Deficiency Records for Manor at St Luke Village,the
Updated as of May 01, 2022
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? |
|---|---|---|---|---|
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 |
| Use approved construction type or materials. | Fire Safety | 2020-10-21 | 2020-11-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-21 | 2020-11-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-21 | 2020-11-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-10-21 | 2020-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-10-02 | 2020-10-28 | N |
| Provide activities to meet all resident's needs. | Health | 2020-10-02 | 2020-10-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-02 | 2020-10-28 | 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 | 2020-10-02 | 2020-10-28 | 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 scheduled meal times. | 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 |
| 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 |
