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

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Severity Designations


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 a complaint, completed on March 14, 2026, it was determined that Nursing and Rehabilitation at the Mansion was in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with the 28. Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

51.3 (e) LICENSURE NOTIFICATION:

51.3 Notification

(e) If a health care facility is
aware of information which shows that
the facility is not in compliance with
any of the Department's regulations
which are applicable to that health
care facility, and that the
noncompliance seriously compromises
quality assurance or patient safety,
it shall immediately notify the
Department in writing of its
noncompliance.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for the failure to comply and the
steps which the health care facility
shall take to bring it into compliance
with the regulation.

Observations: Based on a review of facility provided documents, facility policy, and staff interview, it was determined that the agency failed to notify the Department of Health (DOH) of reportable incidents for two of four residents (Resident R1 and R2). Findings include: Review of "28 Pa. Code Specific identified reportable diseases, infections, and conditions", indicated the diseases, infections and conditions that are reportable to the Department or the appropriate local health authority. Review of this list revealed that Influenza was included in the list of reportable diseases, and must be reported by healthcare practitioners and healthcare facilities within five workdays after being identified by symptoms, appearance or diagnosis. Review of the Pennsylvania Department of Health "Respiratory Virus Outbreak Toolkit" dated 11/24/25, indicated an Influenza outbreak is defined as: One confirmed case of influenza in resident plus one resident with influenza like illness within 72 hours, OR Two confirmed cases of influenza in residents within 72 hours. "An outbreak is considered "over" when 14 days have passed since the last resident tested positive or became symptomatic (if no positive test is available). Any new infections in a resident (for the applicable virus) would restart the 14-day countdown." Review of the facility policy "IC Plan, Program, and Committee" dated 5/7/25, indicated the facility follows current guidelines and recommendations for managing influenza outbreak in the facility. Review of clinical records on 3/14/26, revealed that the facility had four residents who had tested positive for Influenza A between 1/6/26, and 1/19/26. Per the PA DOH guidelines, the outbreak end date was 1/29/26. Review of documentation submitted to the Pennsylvania Department of Health from 1/1/26, through 3/13/26, revealed only two residents who tested positive for Influenza A were reported, with an onset date of 1/6/26. No additional documentation was submitted for the two additional residents (Resident R1 and R2). Review of the clinical record and facility provided documentation revealed Resident R1 tested positive for Influenza A on 1/12/26. Review of the clinical record and facility provided documentation revealed Resident R2 tested positive for Influenza A on 1/19/26. During an interview on 3/14/26, at 11:30 a.m. the Director of Nursing confirmed that the facility failed to notify the Pennsylvania Department of Health of reportable incidents for two of four residents.

Plan of Correction - To be completed: 03/31/2026

R1 and R2 were late reported on 3/23/26
Education completed regarding requirements for influenza reporting.
Audit to be completed of positive influenza to ensure outbreak is reported correctly monthly X 3 months.

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