Two residents received improper pain management that violated basic medical protocols. One resident got opioids when their pain level was zero.
Resident 20, who has multiple sclerosis, had a doctor's order for oxycodone only when pain reached level seven or higher on a 10-point scale. Instead, staff administered the opioid 15 times over three months when the resident's pain was below the threshold.
On July 10, staff gave the resident oxycodone for a pain level of zero.
Other violations occurred on May 1, May 5, May 11, May 19, and May 27 for pain levels of six, six, six, six, and five respectively. In June, staff administered the medication four more times for pain levels of six, five, six, and six. July brought three additional violations for pain levels of five, five, and six.
Resident 8, diagnosed with fibromyalgia, had a standing order for oxycodone every eight hours as needed for pain levels four to 10. But staff routinely skipped required non-drug interventions before giving the opioid.
In May, staff administered the medication twice without attempting alternatives. June saw five doses given, with three administered without trying non-pharmacological interventions first. July brought four more doses, with two given without attempting alternatives.
The nursing home administrator confirmed on July 19 that staff failed to consistently document non-drug interventions before administering as-needed pain medication and failed to follow physician orders.
But pain medication violations were just one problem inspectors documented.
Residents described waiting 30 to 40 minutes for basic care, with some soiling themselves when staff failed to respond to bathroom requests in time.
Resident 48 told inspectors she waits up to 40 minutes for care and starts yelling from her room for bedpan assistance. "If she doesn't yell, then nursing staff don't respond," the inspection report states. During mealtimes, staff ignore her calls because they're helping residents in the dining room.
"The wait times for nursing staff to provide requested and needed care causes her to feel frustrated and angry," Resident 48 told inspectors.
Resident 21 waits over 20 minutes for care and starts screaming for help after 25 minutes. She feels rushed when only one aide is assigned to her hallway. "She is upset, because she doesn't want to be dependent on nursing staff for assistance, but she needs their help with activities of daily living."
Resident 20 rings her call bell and waits 20 to 40 minutes for staff to respond. She believes the problem stems from insufficient staffing.
The complaints weren't isolated incidents. Resident grievances filed with the facility documented the pattern.
An April 3 grievance from Resident 48 complained about "continuously dissatisfied with nursing staff's untimely call bell response time." The facility noted the grievance remained unresolved despite claimed improvements.
Resident 85 filed a grievance April 29 saying staff responded to his call bell but left and never returned to help him out of bed. He remained in bed all day. A June 1 grievance from a family member reported a resident waited over four hours for staff to answer their call bell.
The staffing crisis had measurable consequences.
Resident 38 had a bowel accident after waiting more than 15 minutes for toileting assistance. Resident 151 soiled herself three separate times due to call bell waits longer than 15 minutes.
On July 19, inspectors found Resident 30's bed still unmade at 1:00 PM. The sheets had been removed that morning but not replaced.
When inspectors offered to find staff to help Resident 151 use the bathroom at 9:30 AM, they found no nursing staff available except the RN supervisor, who was covering as a licensed practical nurse due to call-offs.
The numbers confirmed residents' experiences.
Staffing records showed the facility failed to meet minimum state ratios for nurse aides on 18 of 63 shifts reviewed between June 11 and July 17. They fell short of required licensed practical nurse ratios on nine shifts and failed to meet minimum direct care hours per resident on 10 of 21 days.
With 104 residents, the facility had only four nurse aides and two LPNs working each nursing unit on July 19. Two nurse aides and two LPNs had called off without replacement.
The facility averaged 3.22 direct care hours per resident with 98 residents but dropped to 3.06 hours when census increased to 104 residents. The administrator couldn't provide evidence that additional staff were added to handle the increased resident population.
A separate incident revealed failures in dementia care management.
Resident 87, who has Alzheimer's disease and severe cognitive impairment, slapped Resident 35 in the face on July 9 after entering her room uninvited and being told to put down an orange.
The RN supervisor confirmed Resident 87 "was becoming more agitated lately and had the potential to hit someone if they told her no or tried to take something she wanted." She regularly entered other residents' rooms uninvited.
Resident 37 told inspectors Resident 87 enters her room and touches her belongings. "She does not want Resident 87 entering her room."
Resident 35 confirmed the slapping incident and said she wasn't afraid but "did not want Resident 87 entering her room and taking her things due to Resident 87's potential to become angry and hit her again."
Despite the documented pattern of intrusive wandering and physical aggression, Resident 87's care plan failed to address her specific behaviors. A July 10 intervention mentioned redirecting her from other residents' rooms, particularly Resident 35's, but the plan lacked individualized strategies for managing her dementia-related behaviors.
The administrator acknowledged the facility couldn't provide evidence of a comprehensive plan to address Resident 87's dementia-related behaviors or demonstrate consistent efforts to manage her intrusive wandering and potential for physical aggression.
The inspection revealed systematic failures across pain management, staffing, and specialized care for vulnerable residents with dementia.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion At St Luke Village, The from 2024-07-19 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Pavilion At St Luke Village, The
- Browse all PA nursing home inspections