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 299 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 a complaint completed on August 21, 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.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

�483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
�483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

�483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

�483.10(i)(3) Clean bed and bath linens that are in good condition;

�483.10(i)(4) Private closet space in each resident room, as specified in �483.90 (e)(2)(iv);

�483.10(i)(5) Adequate and comfortable lighting levels in all areas;

�483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81�F; and

�483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on three of five nursing units (A, B, E Nursing Units).

Findings include:

An initial tour of the facility on August 21, 2024, 11:00 a.m. revealed the following observations.

Observation of facility room 157 revealed there were broken air conditioning unit with open covers. During the observation Resident R1 stated that the air conditioning unit had been in the same condition for a while at least from June or July of 2024.

Observation of room 275 revealed that base board molding under the air condition unit was missing.

Interview with Employee E4, Nurse aide stated room 256 had water leak from air-condition unit which created flood in the room. Employee stated the air condition unit work more when it was warm outside and caused water leak in the room. During the observation air condition unit was not on and no water was seen on the floor. Employee E4 stated it only leaks when the air condition unit turn on for long time.

Interview with Employee E5, Housekeeping employee, stated room 261 had water leak from air-condition unit.

Observation of room 228, 319 revealed that the air condition unit cover was missing.

Observation of room 318 revealed that the over the head light was not functioning. Resident side of the area did not have any other source of light. During the observation Resident R2 stated the light was broken for 9 months.

Further observation revealed that the door stopper to room 318 was missing which created a dent on the closet door handle. The door lock was also broken. The edges of the door was broken with exposed sharp plywood edges.

Observation of room 325 revealed that the wall plug unit was burned out. Facility used a long extension cord to plug the air condition unit which was on the floor. Resident R3 at the time of the observation stated the plug got burned months ago and it was not replaced.

28 Pa. Code: 201.29(j)(k) Resident rights.

28 Pa. Code: 207.2(a) Administrator's responsibility.

Plan of Correction - To be completed: 09/16/2024

Broken air-conditioner unit in room 157 was repaired. Base-board molding under air conditioner unit in room 275 was replaced. Leaks from air-conditioning units in rooms 256 and 261 were repaired. Air-conditioner unit covers in rooms 228 and 319 were replaced. Over-bed light in room 318 was repaired and door stopper was replaced. Door lock on room 318 was repaired. Wall power outlet was replaced and the extension cord in use was removed.

Audit has been completed of all resident room air-conditioner units to ensure that they are not leaking, have appropriate covers and base-board molding. Where air-conditioning units are identified to be leaking, missing covers or base-board molding, they are being repaired. An audit was completed of over-bed lights to ensure that they all function properly. Where over-bed lights are found to not be functioning properly, they will be repaired. An audit was completed to ensure that all resident room doors have proper hardware to ensure proper latching. An audit was completed of resident room wall outlets and where any non-functioning outlets were identified they have been repaired or replaced. An audit was completed of resident rooms to ensure that no extension cords are in use. Where extension cords are identified they have been removed.

Maintenance has been educated regarding proper installation and maintenance of air-conditioning units, over-bed lights and door hardware. Maintenance was also educated regarding no using extension cords.

An audit will be completed monthly X 3 months and results will be reported in the monthly QAPI Meeting for recommendations of further improvements.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg:

�483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of three residents reviewed (Resident R4).

Findings include:

According to the RAI User's Manual dated October 2024, A "significant change" is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered "self-limiting"; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan."

o Decline in two or more of the following: - Resident's decision-making ability has changed; - Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); - Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; - Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; - Resident's incontinence pattern changes or there was placement of an indwelling catheter; - Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); - Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status; - Resident begins to use a restraint of any type when it was not used before; and/or - Emergence of a condition/disease in which a resident is judged to be unstable.

Review of MDS (Minimum Data Set) for Resident R4 revealed that a quarterly MDS was completed on June 24, 2024. Section M of the assessment revealed that the resident had no pressure ulcers.

A review of the clinical record of Resident R4 revealed a wound progress note which indicated that the resident developed a Stage 3 pressure wound to the coccyx on June 30, 2024.

Review of dietary weight note dated July 22, 2024, revealed that the resident had a significant weight loss on July 19, 2024. Resident lost 10.1% body weight in 1 month and 11.3% in 6 months.

