Federal Nursing-Home Survey Record
PAVILION AT ST LUKE VILLAGE, THE
Does PAVILION AT ST LUKE VILLAGE, THE have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), PAVILION AT ST LUKE VILLAGE, THE (CCN 395265), in HAZLETON, PA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 8 deficiencies; the most serious carries scope/severity E — CMS's "potential for harm" tier, below actual harm. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $104,223 in civil money penalties on file against the facility. This page restates the federal record and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
CMS has $104,223 in civil money penalties on file against this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Civil money penalties on file
$104,223
CMS has $104,223 in civil money penalties on file against this facility.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 2 · CMS state average: 3.0
Deficiency timeline — full federal history
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.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure each resident receives an accurate assessment.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide care or services that was trauma informed and/or culturally competent.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
34 citations from earlier inspection cycles — historical, not current (expand)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Have a Compliance and Ethics Program.
Provide and implement an infection prevention and control program.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide and implement an infection prevention and control program.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Ensure each resident receives an accurate assessment.
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 appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Respond appropriately to all alleged violations.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide and implement an infection prevention and control program.
Reasonably accommodate the needs and preferences of each resident.
Document what happened
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