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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PAVILION AT SAINT LUKE VILLAGE, THE
Inspection Results For:

There are 111 surveys for this facility. Please select a date to view the survey results.

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PAVILION AT SAINT LUKE VILLAGE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on January 28, 2025, it was determined The Pavilion at St Luke Village 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)(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.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 6 shifts out of 21 reviewed.

Findings include:

Review of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Nursing Services, dated July 1, 2023, indicated the following subsections.
(f.1) In addition to the director of nursing services, a facility shall provide all of the following:
(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.

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census per the regulation that was effective July 1, 2024.

January 5, 2025 - 6.30 nurse aides on the night shift, versus the required 7.07 for a census of 106.
January 6, 2025 - 9.07 nurse aides on the evening shift, versus the required 9.73 for a census of 107.
January 9, 2025 - 6.60 nurse aides on the night shift, versus the required 7.27 for a census of 109.
January 10, 2025 - 9.33 nurse aides on the evening shift, versus the required 9.82 for a census of 108.
January 10, 2025 - 5.50 nurse aides on the night shift, versus the required 7.20 for a census of 108.
January 11, 2025 - 7.15 nurse aides on the night shift, versus the required 7.20 for a census of 108.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on January 28, 2025, at approximately 4:30 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 02/26/2025

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 nurse aide to resident ratios on all shifts, ensuring continued 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 continued improvement and comprehensive team approach.
Facility utilizes contracted nursing staff, incentives and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. Call in list used to attempt fill unexpected absences. Resident occupancy reviewed and revised as needed with IDT during staffing meetings.
The NHA/Designee will quality monitor Nurse Aide to resident ratios 5 days per week for 4 weeks, then one per week for 3 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 3 weeks then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

§ 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 nurse staffing, resident census, and staff interview, it was determined the facility failed to provide a minimum of one LPN (licensed practical nurse) per 25 residents on the day shift for 1 shift out of 21 reviewed.

Findings include:

The minimum required ratio on the day shift is one LPN for every 25 residents. A review of the facility's daily staffing records revealed that the facility did not meet the required minimum LPN-to-resident ratios on the following dates:

January 11, 2025 - 3.40 LPNs on the evening shift, versus the required 4.32 for a census of 108.

An interview with the Nursing Home Administrator on January 28, 2025, at approximately 4:30 PM, confirmed the facility had not met the required LPN-to-resident ratios on the above shift.

Plan of Correction - To be completed: 02/26/2025

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 Licensed Practical Nurse staff to resident ratios on all shifts, ensuring continued 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 continued improvement and comprehensive team approach.
Facility utilizes contracted nursing staff, incentives and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. Call in list used to attempt fill unexpected absences. Resident occupancy reviewed and revised as needed with IDT during staffing meetings.
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 3 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 3 weeks then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

§ 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 a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

Review of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Nursing Services, dated July 1, 2023, indicated the following subsections.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period as follows:
(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.

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident per the regulation effective July 1, 2024:

January 5, 2025 - 3.13 direct care nursing hours per resident.
January 10, 2025 - 3.00 direct care nursing hours per resident.
January 11, 2025 - 3.06 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Nursing Home Administrator on January 28, 2025, at approximately 4:30 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 02/26/2025

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 3.20 per patient hours per day, ensuring continued 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 continued improvement and comprehensive team approach.
Facility utilizes contracted nursing staff, incentives and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. Call in list used to attempt fill unexpected absences. Resident occupancy reviewed and revised as needed with IDT during staffing meetings.
The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 3 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 3 weeks then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

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