PAVILION AT ST LUKE VILLAGE, THE
Open-data reference.
PAVILION AT ST LUKE VILLAGE, THE is a for profit - limited liability company facility in HAZLETON, PA with 120 certified beds and a 2-star overall CMS rating. The facility has 42 deficiency records on file. Total penalties: $65K.
1000 STACIE DRIVE, HAZLETON, PA 18201
Phone: 5704535100
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 395265
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 100
- In Hospital
- No
- County
- Luzerne
- Last Inspection
- Sep 12, 2025
Staffing Data
- RN Hours
- 0.58 (nat'l avg: 0.68)
- LPN Hours
- 0.82
- CNA Hours
- 2.10
- Total Nursing Hours
- 3.50 (nat'l avg: 3.89)
- PT Hours
- 0.03
- Nursing Turnover
- 49.0%
- RN Turnover
- 33.3%
What the CMS Record Reveals About PAVILION AT ST LUKE VILLAGE, THE
PAVILION AT ST LUKE VILLAGE, THE operates 120 certified beds in HAZLETON, PA with approximately 100 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (4★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 42 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $65K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.50 total nursing hours per resident day (national average 3.89), with RN coverage at 0.58 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, PAVILION AT ST LUKE VILLAGE, THE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 49.0%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (42 most recent)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2025
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Oct 14, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Oct 14, 2025
Have a Compliance and Ethics Program.
Category: Administration Deficiencies
Corrected: Apr 22, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 22, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 17, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Dec 17, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Dec 17, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 17, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 17, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 17, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Dec 17, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Nov 21, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 21, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Nov 21, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 27, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 27, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 27, 2024
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.
Category: Administration Deficiencies
Corrected: Aug 27, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 27, 2024
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Category: Administration Deficiencies
Corrected: Aug 27, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Aug 27, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 27, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 27, 2024
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 27, 2024
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 27, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 27, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 27, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 27, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 27, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 27, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Aug 27, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Aug 27, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Aug 27, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 7, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: May 7, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Sep 27, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 11.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.3% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.3% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.2% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.1% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 98.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 93.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.6% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 22.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 99.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 86.7% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 33.6% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 15.9% | Yes |
Penalty History 2 penalties totaling $65K
| Date | Type | Amount |
|---|---|---|
| Jul 19, 2024 | Fine | $55K |
| Oct 27, 2023 | Fine | $10K |
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Frequently Asked Questions
What is the overall CMS rating for PAVILION AT ST LUKE VILLAGE, THE?
What are the staffing levels at PAVILION AT ST LUKE VILLAGE, THE?
How many beds does PAVILION AT ST LUKE VILLAGE, THE have?
Does PAVILION AT ST LUKE VILLAGE, THE have any deficiencies on record?
Has PAVILION AT ST LUKE VILLAGE, THE received any fines or penalties?
Who owns PAVILION AT ST LUKE VILLAGE, THE?
When was PAVILION AT ST LUKE VILLAGE, THE last inspected?
What quality measures are tracked for PAVILION AT ST LUKE VILLAGE, THE?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.