Deficiency Records for The Pavilion at St Luke Village
Updated as of July 01, 2022
This is not the most recent data for The Pavilion at St Luke Village. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 | 2021-02-26 | 2021-03-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-26 | 2021-03-30 | 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 | 2021-02-26 | 2021-03-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-02-26 | 2021-03-30 | 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 | 2021-02-26 | 2021-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-26 | 2021-03-30 | N |
| Use approved construction type or materials. | Fire Safety | 2021-02-22 | 2021-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-22 | 2021-03-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-02-22 | 2021-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-02-22 | 2021-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-10 | 2021-01-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-09-09 | 2020-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-04 | 2020-09-09 | 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 | 2019-10-25 | 2019-12-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-25 | 2019-12-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-25 | 2019-12-04 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-10-25 | 2019-12-04 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-10-25 | 2019-12-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-25 | 2019-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-25 | 2019-12-04 | N |
| Have policies on smoking. | Health | 2019-10-25 | 2019-12-04 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
