Saint Luke Pavilion

Total Number of Beds: 120	Percent of Occupied Beds: 93%
Total Number of Residents: 112	Located Within a Hospital: No
Type of Ownership: Non profit - Church related	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 08/29/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.63

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.91

Number of CNA Hours per Nursing Home Resident per Day: 2.1

Number of Staff Hours per Nursing Home Resident per Day: 3.64

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 16%
Percent of High-Risk Residents Who Have Pressure Sores: 12%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 12%
Percent of Residents Who Have Moderate to Severe Pain: 2%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 25%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 1%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 27%
Percent of Residents Who are More Depressed or Anxious: 15%
Percent of Short-Stay Residents With Delirium: 0%
Percent of Residents Who Were Physically Restrained: 0%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 52%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 6%
Percent of Residents With a Urinary Tract Infection: 6%
** Details Last Reported on: 8/29/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-11-16	2002-01-20	Mistreatment Deficiencies	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Resident Rights Deficiencies	Make sure that private space is available in the nursing home for resident groups or residents' families to meet.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Quality Care Deficiencies	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Potential for minimal harm
2001-11-16	2002-01-20	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Resident Assessment Deficiencies	Make sure that doctors visit residents regularly, as required.	Pattern	Minimal harm or potential for actual harm
2001-11-16	2002-01-20	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Resident Rights Deficiencies	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Quality Care Deficiencies	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
2002-10-03	2002-12-30	Environmental Deficiencies	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
2003-08-29	2003-09-30	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2003-08-29	2003-09-30	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
2003-08-29	2003-09-30	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
2003-08-29	2003-09-30	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2003-08-29	2003-09-30	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Actual harm
2003-08-29	2003-09-30	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
2003-08-29	2003-09-30	Nutrition and Dietary Deficiencies	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
2003-08-29	2003-10-15	Quality Care Deficiencies	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
2003-08-29	2003-09-30	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.