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

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SETON MANOR NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  97 surveys for this facility. Please select a date to view the survey results.

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SETON MANOR NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on February 28, 2024, it was determined that Seton Manor Nursing and Rehabilitation Center was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for a total of 23 shifts of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 4 through February 24, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day shift (7:00 a.m. to 3:00 p.m.) on February 9, 16, 17 and 19, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening shift (3:00 p.m. to 11:00 p.m.) on February 4, 5, 6, 7, 8, 10, 12, 14, 15, 16, 17, 19, 20, 23, and 24, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on February 6, 16, 17, and 23, 2024.

In an interview on February 28,. 2024, at 2:00 p.m., the Director of Nursing stated that the facility failed to meet the NA to resident ratios for the days and shifts listed above.






 Plan of Correction - To be completed: 03/19/2024

1) The findings of the nurse aide nursing staff care ratios cannot be retroactively corrected.
2. Facility will provide a minimum of one nurse aide per 12 residents during day shift and one nurse aide per 12 residents on evening shift and one aide per 20 residents overnight.
3. Scheduler will be educated on the requirements there must be a minimum of one aide per 12 residents during dayshift and a minimum of one aide per 12 residents on evening shift and one nurse aid per 20 residents overnight.
4. NHA/designee will conduct random audits to verify that nurse aide dayshift, evening shift and overnight shift ratios meet the requirements daily for 5 days, weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for a total of 15 shifts of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 4 through 24, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on February 5, 6, 9, 15, 17, 18, 19, 22 and 23, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on February 8 and 18, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on February 7, 15, and 19, 2024.

In an interview on February 28, 2024, at 2:00 p.m., the Director of Nursing stated that the facility failed to meet the LPN to resident ratios on the days and shifts listed above.




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 Plan of Correction - To be completed: 03/19/2024

1)Findings of LPN nursing staff care ratios cannot be retroactively corrected.
2) Facility will provide a minimum of one LPN per 25 residents during dayshift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the overnight.
3) Scheduler will be educated on the requirements of one LPN per 25 residents during the day shift , a minimum of one LPN per 30 residents during evening shift and a minimum of one LPN per 40 residents during the overnight shift.
4) NHA/designee will conduct random audits to verify that LPN dayshift, evening shift and overnight shift ratios meet the requirements daily for 5 days, weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for eight of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 4 through 24, 2024, revealed the following total nursing care hours below minimum requirements:

February 4, and February 9, 2024, the hours of direct care for each resident was 2.80
February 15, 2024, the hours of direct care for each resident was 2.70.
February 16, 2024, the hours of direct care for each resident was 2.74.
February 17, 2024, the hours of direct care for each resident was 2.68.
February 19, 2024, the hours of direct care for each resident was 2.55.
February 23, 2024, the hours of direct care for each resident was 2.67.
February 24, 2024, the hours of direct care for each resident was 2.68.

In an interview on February 28, 2024, at 2:00 p.m., the Director of Nursing stated that the facility failed to meet the minimum hours of direct care for the days listed above.








 Plan of Correction - To be completed: 03/19/2024


1)Findings of PPDs cannot be retroactively corrected.
2)The facility will provide the minimum of 2.87 hours of direct care for residents.
3)The scheduler will be educated on maintaining the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.
4)NHA/designee will conduct random audits to verify that the minimum of 2.87 hours of direct care for residents is provided daily for 5 days, weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.


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