PAVILION AT ST LUKE VILLAGE, THE
Inspection History Overview
Health Violations by Year
2024 21 violations
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Respond appropriately to all alleged violations.
Ensure each resident receives an accurate assessment.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Provide safe, appropriate pain management for a resident who requires such services.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
Provide and implement an infection prevention and control program.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2023 10 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate pain management for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Reasonably accommodate the needs and preferences of each resident.
2022 16 violations
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Plan the resident's discharge to meet the resident's goals and needs.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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.
Provide and implement an infection prevention and control program.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure each resident receives an accurate assessment.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Provide safe, appropriate pain management for a resident who requires such services.
2021 6 violations
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
2020 3 violations
Provide and implement an infection prevention and control program.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2019 11 violations
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.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have policies on smoking.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
2018 21 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to organize and participate in resident/family groups in the facility.
Keep residents' personal and medical records private and confidential.
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.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Provide or obtain dental services for each resident.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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.
Provide and implement an infection prevention and control program.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2017 15 violations
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.
Provide housekeeping and maintenance services.
Ensure each resident receives an accurate assessment by a qualified health professional.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care by qualified persons according to each resident's written plan of care.
Provide necessary care and services to maintain or improve the highest well being of each resident .
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.
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
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.
Store, cook, and serve food in a safe and clean way.
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.
Train all employees on what to do in an emergency, and carry out unannounced staff drills.
Detailed Inspection Reports
No detailed inspection reports available yet. Check back soon as we're processing new reports daily.
Fines and Penalties by Year
2022 2 penalties totaling $16,783
2020 1 penalties totaling $8,229
Fire Safety Deficiencies
No description available