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? |
|---|---|---|---|---|
| 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 | 2023-04-28 | 2023-05-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-28 | 2023-05-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-28 | 2023-05-23 | 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 | 2023-04-28 | 2023-05-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-28 | 2023-05-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-28 | 2023-05-23 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-04-28 | 2023-05-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-28 | 2023-05-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-28 | 2023-05-23 | 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 | 2023-04-28 | 2023-05-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-28 | 2023-05-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-28 | 2023-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-28 | 2023-05-23 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-11 | 2023-05-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-11 | 2023-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-11 | 2023-05-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-07 | 2023-03-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-07 | 2023-03-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-07 | 2023-03-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-02-07 | 2023-03-09 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-20 | 2022-06-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-20 | 2022-06-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-05-20 | 2022-06-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-20 | 2022-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-20 | 2022-06-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-20 | 2022-06-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-05-20 | 2022-06-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-20 | 2022-06-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-20 | 2022-06-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-31 | 2022-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-31 | 2022-06-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-31 | 2022-06-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-12 | 2022-05-20 | 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 | 2022-04-12 | 2022-05-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-12 | 2022-05-20 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-12 | 2022-05-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-12 | 2022-04-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-25 | 2022-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-19 | 2021-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-26 | 2021-09-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-26 | 2021-09-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-26 | 2021-09-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-20 | 2021-08-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-20 | 2021-08-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-20 | 2021-08-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-20 | 2021-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-20 | 2021-08-24 | N |
| Have policies on smoking. | Health | 2021-07-20 | 2021-08-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-20 | 2021-08-24 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-16 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | Not Fixed | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-11-16 | Not Fixed | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-28 | Not Fixed | Y |