Interview with the MDS coordinator, Employee E6, on August 21, 2024, at 2:00 p.m. confirmed that Resident R4 had two significant changes in condition after the last MDS quarterly assessment on June 24, 2024, which required a significant change on status assessment within 14 days of the change. Employee E6 stated no significant change assessment was completed for Resident R4.

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

Plan of Correction - To be completed: 09/16/2024

Resident R4's MDS significant change has been scheduled.

RNAC/LNAC will be reeducated regarding MDS significant change criteria and scheduling appropriately.

A (2) week lookback audit will be completed for significant changes.

RNAC/designee will conduct random audits of 5 residents weekly x4 then monthly x2 to ensure compliance. Findings will be submitted to QAPI monthly x2

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

�483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

�483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

�483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

�483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to maintain appropriate nutritional parameters for one of four residents reviewed. (Resident R4).

Findings include:

Review of facility policy "Weights Assessment and Interventions" dated February 15, 2022, revealed "Any weight change of greater than 5 pounds within 30 days will be retaken for confirmation. Dietician will also review monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed by the dietician weather or not the definition of Significant weight change is met. "

Review of weight data for Resident R4 revealed that the resident weighed 138.6 on June 11, 2024, and 124.6 on July 19, 2024 which was 14-pound weight loss over 30 days/ a month.

Review of dietary weight note for Resident R4 dated July 22, 2024, revealed that the resident had a significant weight loss on July 19, 2024. Resident lost 10.1% body weight in 1 month and 11.3% in 6 months.

Further review of the progress note revealed recommendation to continue to monitor weight trends. Weight stability at current weight or weight gain of 2-4 pound/month desired. Provide therapeutic diet as ordered, continue to monitor intake and record amount consumed. Continue supplement House Shakes twice daily as ordered, Resident with increased nutrient needs secondary stage 3 Pressure Ulcer. Continue to monitor intake and record amount consumed and that the physician was made aware.

Continued review of the progress note revealed that the facility did not add any additional nutritional measures followed by the new pressure ulcer and significant weight loss.

Review of meal intake consumption record for Resident R4 revealed that from July 23 to August 20, 2024, staff did not document the amount consumed for all three meals on July 25, 26, 28, 31, August 3, 6, 9, 10, and 11. Staff did not document two of three meals on July 23, 24, 27, August 1, 2, 5, 7, 8, 12, 14, 15, 16, 17, 18, and 19. Staff did not document one of three meal intake on August 4.

Review of weight record revealed that the staff did not do a reweight to verify the significant weight loss per facility policy.

Review of physician progress note for Resident R4 dated August 4, 2024 revealed no evidence that the physician addressed Resident R4's weight loss on July 19, 2024. It was documented that "denies fatigue, fever, chills, night sweats, appetite changes, changes in weight, weakness" It was documented as resident has dyslipidemia (abnormally elevated cholesterol or fats (lipids) in the blood.) and continue taking medication.

Review of physician progress note for Resident R4 dated August 13, 2024 revealed no evidence that the physician addressed Resident R4's weight loss on July 19, 2024.

Interview with Dietician, Employee E7, on August 21, 2024, at 2 00 p.m. confirmed that Resident R4's weight loss was not confirmed by reweighing. Employee E7 confirmed that the facility did not monitor Resident R4's meal intake as recommended. Employee E7 stated facility did not add nutritional supplement because of budget even though resident required increased nutritional needs due to new weight loss and new stage 3 pressure ulcer. Employee E7 stated facility was using a lot of supplements for residents so new order of supplements were not encouraged.
Employee E7 also stated she notified a nurse practitioner of Resident R4's weight loss via placing weight data in her mailbox.

Interview with Director of Nursing (DON) on August 21, 2024, at 2 00 p.m. stated the nurse practitioner Employee E7 notified of Resident R4's weight loss was not Resident R4's practitioner, she was from a long term care plan provider which Resident R4 was not enrolled in. DON confirmed that there was no evidence that Resident R4's physician was notified of the weight loss.

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

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

Plan of Correction - To be completed: 09/16/2024

Resident R4's supplements reviewed and appropriately adjusted.

Dietitian will be reeducated on policy and procedures regarding physician/provider notification including name, significant weight loss, appropriate nutritional parameters/measures following weight loss and wounds.

A 1 month lookback audit will be completed for re-weights, significant weight loss, nutritional interventions and documented physician/provider notification including name.

