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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 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 July 29, 2024, 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 July 29, 2024, it was determined 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 Multiple Occupancies - Construction Type:

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.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating of common wall openings, on one of two floors.

Findings include:

1. Observation on July 29, 2024, at 12:32 p.m., revealed the double doors at the Castle connection had the latching hardware removed and replaced with magnetic holds only.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 29, 2024, at 2:00 p.m., confirmed the doors lacked positive latching.

Plan of Correction - To be completed: 08/21/2024

1.Latching hardware to be reinstalled so door positivvely latches.

2.Maintenance Director will check all fire doors to enire they have a positive latch.

3.Maintenance Director will monitor this daily through walking rounds.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain egress doors in one location on one of two floors.

Findings include:

1. Observation on July 29, 2024, at 1:18 p.m., revealed the double doors egress doors in the Lower level leading to the patio with installed delayed egress devices failed to operate as designed and did not release the doors when tested.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 29, 2024, at 2:00 p.m., confirmed the delayed egress devices failed to release the doors when tested.

Plan of Correction - To be completed: 08/21/2024

1.Doors were repaired, egress doors now release and open.

2.Maintenance Director checked doors with delayed egress to ensure the delayed egress works.

3. Maintenance Director will check delayed egress doors as pasrt of his routine walking rounds.

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 (LONG TERM CARE BUILDING) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barriers on one of two floors.

Findings include:

1. Observation on July 29, 2024, at 12:44 p.m., revealed an open, unsealed three-inch hole in the smoke barrier, above the doors same side as and near room 62.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 29, 2024, at 2:00 p.m., confirmed the open area in the smoke barrier.

Plan of Correction - To be completed: 08/21/2024

1. The unsealed penetration will be sealed using a UL approved stop gap penetration system

2.Maintenance director to check abopve smoke barrier walls to ensure there are no other penetrations.

3.Maintenance Director will randomly monitor this during his preventative maintenance rounds.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement