Pavilion at St Luke Village, The

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 17, 2026

  Based on observations, a review of facility policies, clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to provide adequate supervision and implement effective, individualized interventions to prevent repeated falls for one of 23 residents reviewed (Resident 104) resulting in actual harm including a subdural hematoma and sacral fracture, requiring hospitalization.Findings include: A review of the facility's Accidents and Supervision policy, last reviewed by the facility on February 12, 2026, indicated the facility would provide each resident with adequate supervision and appropriate assistive devices to prevent accidents. […]

• Actual harm, isolatedF686Mar 26, 2025

  Based on a comprehensive review of clinical records, facility policies, and staff interviews, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer for one of 14 sampled residents (Resident CR 1), resulting in actual harm. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. […]

• Actual harm, isolatedF686Jul 19, 2024

  Based on select facility policy and clinical records, and staff interviews it was determined that the facility failed to provide necessary care to promote healing, and prevent worsening of a pressure sore, resulting in deterioration and clinical complications with the resident's pressure sore for one resident out of 24 sampled (Resident 94). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. […]

• Actual harm, isolatedF689Oct 27, 2023

  Based on a review of clinical records and investigative reports, and staff interviews, it was determined that the facility failed to ensure that the resident's environment was free of potential accident hazards, resulting in a fall with injury, a fractured clavicle, to one resident out of three sampled residents (Resident 18). Findings include: A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses, which included adult failure to thrive, left, and right knee contracture, abnormal posture, and dementia. […]

• Actual harm, isolatedF805Aug 9, 2022

  Based on review of clinical records, the facility's diet manual and menus, and select facility investigative reports and staff interviews, it was determined that the facility failed to ensure that a resident identified with chewing and swallowing difficulties was consistently served food in a form to meet this resident's individual needs resulting in choking episode requiring hospitalization for [CONDITION(S)] for one resident out of five sampled (Resident 1). Findings include: A review of the clinical record of Resident 1 revealed admission to the facility on [DATE], with diagnoses, which included dysphagia (difficulty swallowing) and cerebral infarction (stroke). […]