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Deficiency Records for The Pavilion at St Luke Village
View the most recent health deficiencies and inspection results for The Pavilion at St Luke Village. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for The Pavilion at St Luke Village. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2025-09-12 | 2025-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-09-12 | 2025-10-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-09-12 | 2025-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-09-12 | 2025-10-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2025-09-12 | 2025-10-14 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-09-12 | 2025-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-09-12 | 2025-10-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-09-12 | 2025-10-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-26 | 2025-04-22 | Y |
| Have a Compliance and Ethics Program. | Health | 2025-03-26 | 2025-04-22 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-11-21 | 2024-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-11-21 | 2024-12-17 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-11-21 | 2024-12-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-11-21 | 2024-12-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-11-21 | 2024-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-11-21 | 2024-12-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-11-21 | 2024-12-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-10-16 | 2024-11-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-16 | 2024-11-21 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-10-16 | 2024-11-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-07-19 | 2024-08-27 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-07-19 | 2024-08-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-19 | 2024-08-27 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-07-19 | 2024-08-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-07-19 | 2024-08-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-19 | 2024-08-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-19 | 2024-08-27 | N |
| Respond appropriately to all alleged violations. | Health | 2024-07-19 | 2024-08-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-19 | 2024-08-27 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-19 | 2024-08-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-19 | 2024-08-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-07-19 | 2024-08-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-09 | 2024-05-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-09 | 2024-05-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-07 | 2023-09-27 | Y |