Pennsylvania Department of Health
CARE PAVILION NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CARE PAVILION NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 286 surveys for this facility. Please select a date to view the survey results.

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CARE PAVILION NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to three complaints completed on February 22, 2024, it was determined that Care Pavilion Nursing and Rehabilitation Center 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

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.

�483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

�483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

�483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on interviews with facility staff and residents and review of facility documents, it was determined that the facility failed to report an incident of alleged verbal abuse to the Department of Health as required for one of five resident reviewed (Resident R2).

Findings include:

Review of facility document titled "Formal Investigation Report" and dated January 14, 2024, revealed a witness statement by Resident R2 alleging verbal abuse by a staff member. Resident R2 alleged that on January 14, 2024, during the 3 p.m. to 11 p.m. shift, she overheard a nursing assistant providing care to her roommate refer to her (resident R2) as a junkie and a whore.

Review of Resident R2 revealed that the resident was admitted to the facility on June 7, 2018, with the diagnoses of adult failure to thrive (a state of decline caused by multiple chronic concurrent diseases), diabetes (a disorder of the body's metabolism caused by insufficient insulin production), anemia (a condition in which the body does not have enough healthy red blood cell), history of alcohol abuse, cirrhosis of the liver (chronic liver damage that can be caused by alcohol abuse), malignant neoplasm of liver (liver cancer) and depression (a mental health disorder characterized by a lowering of mood). Additional review of the clinical record revealed that the resident was fully alert and oriented and cognitively intact.

An interview was conducted with Resident R2 on February 22, 2024 at 11:00 a.m. Resident R2 confirmed that she had an encounter with a nursing assistant on January 14, 2024 and repeated her assertion that the nursing assistant made inappropriate comments about her.

An interview was conducted with the Director of nursing, Employee E2 on February 22, 2024 at 1:00 p.m. Employee E2 stated that an investigation was conducted into the incident. Witness statements were obtained, police were notified, the mobile crisis unit was notified, a psych consult was placed and notifications were made to the primary care physician and the resident representative. The investigation did not yield sufficient evidence to substantiate the allegation of abuse. It was confirmed during the interview that the incident involving Resident R2 and a nursing assistant on January 14, 2024 was not reported to the Department of Health as required

201.14. (c) Responsibility of licensee.

Plan of Correction - To be completed: 02/28/2024

No retro action needed.

Facility will accurately report events to the department of health.

NHA/DON will be educated to accurately report events to the department of health

RDO/designee will audit 3X weekly X3 and then monthly X2 to ensure report events to the department of health

Results will be reviewed during the facilities monthly QAPI meeting to determine the need for further review.

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