Deficiency Records for Manor at St Luke Village,the
Updated as of September 01, 2016
This is not the most recent data for Manor at St Luke Village,the. For the most recent information, click here.
A list of the most recent deficiencies for Manor at St Luke Village,the. 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? |
|---|---|---|---|---|
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2016-04-21 | 2016-06-16 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-04-21 | 2016-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-04-21 | 2016-06-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-04-21 | 2016-06-16 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2016-04-21 | 2016-06-16 | N |
| Approved construction type or materials. | Fire Safety | 2016-04-26 | 2016-06-03 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-04-26 | 2016-06-03 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-04-26 | 2016-06-03 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-04-26 | 2016-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-12-08 | 2016-01-12 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-05-08 | 2015-07-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2015-05-08 | 2015-07-15 | N |
| Approved construction type or materials. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| Exits that are accessible at all times. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| Other fire safety features required by fire safety codes. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-05-21 | 2015-07-07 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2015-05-08 | 2015-06-29 | N |
| Provide housekeeping and maintenance services. | Health | 2015-05-08 | 2015-06-29 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-05-08 | 2015-06-29 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2015-05-08 | 2015-06-29 | N |
| Provide or obtain dental services for each resident. | Health | 2015-05-08 | 2015-06-29 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-05-08 | 2015-06-29 | N |
| Approved construction type or materials. | Fire Safety | 2014-04-30 | 2014-05-30 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2014-04-30 | 2014-05-30 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2014-04-30 | 2014-05-30 | N |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2014-04-30 | 2014-05-30 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2014-04-30 | 2014-05-30 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2014-04-10 | 2014-05-28 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2014-04-10 | 2014-05-28 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2014-04-10 | 2014-05-28 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2014-04-10 | 2014-05-28 | N |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2014-04-10 | 2014-05-28 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2014-04-10 | 2014-05-28 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2014-04-10 | 2014-05-28 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2014-04-10 | 2014-05-28 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2014-04-10 | 2014-05-28 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2013-11-01 | 2013-12-10 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2013-11-01 | 2013-12-10 | Y |
