Public Record
The Pavilion at St Luke Village
Operated by Avardis Health
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 120
- Avg. residents per day
- 106.2
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 42
- Inspections on file
- 7
- Last inspection
- 2025-09-12
*CMS
*CMS
*CMS
Citations
42 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0693Generalpotential for harm
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.
- 0895Generalpotential for harm
Have a Compliance and Ethics Program.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0688Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0584Generalpotential for harm
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.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0561Generalpotential for harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0744Generalpotential for harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0849Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0584Generalpotential for harm
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.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0777Generalpotential for harm
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection8 deficiencies
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a…
Read full statement of deficiencies - Inspection2 deficiencies
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a comprehensive review of clinical records, facility policies, and staff interviews, it was determined…
Read full statement of deficiencies - Inspection7 deficiencies
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a…
Read full statement of deficiencies - Inspection3 deficiencies
F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observations and resident and staff interviews, it was…
Read full statement of deficiencies - Inspection19 deficiencies
F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE…
Read full statement of deficiencies - Inspection2 deficiencies
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on…
Read full statement of deficiencies - Inspection1 deficiency
F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed…
Read full statement of deficiencies
Ownership
Avardis Health
38nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is The Pavilion at St Luke Village?
- The Pavilion at St Luke Village is a Medicare- and Medicaid-certified nursing home in Hazleton, PA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 395265.
- What is the CMS rating for The Pavilion at St Luke Village?
- The Pavilion at St Luke Village has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does The Pavilion at St Luke Village have?
- The Pavilion at St Luke Village is certified for 120 beds. It serves an average of 106.2 residents per day.
- How many citations does The Pavilion at St Luke Village have?
- The Pavilion at St Luke Village has 42 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was The Pavilion at St Luke Village last inspected?
- The Pavilion at St Luke Village was last inspected on September 12, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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