Inspection Results » Pavilion at St Luke Village, The

Health Inspection on October 26, 2018 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-11-28)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-11-28)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-11-28)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-11-28)
   • 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 ne (Corrected 2018-11-28)
   • Honor the resident's right to organize and participate in resident/family groups in the facility. (Corrected 2018-11-28)
   • Have the Quality Assessment and Assurance group have the required members and meet at least quarterly (Corrected 2018-11-28)
   • Provide or obtain dental services for each resident. (Corrected 2018-11-28)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-28)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-11-28)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-11-28)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-11-28)
   • 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. (Corrected 2018-11-28)
   • Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Corrected 2018-11-28)
   • Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. (Corrected 2018-11-28)
   • Keep residents' personal and medical records private and confidential. (Corrected 2018-11-28)