Manor at St Luke Village,The

In the surveyor’s words

From the most serious findings on record at Manor at St Luke Village,The, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 12, 2022

  Based on a review of clinical records, facility provided documentation, select investigative reports and staff interview, it was determined that the facility failed to consistently provide necessary assistance devices and/or utilize safe technique while performing activities of daily living (showering/bathing) to prevent a fall resulting in serious injuries, a fractured left femur and sacrum, for one out of 4 sampled residents (Resident CR 2). Findings include: A review of the clinical record revealed that Resident CR 2 was admitted to the facility on [DATE], with diagnoses of muscle weakness, [CONDITION(S)] (a disorder of the central nervous system that affects movement, often including tremors), protein-calorie malnutrition, anxiety, dysphagia (difficulty swallowing foods or liquids),… […]

• Actual harm, isolatedF689Jan 25, 2022

  Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently provide adequate staff supervision and assistance and implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls resulting in a serious injury, a [CONDITION(S)], for one of 4 sampled (Residents CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF803Jan 8, 2026

  Based on a review of the facility's planned menu, weekly menu cycle, and menu extensions, as well as resident and staff interviews, it was determined that the facility failed to ensure planned menus were sufficiently reviewed and updated to provide adequate variety and to prevent repetitive meal selections in accordance with resident preferences which affected 5 out of 8 residents interviewed, who reported experiencing repetitive meals and limited variation in menu selections that did not reflect their stated food preferences.Findings included: During a Resident Council meeting conducted on January 6, 2026, at 10:00 AM, concerns were raised regarding the lack of variety in the facility's menu. Residents, 34 and 70, indicated that they have a problem with the variety of options on the menu. […]

• No harm, potential for more than minimal, widespreadF880Jan 28, 2025

  Based on observations, review of the facility's infection control tracking logs and infection control and prevention policy and staff interviews it was determined the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases including upper respiratory infection for 1 of 23 residents reviewed (Resident 1). Findings include: A review of the facility's infection control policy, last revised on January 23, 2025, indicated that the policy was designed to facilitate a safe, sanitary, and comfortable environment while preventing and managing the transmission of infectious diseases The objectives of the infection control policies and practices were to: a. Prevent, detect, investigate and control infections in the facility. b. […]

• No harm, potential for more than minimal, widespreadF725May 31, 2024

  Based on a review of nurse staffing, clinical records, grievances lodged with the facility and the minutes from Residents Council meetings and staff, resident and family interviews, it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality of care to residents, and in accordance with each resident's plan of care, to meet individualized needs and promote the resident's health and well-being. Findings included: A review of grievances filed with the facility revealed a grievance dated March 9, 2024, indicating that Resident 199 was not offered a shower because facility staff told her that they were too short {of staff} to give her a shower. […]