Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on December 11, 2021, it was determined that Seton Manor Nursing and Rehabilitation Center was not in compliance with the following 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.

 Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Based on observation it was determined that the facility failed to store food under sanitary conditions in the kitchen.

Findings include:

Observation during a tour of the kitchen on December 11, 2021, at 10:40 a.m.., revealed that there was a hole in the wall by the dish machine, with debris from the wall on the floor beneath it. The vent on the ice cream freezer was covered in dust and dirt. In the sink next to the ice cream freezer there was garbage in the drain. The hand washing sink across from the pot sink was observed with water inside it that was not draining. In the walk-in refrigerator there was a container of chicken noodle soup dated November 25, an opened, undated container of mayonnaise, ravioli dated December 3, and whipped topping dated November 29. There was an opened, undated container of thickened cranberry juice and a case of thawed thickened vanilla shakes with no date that indicated when they were put in the walk-in refrigerator to thaw. The manufacturer's instructions printed on the shake container stated that the shakes were to be discarded 14 days after thawing. In an interview at that time the Director of Dietary stated that all food items were to be dated with an opened date and discarded after seven days. In the refrigerated storage truck there was an opened undated bag of macaroni noodles. In the dry storage room there was an opened undated bag of rice and a crumbled up piece of paper in a box of plastic utensils.

 Plan of Correction - To be completed: 12/21/2021

Hole in the wall by the dish machine was repaired. Ice Cream freezer vent was cleaned. Both hand washing sinks were repaired and operable. All outdated and undated food was discarded. The opened box of plastic utensils was discarded.

Dietary Manager or designee will educate dietary staff on proper labeling of food, discarding of food and cleaning of vents.

Dietary Manager or designee will randomly audit labeling of food and cleaning of vents weekly for 3 months. Results will be reported to QA.

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