Deficiency Records for Manor at St Luke Village,the
Updated as of January 01, 2020
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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-22 | 2019-06-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-17 | 2019-06-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-17 | 2019-06-20 | 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 | 2019-05-17 | 2019-06-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-17 | 2019-06-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-17 | 2019-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-17 | 2019-06-20 | 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 | 2019-05-17 | 2019-06-20 | 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 | 2019-05-17 | 2019-06-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-05-17 | 2019-06-20 | 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 | 2019-05-17 | 2019-06-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-17 | 2019-06-20 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of schedul | Health | 2019-05-17 | 2019-06-20 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-17 | 2019-06-20 | 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 | 2019-05-17 | 2019-06-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-17 | 2019-06-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-17 | 2019-06-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-05-17 | 2019-06-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-17 | 2019-06-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-03-27 | 2019-05-17 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-03-01 | 2018-06-01 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2018-04-23 | 2018-05-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-04-23 | 2018-05-29 | N |
| Use approved construction type or materials. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-20 | 2018-05-23 | 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 | 2018-04-20 | 2018-05-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-20 | 2018-05-23 | N |
| Provide or obtain dental services for each resident. | Health | 2018-04-20 | 2018-05-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-20 | 2018-05-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-20 | 2018-05-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-04-20 | 2018-05-23 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-04-20 | 2018-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-20 | 2018-05-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-04-20 | 2018-05-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-01 | 2018-04-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-03-01 | 2018-04-20 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-05-12 | 2017-06-15 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-05-12 | 2017-06-15 | N |
| Provide housekeeping and maintenance services. | Health | 2017-05-12 | 2017-06-15 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-05-12 | 2017-06-15 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-05-12 | 2017-06-15 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-05-12 | 2017-06-15 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-12 | 2017-06-15 | N |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2017-05-12 | 2017-06-15 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-05-12 | 2017-06-15 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-05-12 | 2017-06-15 | 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 | 2017-05-12 | 2017-06-15 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2017-05-12 | 2017-06-15 | N |
| Provide special eating equipment and utensils for each resident who needs them. | Health | 2017-05-12 | 2017-06-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-12 | 2017-06-15 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-05-12 | 2017-06-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-12 | 2017-06-15 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-05-12 | 2017-06-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-12 | 2017-06-15 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-05-12 | 2017-06-15 | 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 | 2017-05-12 | 2017-06-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-05-15 | 2017-05-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-20 | 2017-05-12 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-03-20 | 2017-05-12 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-03-20 | 2017-05-12 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-03-20 | 2017-05-12 | Y |
