Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 395265

Pavilion At St Luke Village, The

42 federal citations on record , and 2 federal enforcement actions totaling $65,478.

Record summary

Federal record · Q1 2026
42
Total citations
42
Last 3 years
2
Actual harm+
2
Federal penalties
$65,478
Total fines
2
Overall ★ rating

Most common violation categories here

Quality of Care14 Resident Rights8 Medication & Pharmacy6 Care Planning5 Administration3

Most common F-tags at this facility

F6863 F6843 F7553 F8803 F5502

Citation history

42 on record
SurveyF-TagViolationSeveritySource
Sep 12, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EStandard
Sep 12, 2025F699Provide care or services that was trauma informed and/or culturally competent.DStandard
Sep 12, 2025F693Ensure 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.DStandard
Sep 12, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard
Sep 12, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Sep 12, 2025F641Ensure each resident receives an accurate assessment.EStandard
Sep 12, 2025F565Honor the resident's right to organize and participate in resident/family groups in the facility.EStandard
Sep 12, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EStandard
Mar 26, 2025F895Have a Compliance and Ethics Program.DComplaint
Mar 26, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Nov 21, 2024F880Provide and implement an infection prevention and control program.FComplaint
Nov 21, 2024F758Implement 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.DStandard
Nov 21, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DStandard
Nov 21, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Nov 21, 2024F688Provide 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.EStandard
Nov 21, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.EStandard
Nov 21, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EStandard
Oct 16, 2024F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DComplaint
Oct 16, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Oct 16, 2024F584Honor 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.DComplaint
Jul 19, 2024F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EComplaint
Jul 19, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Jul 19, 2024F880Provide and implement an infection prevention and control program.EStandard
Jul 19, 2024F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Jul 19, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Jul 19, 2024F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.DStandard
Jul 19, 2024F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Jul 19, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EStandard
Jul 19, 2024F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.DStandard
Jul 19, 2024F697Provide safe, appropriate pain management for a resident who requires such services.EStandard
Jul 19, 2024F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.EStandard
Jul 19, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GStandard
Jul 19, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard
Jul 19, 2024F641Ensure each resident receives an accurate assessment.DStandard
Jul 19, 2024F610Respond appropriately to all alleged violations.DStandard
Jul 19, 2024F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DStandard
Jul 19, 2024F584Honor 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.DStandard
Jul 19, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DStandard
Jul 19, 2024F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.DStandard
Apr 9, 2024F880Provide and implement an infection prevention and control program.DComplaint
Apr 9, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint
Sep 7, 2023F558Reasonably accommodate the needs and preferences of each resident.DComplaint

Federal enforcement history

Federal regulators have imposed 2 enforcement actions against this facility, including 2 civil money penalties totaling $65,478 .

DateTypeFinePayment denial
Jul 19, 2024Fine$55,419—
Oct 27, 2023Fine$10,059—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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