Pennsylvania Department of Health
PAVILION AT SAINT LUKE VILLAGE, THE
Patient Care 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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PAVILION AT SAINT LUKE VILLAGE, THE
Inspection Results For:

There are  103 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.
PAVILION AT SAINT LUKE VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on April 9, 2024, it was determined that The Pavilion at St. Luke Village was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on observations, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement a system to assure timely disposition of resident medications (the process of returning and/or destroying unused medications) to prevent loss and potential drug diversion.

Finding include:

Review of facility policy entitled, "Disposal/Destruction of Expired or Discontinued Mediation", date revised October 30, 2023, revealed that facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations. Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. In Pennsylvania, discontinued and unused medications and medications of discharged or deceased residents shall be immediately removed from the medication cart and brought to nursing supervisory staff. Discontinued and unused medications shall be disposed of at least quarterly. Facility should dispose of discontinued medication, outdated medications, or medications left in Facility after a resident has been discharged in a timely fashion or no more than 90 days.

During an observation of the facility's second floor medication room on April 9, 2024, at approximately 9:05 AM accompanied by Employee 2 (Registered Nurse RN - Unit Manager) revealed resident medications stored in the drawers below the counter that included antibiotics, potassium, diabetes, anti-inflammatory, hypertension, pain, and diuretic medications. These medications were in bubbled, blister cards with a preprinted pharmacy label noting the medication, dosage, quantity, and resident names. Located on top of one of the stacks of blister cards, was a white, unlined, piece of paper, with a handwritten note that said "all need to take turns" as read by Employee 2 RN.

A prelabeled bubbled, blister card of Macrobid, noted the dosage and amount of the medication, but lacked a resident's name, which appeared to have been scratched off the label as observed by Employee 2, RN. The label noted Macrobid (an antibiotic) 100 mg, give (illegible- written over) capsules (300 mg) by mouth 2 times a day for UTI for 3 days. Prep date January 19, 2024. Handwritten was *direction change* 100 mg BID. Located within the labeled bubbled, blister card were 11 capsules, as counted by Employee 2, RN, at that time.

Resident CR3 had a physician order for Rifampin (an antibiotic medication) oral capsule 300 mg, give 1 capsule by mouth 2 times a day for joint infection right knee until December 13, 2023, start date November 5, 2023, and discontinued November 10, 2023. Resident CR3 was transferred to another skilled nursing facility on November 9, 2023. The resident's medications were located within the labeled bubbled, blister card were 8 capsules, as counted by Employee 2, RN when observed on April 9, 2024.

Resident 5 had a physician order for glipizide (a diabetic medication) oral tablet 5 mg, give 2.5 mg by mouth in the evening related to diabetes, start date July 31, 2023, discontinued March 15, 2024, and observed remaining in the labeled bubbled, blister card were 12 tablets, as counted by Employee 2, RN, on April 9, 2024.

Resident CR2 had a physician order for Linezolid (an antibiotic medication) oral tablet 600 mg, give 1 tablet by mouth 2 times a day for sepsis (a blood stream infection) for 14 days, start March 16, 2024, the resident was discharged to home on April 4, 2024. The resident's remaining medication in the blister card were 4 tablets, as counted by Employee 2, RN, on April 9, 2024.

Resident 18 had a physician order for Mobic (an anti-inflammatory medication) oral tablet 7.5 mg, give 1 tablet by mouth in the afternoon for shoulder pain for 5 days, start March 15, 2024, and the resident's remaining medication in the bubbled, blister card was 1 tablet, as counted by Employee 2, RN, on April 9, 2024.

Resident 69 had a physician order for Metolazone (a diuretic) oral tablet 5 mg, give 1 tablet by mouth in the morning related to essential hypertension for 5 days, start January 5, 2024, and the 24 tablets remaining in the observed blister card, as counted by Employee 2, RN, on April 9, 2024.

