Pennsylvania Department of Health
NURSING AND REHABILITATION AT THE MANSION
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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NURSING AND REHABILITATION AT THE MANSION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to two Complaint Investigations, completed on November 17, 2025, at Nursing and Rehabilitation at the Mansion it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 01/04/2026

1. NA ratios cannot be corrected as this is a past occurrence.
2. Calculations of shift NA ratios will be completed and reviewed daily for accuracy by the DON/ADON.
3.The facility continues to put forth efforts to recruit and retain new nursing staff members. Agency continues to be utilized to support staffing needs.
4. Schedules and NA ratios will be audited daily by the scheduler and DON/Designee. The results of the findings will be reported monthly at the Quality Assurance Performance Improvement meeting.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 40 residents during the night for seven of 21 days reviewed. Findings include: Review of nursing staff care hours provided by the facility for June 30, 2025, through July 5, 2025, September 28, 2025, through October 4, 2025, and November 10, 2025, through November 16, 2025, revealed the following nurse aides scheduled for the resident census: Night Shift (Requires one LPN per 40 residents) June 29, 2025, 1.16 LPNs for a census of 65; requires 1.63 LPNs June 30, 2025, 1.00 LPNs for a census of 64; requires 1.60 LPNs July 1, 2025, 1.16 LPNs for a census of 64; requires 1.60 LPNs July 2, 2025, 1.00 LPNs for a census of 62; requires 1.55 LPNs July 5, 2025, 1.09 LPNs for a census of 61; requires 1.53 LPNs October 1, 2025, 1.09 LPNs for a census of 60; requires 1.50 LPNs November 10, 2025, 1.00 LPNs for a census of 66; requires 1.65 LPNs The above information was reviewed with the Nursing Home Administrator and Director of Nursing on November 17, 2025, at 11:30 AM.

Plan of Correction - To be completed: 01/04/2026

1. LPN ratios cannot be corrected as this is a past occurrence.
2. Calculations of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler and DON/ADON.
3. The facility continues to put forth efforts to recruit and retain new nursing staff members. Agency continues to be utilized to support staffing needs.
4. Schedules and LPN ratios will be audited daily by the scheduler and DON/Designee. The results of the findings will be reported monthly at the Quality Assurance Performance Improvement meeting.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations: Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, for six of 21 days reviewed. Findings include: Review of nursing staff care hours provided by the facility for June 30, 2025, through July 5, 2025, September 28, 2025, through October 4, 2025, and November 10, 2025, through November 16, 2025, revealed the following nurse aides scheduled for the resident census: June 26, 2025, with 2.99 hours per resident per day. July 5, 2025, with 3.30 hours per resident per day. October 4, 2025, with 3.13 hours per resident per day. November 10, 2025, with 3.08 hours per resident per day. November 14, 2025, with 3.03 hours per resident per day. November 15, 2025, with 3.02 hours per resident per day. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on November 17, 2025, at 11:30 AM.

Plan of Correction - To be completed: 01/04/2026

Facility unable to correct previous staffing hours.
Facility will calculate PPD daily and reviewed for accuracy.
The facility continues to put forth efforts to recruit and retain new nursing staff members. Agency continues to be utilized to support staffing needs.
Schedule and PPD will be audited daily by the DON/ADON. The results of the findings will be reporting at the monthly QAPI meeting.

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