ElderGrade

Inspection citations at Pavilion At St Luke Village, The

42 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 10 1
2024 31 1
2023 1 0
D September 12, 2025 Tag F0699 Corrected Oct 2025

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

D September 12, 2025 Tag F0693 Corrected Oct 2025

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D September 12, 2025 Tag F0657 Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

E September 12, 2025 Tag F0842 Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

E September 12, 2025 Tag F0684 Corrected Oct 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

E September 12, 2025 Tag F0641 Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

E September 12, 2025 Tag F0565 Corrected Oct 2025

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

E September 12, 2025 Tag F0550 Corrected Oct 2025

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

D March 26, 2025 Tag F0895 Complaint investigation Corrected Apr 2025

Administration Deficiencies

Have a Compliance and Ethics Program.

No actual harm, potential for more than minimal harm

G March 26, 2025 Tag F0686 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm to a resident

D November 21, 2024 Tag F0758 Corrected Dec 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D November 21, 2024 Tag F0755 Corrected Dec 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D November 21, 2024 Tag F0690 Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

E November 21, 2024 Tag F0688 Corrected Dec 2024

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

E November 21, 2024 Tag F0686 Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

E November 21, 2024 Tag F0550 Corrected Dec 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

F November 21, 2024 Tag F0880 Complaint investigation Corrected Dec 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D October 16, 2024 Tag F0757 Complaint investigation Corrected Nov 2024

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D October 16, 2024 Tag F0684 Complaint investigation Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D October 16, 2024 Tag F0584 Complaint investigation Corrected Nov 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0849 Corrected Aug 2024

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0842 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0777 Corrected Aug 2024

Administration Deficiencies

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0744 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0690 Complaint investigation Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0641 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0610 Corrected Aug 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0600 Corrected Aug 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0584 Corrected Aug 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0580 Corrected Aug 2024

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0561 Corrected Aug 2024

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0880 Corrected Aug 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0756 Corrected Aug 2024

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0755 Corrected Aug 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0725 Complaint investigation Corrected Aug 2024

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0697 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0694 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0684 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

G July 19, 2024 Tag F0686 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm to a resident

D April 9, 2024 Tag F0880 Complaint investigation Corrected May 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.