Resident 26 had a physician order for Metolazone (a diuretic) oral tablet 5 mg, give 5 mg by mouth 1 time a day for bilateral lower extremity (BLE) edema for 4 days, start date April 1, 2024. with one tablet remaining in the observed card when counted by Employee 2, RN, on April 9, 2024.

Resident 52 had a physician order for Gabapentin (pain medication) oral capsule 100 mg, give 1 capsule by mouth 1 time a day for pain, take 2 capsules to equal 200 mg, start date March 12, 2024, discontinued April 8, 2024. When observed on April 9, 2024, in the med room the blister card contained 29 capsules, as counted by Employee 2, RN.

Resident 44 had a physician order for Potassium Chloride ER (a medication to treat low potassium) oral tablet 20 MEQ, give 1 tablet by mouth one time a day for hypokalemia, start date March 25, 2024, discontinued April 4, 2024, with four tablets remaining in the med room in the card on April 9, 2024.

During an interview with Employee 2, RN, on April 9, 2024, at approximately 9:22 AM, she was unable to explain why the medications were stored in the drawer or explain the meaning of the handwritten note that stated "all need to take turns" on top of the discontinued medications. She further confirmed that these discontinued meds were not in a location designated for storage of medications awaiting final disposition. Employee 2 stated that when medications have been discontinued, changed, and or if a resident expires, the medications are to be inventoried, and placed in a pharmacy bag. She further stated that pharmacy deliveries to the facility occur daily so discontinued medications could possibly be returned to the facility daily. She also confirmed that nursing staff should have given these medications to the pharmacy for disposition and they should not remain in the facility in storage.

During an observation of the facility's third floor medication room on April 9, 2024, at approximately 9:28 AM accompanied by Employee 1 (Licensed Practical Nurse - LPN) medications were observed in drawer and cupboard below the counter, along with resident care equipment to include blood pressure cuff, medical machinery such as cardiac transmitters, paper tablets, dressings, laboratory test tubes, tape measures, pill crushers, markers, and pens. These medications were in boxes, and a plastic zip lock bag with preprinted pharmacy label noting the medication, dosage, quantity, and resident names. The medications in these drawers, and cabinet with resident names, included heparin vials (medication to treat blood clots), Paxlovid (medication to treat Covid), and Ipratropium - Albuterol solution (medication to treat wheezing).

Resident CR1 had a physician order for Paxlovid (300/100) oral tablet, give 1 tablet by mouth two times a day for COVID for 5 days, start date December 21, 2023, and the resident expired January 30, 2024. Observation on April 9, 2024, revealed 4 tablets were remaining in the box as counted by Employee 1, LPN.

Resident 66 had a physician order for Heparin Sodium injection solution, 5000 unit/ml, inject 1 ml subcutaneously BID for deep vein thrombosis (DVT) prevention for 15 days. 1 ml (5,000 units), start date February 8, 2024. Observation on April 9, 2024, revealed a labeled plastic zip lock bag containing 5 vials, as counted by Employee 1, LPN.

Resident 71 had a physician order for Ipratropium - Albuterol solution 0.5 - 2.5 (3) MG/3 ML, take 3 ml inhale orally via nebulizer every 4 hours as needed for wheezing, start date January 2, 2024. Observation revealed 5 packets remaining in labeled box for a total 25 solutions, as counted by Employee 1, LPN, on April 9, 2024.

During an interview with Employee 1, LPN, on April 9, 2024, at approximately 9:40 AM, she was unable to explain why the discontinued resident medications were stored in the drawer and cabinet, among numerous supplies. She further confirmed that they were not stored in a location designated for discontinued medications awaiting final disposition or marked to identify the medications are discontinued and subject to destruction. Employee 1 stated that when medications are discontinued or changed, or if a resident expires, the medications are to be inventoried, and placed in a pharmacy bag. She further stated that pharmacy deliveries occur daily to the facility, and on occasion, multiple times a day. She also confirmed that nursing staff should have given these medications to the pharmacy for disposition and the medications should not remain in the facility in storage.

