm code by room 30.

2. Maintenance Director or designee will provide education to current employees and newly hired staff during staff meetings and new employee orientation.

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 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0291

Based on documentation and interview, it was determined the facility failed to maintain and inspect emergency lighting, affecting the entire facility.

Findings include:

Document review on May 19, 2025, at 8:00 a.m., revealed the facility could not provide documentation of annual 90 minute emergency lighting testing.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the lack of documentation.




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

1. The annual 90 minute emergency lighting test has been completed by an approved vendor.

2. Documentation of testing will be maintained in the facilities Life Safety Binder.

3. Maintenance Director will ensure 90 minute emergency lighting test is completed as part of the facilities preventative maintenance program and tracked in Tels.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting one of two levels in the facility.

Findings include:

Observation on May 19, 2025, at 10:20 a.m., revealed in the upper level Kitchen, the kitchen hood suppression system was missing monthly inspections.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the missing monthly inspections.




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

1. The kitchen hood suppression system has been inspected by an approved vendor.

2. Documentation of inspection will be maintained in the facilities Life Safety Binder.

3. Maintenance Director will ensure kitchen hood suppression system is completed monthly as part of the facilities preventative maintenance program and tracked in Tels.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.

Findings include:

Document review on May 19, 2025, at 8:00 a.m., revealed the facility was not able to provide documentation of the following tests and inspections:

a. Quarterly sprinkler inspections for the 1st and 2nd quarters;
b. 3 year dry sprinkler full flow testing;
c. 5 year internal valve and pipe inspection.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the lack of documentation.



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

1. The sprinkle system has been inspected and is scheduled to be inspected quarterly. 3 year dry sprinkler full flow testing was completed by an approved vendor. The 5 year internal valve and pipe inspection has been completed by an approved vendor.

2. Documentation of testing will be maintained in the facilities Life Safety Binder.

3. Maintenance Director will ensure 3 year dry sprinkler full flow testing, 5 year internal valve and pipe inspection is completed as part of the facilities preventative maintenance program and tracked in Tels.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0355

Based on observation and interview, it was revealed the facility failed to maintain and inspect portable fire extinguishers, affecting one of two levels in the facility.

Findings include:

Observation on May 19, 2025, at 10:18 a.m., revealed in the upper level kitchen, both K-rated fire extinguishers were missing monthly inspections.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the missing monthly inspections.




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

1. The portable fire extinguishers identified have been inspected and tagged.

2. Maintenance Director will monitor the inspections of the fire extinguishers during daily walking rounds.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting one of two levels in the facility.

Findings include:

Observation on May 19, 2025, at 10:39 a.m., revealed on the lower level, the smoke barrier near resident room 12 had an opening and an open penetration around data wires above the ceiling.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the opening and open penetration.





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

1. Approved through penetration fire stop system will be used to seal the penetrations through the rated partitions. System numbers should be kept on file for future reference.

2. Maintenance Director will routinely check above ceiling tiles following any work completed by a contractor involving moving ceiling tiles.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two levels.

Findings include:

Observation on May 19, 2025, at 10:38 a.m., revealed on the lower level, storage within three feet of the electrical panels next to resident room 12. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

Exit interview with the Administrator and the Maintenance Director on May 19, 2025, at 11:00 a.m., confirmed the storage in front of the electrical panels.








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

1. Area within 3 feet of the electrical panel have been cleared.

2. Facility staff educated to ensure area is kept clear.

3. Maintenance Director will ensure area is kept cleared during daily walking rounds.


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