Pennsylvania Department of Health
BALL PAVILION, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BALL PAVILION, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on March 21, 2025, it was determined that The Ball Pavilion 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:

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

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(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on review of facility contract and policy, and clinical record review, and staff interviews, it was determined that the facility failed to ensure that monthly pharmacy drug regimen reviews were completed for five of five residents reviewed (Residents R11, R13, R17, R30, and R52).

Findings include:

A facility contract entitled "Care Apothecary Consultant Pharmacy Retainer Agreement" dated 6/07/24, indicated that: monthly reviews of the drug regimen of each resident at Ball Pavilion will be conducted; recommendations, plans for implementation, and continuing assessment regarding medication policies and use through dated, and signed reports will be provided to administrator; and the pharmacy agrees to be responsible for providing continuous Consultant Pharmacist Services to the facility through the term of the agreement.

A facility policy entitled "Pharmacy Consultant Report at Ball Pavilion" dated 9/09/24, indicated that the Pharmacy Consultant will e-mail Director of Nursing, Administrator, RNAC (Registered Nurse Assessment Coordinator), and Rehab Director with monthly pharmacy summary.

Resident R11's clinical record revealed an admission date of 4/26/24, with diagnoses including Parkinson's Disease (disease of involuntary muscle movements) atrial fibrillation (irregular heart beat) and orthostatic hypotension (low blood pressure when in a standing position).

Resident R13's clinical record revealed an admission date of 2/22/22, with diagnoses including dementia, Type 2 diabetes (happens when the body cannot use insulin correctly and sugar builds up in the blood), irregular heartbeat, and anxiety.

Resident R17's clinical record revealed an admission date of 6/25/24, with diagnoses including dementia with mood disturbance, anoxic brain damage (occurs when the brain is deprived of oxygen, leading to brain cell death and potentially permanent brain damage or even death), heart disease and convulsions.

Resident R30's clinical record revealed an admission date of 12/12/23 with a diagnoses of Alzheimer's disease (a disease characterized by forgetfulness and confusion) Type 2 diabetes (condition of poor blood sugar control) and hypertension (high blood pressure).

Resident R52's clinical record revealed an admission date of 6/20/18, with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure.

Residents R11, R13, R17, R30, and R52's clinical records lacked evidence that a Pharmacy Consultant review was conducted for October 2024, November 2024, and December 2024.

During an interview on 3/20/25, at 2:20 p.m. the Registered Nurse Assessment Coordinator confirmed that the pharmacy did not provide a Pharmacy Consultant to conduct the monthly reviews of the drug regimen of each resident during October 2024, November 2024, and December 2024.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 211.5(f)(x) Medical records

28 Pa. Code 211.9(f)(3) Pharmacy Services

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 05/20/2025

To correct the deficiency as it relates to the individuals affected by the deficient practice, a medication regimen review was conducted by the pharmacy consultant between 3/1/2025 and 3/17/2025 and all recommendations reported to Registered Nurse Assessment Coordinator, Administrator, Director of Nursing and Medical Director and followed up at that time.

To protect residents having the potential to be affected by the same deficient practice, the pharmacy consultant will conduct a thorough review of all resident medications and document findings monthly. Nurses will be educated on the importance of drug regimen review and the immediate process to report and act on any identified irregularities.

To ensure that the deficient practice does not recur, the pharmacy consultant will conduct monthly drug regimen reviews for all residents and will report irregularities to the Registered Nurse Assessment Coordinator, Administrator and Director of Nursing. A report will be sent via email. If a report is not received by the last week of the month, Administrator will contact pharmacy consultant and request this review.

To monitor corrective action and ensure that the deficient practice will not recur, the Director of Nursing and Administrator will conduct monthly audits to ensure drug regimen review have been completed. The Director of Nursing will monitor the completion and documentation of all drug regimen reviews and will ensure that any identified irregularities are addressed. This audit be reviewed at the monthly QAPI meeting for the next three months.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

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.