During an interview with the Director of Nursing (DON) on April 9, 2024, at approximately 10:20 AM, revealed that all the discontinued medications should be picked up by the pharmacy timely or destroyed by nursing staff, and not stockpiled in the nursing medication rooms. The DON confirmed that medications are to be in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

During an interview with the Nursing Home Administrator (NHA) on April 9, 2024, at approximately 11:22 AM, the NHA stated that the facility is to return the discontinued medications awaiting final disposition to the pharmacy, at a minimum 4 times a year (quarterly). However, the NHA unable to explain the medications belonging to Resident CR3, who had been discharged from the facility in November 2023. She further confirmed the facility failed to implement procedures to promote the timely disposition of resident medications and security of medications awaiting final dispositions.


28 Pa Code 211.12 (d)(3)(5) Nursing services.

28 Pa Code 211.9 (a)(1)(d)(j.1)(1)(2)(3)(4)(5)(k) Pharmacy services



 Plan of Correction - To be completed: 05/07/2024

Residents CR1, CR2, CR3, 5, 18, 26, 44, 56, 66, 69, 71 medications were immediately destroyed per facility policy.

A look back of discontinued medications will be reviewed by DON/Designee to ensure proper disposition is completed.

To prevent this from reoccurring, discontinued medications will be stored in a designated location in the med room and destroyed or returned minimum weekly by RN supervisor.
DON/Designee educated all Licensed Staff on facility process for medication destruction and disposition.

DON/Designee will conduct quality monitoring to ensure disposition/destruction 5 days per week for 4 weeks, 1 x week for 3 weeks then monthly x 2 months. Findings will be submitted to the facility QAPI committee for review and recommendations as needed.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection in one out of two medication rooms (3 rd floor medication room).

Findings include:

Observation of the facility's third floor medication room on April 9, 2024, at approximately 9:28 AM accompanied by Employee 1 (Licensed Practical Nurse - LPN) revealed a small, dormitory size medication refrigerator located on the floor. Inside the refrigerator observations revealed resident medications were stored along with Observed two plastic, one-gallon containers of iced tea and on the door of the refrigerator were six 16 fluid oz. bottles of salad dressings.

Interview with Employee 1, LPN, on April 9, 2024, at approximately 9:40 AM, confirmed that the food and beverages stored in the medication refrigerator belonged to staff.

Interview with the Director of Nursing (DON) on April 9, 2024, at approximately 10:20 AM, confirmed the facility failed to store medication medications under sanitary conditions to prevent the potential spread of infection.




28 Pa. Code 211.10 (a)(d) Resident care policies

28 Pa. Code 211.12 (c)(d)(5) Nursing Services.




 Plan of Correction - To be completed: 05/07/2024

Facility Immediately corrected Infection Control Procedure in relation to medication room.

DON/Designee will complete Medication Refrigerator inspections to ensure sanitary conditions and prevent the spread of infection.

Daily Quality Monitoring rounds for Medication Fridges by Clinical Leadership were implemented to ensure continued compliance with proper infection control measures.
Licensed staff educated on use of proper infection control measures in relation to the medication refrigerator to ensure sanitary conditions and prevent the spread of infection.

DON/Designee will quality monitor medication Refrigerators 5 days per week for 4 weeks, 1 x week x 3 weeks then monthly x 2 months. Findings will be submitted to the facility QAPI committee for review and recommendations as needed.

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 nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum Nurse Aides (NA) staff to resident ratio was provided on the day and evening shifts for eight shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records April 2, 2024, through April 8, 2024, revealed that on the following dates the facility failed to provide minimum Nurse Aides (NA) staff of 1:12 on the day and evening shift based on the facility's census.

Review of facility census data indicated that on April 2, 2024, the facility census was 102, which required 8.50 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 6.94 NA worked the evening shift on April 2, 2024.

Review of facility census data indicated that on April 3, 2024, the facility census was 102, which required 8.50 nurse aides (NA) during day shift. Review of the nursing time schedules revealed only 8.25 NA worked the day shift on April 3, 2024.