Dietician/designee will conduct random audits of 5 residents weekly x4 then monthly x2 to ensure compliance. Findings will be submitted to QAPI monthly x2

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician:

�483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

�483.30(a) Physician Supervision.
The facility must ensure that-

�483.30(a)(1) The medical care of each resident is supervised by a physician;

�483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.

Observations:

Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 4 residents with weight loss reviewed (Resident R4).

Findings include:

Review of facility policy "Weights Assessment and Interventions" dated February 15, 2022, revealed "Any weight change of greater than 5 pounds within 30 days will be retaken for confirmation. Dietician will also review monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed by the dietician weather or not the definition of Significant weight change is met.

If a weight loss meets the definition of significant, the dietician should discuss with the interdisciplinary team and make recommendation."

Review of weight data for Resident R4 revealed that the resident weighed 138.6 on June 11, 2024, and 124.6 on July 19, 2024. Which was 14-pound weight loss over 30 days/ a month.

Review of dietary weight note for Resident R4 dated July 22, 2024, revealed that the resident had a significant weight loss on July 19, 2024. Resident lost 10.1% body weight in 1 month and 11.3% in 6 months. Further review of the progress note revealed that it was documented as the Physician made aware. However, the name of the physician or the provider was not documented.

Review of physician progress note for Resident R4 dated August 4, 2024, revealed no evidence that the physician addressed Resident R4's weight loss on July 19, 2024. It was documented that "denies fatigue, fever, chills, night sweats, appetite changes, changes in weight, weakness" It was documented as resident has dyslipidemia (abnormally elevated cholesterol or fats (lipids) in the blood.) and continue taking medication.

Review of physician progress note for Resident R4 dated August 13, 2024, revealed no evidence that the physician addressed Resident R4's weight loss on July 19, 2024.

Interview with Dietician, Employee E7, on August 21, 2024, at 2 00 p.m. stated she notified a nurse practitioner of Resident R4's weight loss via placing weight data in her mailbox.

Interview with Director of Nursing (DON) on August 21, 2024, at 2 00 p.m. stated the nurse practitioner Employee E7 notified of Resident R4's weight loss was not Resident R4's practitioner, she was from a long term care plan provider which Resident R4 was not enrolled in. DON confirmed that there was no evidence that Resident R4's physician was notified of the weight loss.

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

28 Pa. Code:211.2(a) Physician services.

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 09/16/2024

MD is aware of R4's weight loss and physician/provider assessment completed.

Reviewed with physician/providers proper documentation for significant weight loss.

Dietician will conduct a 1 month lookback audit for significant weight loss and notify physician/providers to complete MD assessment and document appropriately.

Dietician/designee will conduct random audits of 5 residents biweekly x2 then monthly x2 to ensure compliance. Findings will be submitted to QAPI monthly x3

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

�483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe and functional environment for one of four floors (Third floor).

Finding Include:

Observation of facility Third floor west nursing unit on August 21, 2024, at 12:00 p.m. revealed that next to room 323 there were two large trash containers without lids on the hallway. There was water in both containers. There were also sheets on the floor. However, the floor appeared dry during the observation. There was no rain at the time of the observation.

Interview with Nurse Aide, Employee E8, stated there was leak from the ceiling and the containers and sheets were placed there to collect the water. Employee E8 stated the leak was going on for months.

Interview with Resident R3 on August 21, 2024, at 12:30 p.m. stated he was a resident at the facility for years and the water leak has been going on for almost least a year. Resident stated sometimes the leak was so bad that it created wet floors which was not safe for people to walk by.

Interview with Administrator on August 21, 2024, at 2:15 p.m. stated facility had issues with water leak from the ceiling on third floor. Administrator stated he thought the issue was resolved and was not aware the leak was still present.

28 Pa. Code 201.14 (a) Responsibility of licensee.

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

Plan of Correction - To be completed: 09/16/2024

3rd Floor-West leak from ceiling next to room 323 was repaired.

An audit has been completed of 3rd Floor-West ceilings to ensure no additional leaks are present. Where any leaks are identified they have been repaired.

Maintenance staff have been educated regarding identification of ceiling leaks and proper repairs required when ceiling leaks are identified.

An audit will be completed monthly X 3 months and results will be reported in the monthly QAPI Meeting for recommendations of further improvements.

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