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on clinical record and policy review, and staff interview, it was determined that the facility failed to provide care regarding treatment, consistent with professional standards of practice, to an existing injury to facilitate wound healing for one of five residents reviewed (Resident R52).

Findings include:

A facility policy entitled "Provide Treatment to Pressure Injury" dated 9/09/24, indicated that residents with a Stage 2 (partial thickness loss of dermis [presenting as a shallow open ulcer without slough) be assessed for a positioning program and support devices.

Resident R52's clinical record revealed an admission date of 6/20/18, with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure.

Review of assessments and documentation provided by the contracted wound care specialist revealed:

-8/19/24, initial assessment of a partial thickness moisture associated skin damage (MASD- erosion or inflammation of the skin caused by long-term exposure to moisture); wound on the left buttock measured 8.6cm (centimeters) X 1.9cm X 0.1cm and included orders for side-to-side offloading while in bed.

-10/21/24, partial thickness MASD wound on the left buttock measured 6.2cm X 0.6cm X 0.1cm, condition improving, and included orders for side-to-side offloading while in bed.

-12/09/24, partial thickness MASD wound on the left buttock measured 1.5cm X 0.2cm X 0.1cm, condition improving, and included orders for side-to-side offloading while in bed.

-2/17/25, partial thickness MASD wound on the left buttock measured 1.5cm X 1.3cm X 0.2cm, condition deteriorating, and included orders for side-to-side offloading while in bed.

Review of Resident R52's Minimum Data Set (MDS- standardized assessment tool that measures health status in nursing home residents) revealed:

-Quarterly MDS dated, 8/14/24, Section GG0170, Mobility was coded as requiring substantial/maximal assistance to roll left and right.
-Quarterly MDS dated 10/23/24, Section GG0170, Mobility was coded as requiring partial/moderate assistance to roll left to right.
-Quarterly MDS dated 12/22/24, Section GG0170, Mobility was coded as requiring substantial/maximal assistance to roll left and right.
-Annual MDS dated 2/19/25, Section GG0170, Mobility was coded as requiring partial/moderate assistance to roll left to right.

Further review of Resident R52's clinical record lacked evidence of a physician's order for side-to-side offloading (turn and position) in bed as recommended by the wound care specialist; the care plan entitled "potential/actual impairment to skin integrity" dated 2/21/24, lacked evidence of an intervention side-to-side offloading in bed, and lacked documentation that Resident R52 was provided side-to-side offloading while in bed.

During an interview on 3/21/25, at 11:46 a.m. the Registered Nurse Assessment coordinator confirmed that Resident R52 should have an offloading side-to-side program in place to prevent worsening of his/her wound.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Plan of Correction - To be completed: 05/20/2025

To correct the deficiency as it relates to the individuals affected by the deficient practice, the Wound RN added turning and positioning for resident R52. Education given to Wound RN on standard turning orders for any MASD as well as for all residents who are unable to reposition themselves independently. Wound RN to implement going forward.

To protect residents having the potential to be affected by the same deficient practice, Registered Nurse Assessment Coordinator will review all current orders/tasks on all current residents in facility. If no orders/tasks are found for turning and positioning, will converse with Wound RN about if orders/tasks should be present and follow accordingly. New policy entitled Pressure Ulcer Prevention was created to put prevention measures in place. This policy will be reviewed with all nurse aides and nurses at their April monthly meeting.

To ensure that the deficient practice does not recur, Registered Nurse Assessment Coordinator and Wound RN will review weekly report and progress notes from Wound NP, update orders/tasks as ordered from Wound NP.

To monitor corrective action and ensure that the deficient practice will not recur, a bi-weekly audit of 5 random residents will be implemented to monitor for appropriateness of orders/tasks. This audit will be completed by the Registered Nurse Assessment Coordinator. This audit will be reviewed at the monthly Quality Assurance and Performance Improvement meeting for the next three months.

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for three of 24 residents reviewed (Residents R35, R51, and R52).

