A list of the most recent deficiencies for The Pavilion at St Luke Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-27 | 2023-11-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-27 | 2023-11-28 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-27 | 2023-11-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-11-28 | N |
| 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 | 2023-10-27 | 2023-11-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-27 | 2023-11-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-27 | 2023-11-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-27 | 2023-11-28 | 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 | 2023-10-27 | 2023-11-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-07 | 2023-09-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-04 | 2022-12-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-04 | 2022-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-04 | 2022-12-06 | 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 | 2022-11-04 | 2022-12-06 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-04 | 2022-12-06 | 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 | 2022-11-04 | 2022-12-06 | N |
| 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 | 2022-11-04 | 2022-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-04 | 2022-12-06 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-08-09 | 2022-08-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-08 | 2022-02-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-21 | 2022-02-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-21 | 2022-02-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-21 | 2022-02-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-21 | 2022-02-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-21 | 2022-02-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-21 | 2022-02-25 | N |
| Use approved construction type or materials. | Fire Safety | 2022-01-31 | 2022-02-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-31 | 2022-02-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-01-31 | 2022-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-31 | 2022-02-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-31 | 2022-02-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-31 | 2022-02-23 | N |