Review of facility census data indicated that on April 3, 2024, the facility census was 101, which required 8.42 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 6.69 NA worked the evening shift on April 3, 2024.

Review of facility census data indicated that on April 4, 2024, the facility census was 101, which required 8.42 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 8.09 NA worked the evening shift on April 4, 2024.

Review of facility census data indicated that on April 5, 2024, the facility census was 100, which required 8.33 nurse aides (NA) during day shift. Review of the nursing time schedules revealed only 8.25 NA worked the day shift on April 5, 2024.

Review of facility census data indicated that on April 6, 2024, the facility census was 102, which required 8.50 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 7.22 NA worked the evening shift on April 6, 2024.

Review of facility census data indicated that on April 7, 2024, the facility census was 102, which required 8.50 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 6.19 NA worked the evening shift on April 7, 2024.

Review of facility census data indicated that on April 8, 2024, the facility census was 101, which required 8.42 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 7.47 NA worked the evening shift on April 8, 2024.

During an interview on April 9, 2024, at approximately 11:55 AM, the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.




 Plan of Correction - To be completed: 05/07/2024

The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on past shifts identified.

The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on previous shifts.

The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 1:12 Nurse Aide staff to resident ratios on day and evening shifts, ensuring proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON and other team members as necessary to review per patient ratios 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for a comprehensive team approach.

The NHA/Designee will quality monitor Nurse Aide to resident ratios 5 days per week for 4 weeks, then one per week for 2 weeks then monthly for 2 months to ensure minimum Nurse Aide to resident ratios are met.

The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 2 weeks then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

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 nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio was provided on the night shift for one shift out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records April 2, 2024, through April 8, 2024, revealed that on the following date the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

A review of facility census data indicated that on April 5, 2024, the facility census was 100 on night shift, which required 2.50 LPN during night shift. Review of the nursing time schedules revealed 2.13 LPN worked the night shift on April 5, 2024.

During an interview on April 9, 2024, at approximately 11:55 AM, the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum licensed practical nurse staffing ratios on the above shift.




 Plan of Correction - To be completed: 05/07/2024

The facility cannot retroactively correct the Licensed Practical Nurse Staff to resident ratios on past shift identified.

The facility cannot retroactively correct the Licensed Practical Nurse Staff to resident ratios on previous shifts.

The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 1:40 Licensed Practical Nurse staff to resident ratios on Night Shifts, ensuring proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for a comprehensive team approach.

The NHA/Designee will quality monitor Licensed Practical Nurse Staff to resident ratios 5 days per week for 4 weeks, then one per week for 2 weeks then monthly for 2 months to ensure minimum Licensed Practical Nurse to resident ratios are met.

The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 2 weeks then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

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 review of facility nurse staffing data, it was determined that the facility failed to maintain a minimum of 2.87 hours of direct resident care for each resident.

Findings include:

A review of facility nurse staffing data, including deployment sheets for the week of April 2, 2024, through April 8, 2024, the facility's 24 hour daily nurse staffing nurse staffing was below 2.87 hrs per resident on the following day:

April 2, 2024 nursing hours of direct resident care for each resident was 2.78
April 3, 2024 nursing hours of direct resident care for each resident was 2.83
April 8, 2024 nursing hours of direct resident care for each resident was 2.86

Interview with the Nursing Home Administrator (NHA) on April 9, 2024, at approximately 11:55 AM, confirmed the nursing hours indicated above.





 Plan of Correction - To be completed: 05/07/2024

The facility cannot retroactively correct the per patient hours on past days identified.

The facility cannot retroactively correct the per patient hours on previous days.

The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 2.87 per patient hours per day, ensuring proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for a comprehensive team approach.

The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 2 weeks then monthly for 2 months to ensure minimum 2.87 per patient hours are met.

The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 2 weeks then monthly for 2 months to ensure staffing meetings are occurring with required attendees.


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

Visit the PA Power Port