Findings include:

Resident 35's clinical record revealed an admission date of 10/01/24, with diagnoses including dementia, stroke with right-sided weakness, Schizophrenia (a serious mental health condition that affects how people think, feel and behave, and may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), and intellectual disabilities.

Review of R35's Quarterly MDS dated 11/27/24, under Section M0300, Skin Conditions revealed it was coded as having a "Stage Three" (full thickness tissue loss).

Resident R35's clinical record revealed assessment documentation provided by the contracted wound care specialist as follows:

-11/11/24, initial examination of moisture associated skin damage (MASD- erosion or inflammation of the skin caused by long-term exposure to moisture) partial thickness wound to the gluteal cleft.
-11/25/24, follow-up assessment MASD partial thickness wound to the gluteal cleft.

Resident R51's clinical record revealed an admission date of 7/08/24, with diagnoses including sepsis (the body's immune system has an extreme response to an infection, causing organ dysfunction), Stage Four pressure ulcer of the right buttock (full-thickness tissue loss with exposed bone, tendons, or muscle), and quadriplegia (paralysis that affects all a person's limbs).

Review of Resident R51's Quarterly MDS dated 12/11/24, under Section M0300, Skin Conditions revealed it was coded as a "Stage Four, not present on admission."

Resident R51's clinical record revealed assessment documentation provided by the contracted wound care specialist dated 12/09/24, and indicated that his/her Stage Four wound was not acquired at the facility.

Resident R52's clinical record revealed an admission date of 6/20/18, with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure.

Review of Resident R52's Quarterly MDS's dated 10/23/24, and 12/11/24, and Annual MDS dated 2/19/25, Section M Skin Conditions, was coded as having a "Stage Three" pressure ulcer.

Resident R52's clinical record revealed assessments and documentation provided by the contracted wound care specialist as follows:

-8/19/24, initial assessment of a partial thickness moisture associated skin disorder wound on the left buttock measured 8.6 cm (centimeters) X 1.9 cm X 0. 1cm and included orders for side-to-side offloading while in bed.
-10/21/24, partial thickness moisture associated skin disorder wound on the left buttock measured 6. 2cm X 0.6 cm X 0. 1cm, condition improving, and included orders for side-to-side offloading while in bed.
-12/09/24, partial thickness moisture associated skin disorder wound on the left buttock measured 1. 5cm X 0. 2cm X 0. 1cm, condition improving, and included orders for side-to-side offloading while in bed.
-2/17/25, partial thickness moisture associated skin disorder wound on the left buttock measured 1. 5cm X 1.3 cm X 0. 2cm, condition deteriorating, and included orders for side-to-side offloading while in bed.

During an interview on 3/21/25, at 11:56 a.m. the Registered Nurse Assessment Coordinator confirmed that the wound staging on the above MDS's for Residents R35, R51, and R52 were coded incorrectly.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f)(11)(iv)(ix) Medical records

Plan of Correction - To be completed: 05/20/2025

To correct the deficiency as it relates to the individuals affected by the deficient practice, MDSes, orders, and documentation were reviewed for accuracy in identified residents R35, R51, and R52. Information reviewed and MDSes were updated as needed.

To protect residents having the potential to be affected by the same deficient practice, all MDSes with skin impairment in Section M for 2025 will be reviewed for accuracy. Any additional incorrect MDSes will be updated. All new MDSes will be reviewed in this section by the Director of Nursing prior to signing off as a complete MDS.

To ensure that the deficient practice does not recur, both Registered Nurse Assessment Coordinator and Director of Nursing will review and sign the signature log saying they agree with the way Section M is coded. Comparison with the RAI manual will be done with every skin impairment coded on Section M, this serves as re-education to the Resident Nurse Assessment Coordinator.

To monitor corrective action and ensure that the deficient practice will not recur, a bi-weekly audit of 5 random MDSes picked using all current residents will be implemented to monitor for correctness of Section M. This audit will be done by the Director of Nursing. This audit will be reviewed at the monthly QAPI meeting for the next three months.

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