Pavilion At St Luke Village, The
PAVILION AT ST LUKE VILLAGE, THE in HAZLETON, PA — inspection on July 19, 2024.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 148's Medication Administration Record dated July 12, 2024, through July 14, 2024, revealed the physician ordered intravenous antibiotic medication, Daptomycin, was not administered on July 12, 2024 July 13, 2024, and July 14, 2024.
Interview with the Nursing Home Administer (NHA) on July 19, 2024, at approximately 10:00 AM confirmed the facility failed to provide Resident 148's intravenous antibiotic medication as prescribed because it was not available in the facility as the facility's pharmacy did not timely deliver the antibiotic drug.
Refer
During an interview on July 16, 2024, at approximately 1:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide documented evidence that Resident 24's unexplained vaginal bleeding was investigated as a potential injury of unknown origin and Resident 24 was physically examined to ensure she was free from abuse or mistreatment.
The NHA and DON confirmed that Resident 24 was severely cognitively impaired and unable to communicate the possible cause of the bleeding.
The NHA and DON confirmed that the facility did conduct an investigation and examination to rule out abuse, neglect or mistreatment as a potential cause of the resident's vaginal bleeding.
In response to surveyor inquiry during the survey, a nursing progress note dated July 16, 2024, at 3:31 PM was entered into the clinical record noting that a head-to-toe assessment was conducted of Resident 24 for vaginal bleeding.
The resident was examined for signs of abuse, and no suspicious findings were identified.
395265
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 395265 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201
According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records.
According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations.
The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place.
A review of the clinical record revealed that Resident 35 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis (the space around the spinal cord becomes too narrow which puts pressure on the spinal cord and nerves) and hypertension.
A review of Resident 87's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease.
Review of a facility incident report dated July 9, 2024, at 4:30 PM revealed that Resident 35 reported to a staff member that Resident 87 was in her room uninvited and slapped her in the face when she told Resident 87 to put down her orange.
395265
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 395265 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201
The facility failed to demonstrate timely implementation of recommended measures to promote healing of the pressure sore, including pressure reducing measures and devices, Prevalon boots and repositioning.
The facility failed to timely notify the physician of the results of the xray identifying the bone infection to assure prompt treatment.
Nursing staff failed to consistently document thorough assessment of the pressure sore to timely identify declines in the wound's condition.
An interview with the Nursing Home Administrator on July 18, 2024, at approximately 10:30 AM confirmed the facility was unable to provide evidence of timely development and implementation of measures necessary to promote healing of a pressure ulcer.
28 Pa.
Code 211.10 (a)(c)(d) Resident care policies
28 Pa.
Code 211.12 (c)(d)(1)(3)(5) Nursing services.
395265
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 395265 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201
During an interview on July 19, 2024, at approximately 9:20 AM, the Nursing Home Administrator (NHA) verified that the facility was unable to provide documented evidence of the results of these pharmacy drug regimen reviews, and the pharmacist's recommendations or identification of irregularities in the above residents' drug regimens and documented evidence that the physician had acted upon these reports when required.
28 Pa.
Code 211.9 (k) Pharmacy services.
28 Pa.
Code 211.12 (c) Nursing services.
28 Pa.
Code 211.2 (d)(3) Medical Director
395265
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 395265 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201
Findings included:
A grievance lodged with the facility dated April 3, 2024, indicated that Resident 48 reported that she was continuously dissatisfied with nursing staff's untimely call bell response time.
The facility noted that the grievance is not resolved to the resident's liking, despite facility improvements in staff's call bell response.
A grievance filed with the facility dated April 29, 2024, indicated that Resident 85 expressed concerns that staff initially responded to his call bell but left and never came back to get him out of bed as requested.
The grievance indicated that he remained in bed all day as a result.
The facility noted that the grievance was resolved.
A grievance lodged with the facility dated June 1, 2024, indicated that a resident's family member/representative voiced concerns on behalf of the resident, reported that the resident waited over four hours for nursing staff to answer the resident's call bell and that nursing staff does not provide his morning care at the resident's preferred time.
The grievance identified the family member but did not include the resident's name.
The facility noted that the grievance was resolved.
Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 24, 2024 revealed that Resident 21 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).
A review of the clinical record revealed that Resident 48 was admitted to the facility on [DATE], with diagnoses to include major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of a quarterly MDS assessment dated [DATE] revealed that Resident 48 is cognitively intact with a BIMS score of 15.
395265
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 395265 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201