Health inspection·July 19, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed. The resident explained that the other day she waited longer than 15 minutes for nursing staff to answer the call bell when she had to have a bowel movement, and as a result of the long wait for staff assistance with toileting, she had an accident (bowel incontinence). During an interview with the nursing home administrator on July 19, 2024, at 11:30 AM the NHA confirmed that there was documented evidence that the facility had acted upon the resident's increased bowel incontinence and completed incontinence evaluations and implemented any scheduled toileting programs in response to the resident's decline in bowel function and frequent incontinence of urine. 28 Pa. Code 211.12 (d)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395265 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, a review of nurse staffing, and grievances filed with the facility, and interviews with staff and residents, it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality care to each resident including eight residents out of 24 sampled (Residents 19, 20, 21, 48, 151, 38, 30 and 85), including concerns expressed in grievances filed with the facility (Resident 85). Findings included: A grievance lodged with the facility dated April 3, 2024, indicated that Resident 48 reported that she was continuously dissatisfied with nursing staff's untimely call bell response time. The facility noted that the grievance is not resolved to the resident's liking, despite facility improvements in staff's call bell response. A grievance filed with the facility dated April 29, 2024, indicated that Resident 85 expressed concerns that staff initially responded to his call bell but left and never came back to get him out of bed as requested. The grievance indicated that he remained in bed all day as a result. The facility noted that the grievance was resolved. A grievance lodged with the facility dated June 1, 2024, indicated that a resident's family member/representative voiced concerns on behalf of the resident, reported that the resident waited over four hours for nursing staff to answer the resident's call bell and that nursing staff does not provide his morning care at the resident's preferred time. The grievance identified the family member but did not include the resident's name. The facility noted that the grievance was resolved. Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 24, 2024 revealed that Resident 21 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of the clinical record revealed that Resident 48 was admitted to the facility on [DATE], with diagnoses to include major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of a quarterly MDS assessment dated [DATE] revealed that Resident 48 is cognitively intact with a BIMS score of 15. A clinical record review revealed Resident 20 was admitted to the facility on [DATE], with diagnoses that included coronary artery disease (a type of heart disease where the arteries cannot deliver enough oxygen-rich blood to the heart). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 20 is cognitively intact with a BIMS score of 13. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395265 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included coronary artery disease (a type of heart disease where the arteries cannot deliver enough oxygen-rich blood to the heart). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 19 is cognitively intact with a BIMS score of 15. During a group interview conducted on July 17, 2024, at 10:00 AM, Resident 48 stated that she waits 30 to 40 minutes for nursing staff to provide her care. She explained that the facility is particularly short staffed on the evening shift. Resident 48 stated that if she has to go to the bathroom after 15 minutes, she will start yelling from her room for staff assistance with a bedpan. Resident 48 stated that if she doesn't yell, then nursing staff don't respond. Resident 48 further explained that during meal times, nursing staff don't respond even when she is yelling for their assistance because they are helping residents in the dining room. She stated that the wait times for nursing staff to provide requested and needed care causes her to feel frustrated and angry. During an interview on July 17, 2024, at 10:45 AM, Resident 21 stated that she experiences long wait times for nursing staff to provide her care, stating that she often waits over 20 minutes for nursing staff to provide her care. Resident 21 stated that she feels frustrated, and after 25 minutes, she starts screaming for help from nursing staff. She explained that there are not a lot of nursing staff, and the wait times are worse when there is less nursing staff working. Resident 21 stated that when there is only one nurse aide assigned to her hallway, it makes her feel rushed when she needs assistance to use the bathroom. She explained that she is upset, because she doesn't want to be dependent on nursing staff for assistance, but she needs their help with activities of daily living. During an interview on July 17, 2024, at 11:15 AM, Resident 20 stated that she rings her call bell and waits between 20 and 40 minutes for nursing staff to respond. She explained that she is independent and can do most things herself, but she is upset when it takes so long for nursing staff to respond when she does need their help. Resident 20 stated that she believes that the issue is because there are not enough nursing staff working at the facility. During an interview on July 18, 2024, at 9:45 AM Resident 19 stated that the facility is often short on nurse staffing and sometimes only assigns one nurse aide to his hallway. He explained that the facility is short on nursing staff at least twice a week, and the weekends are the worst. Resident 19 stated the facility has increased the number of new residents admitted over the past few weeks, but has not increased the amount of nursing staffing. He explained that he waits 20 minutes or longer for nursing care after ringing his call bell for staff assistance. Interview with Resident 38 on July 16, 2024, at 12:20 PM the resident stated that nursing staff often take a long time to answer her call bell and the other day she waited longer than 15 minutes for the call bell to be answered and had an accident (bowel incontinence) because nursing staff did not respond timely to the resident's request for toileting assistance. Observation on July 18, 2024, at 1:00 PM revealed that Resident 30's bed was not yet made. Interview with Resident 30 at this time revealed that her sheets were due to be changed and were removed that morning but had not yet been replaced. Observation of the Third-floor nursing unit on July 19, 2024, at 9:00 AM revealed that there were 4 nurse aides and 2 LPNs (Employee 7 RN Supervisor was working as an LPN) working on the unit. During interview at this time with Employee 7 (RN Supervisor), Employee 7 stated that 2 nurse aides and 2 LPNs had called off and were not replaced. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395265 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's deployment sheet for the day shift of July 19, 2024, revealed that the facility's census was 104 residents. There were 4 nurse aides and 2 LPNs working on the Second-floor Nursing Unit, and 4 nurse aides and 2 LPNs working on the Third-floor nursing unit. There was also a restorative nurse aide who covered both nursing units and one RN Charge nurse floating between the nursing units. Interview with Resident 151, a cognitively intact resident, on July 19, 2024, at 9:30 AM revealed that she was unhappy with the nursing care at the facility. Resident 151 stated that due to long call bell waits (longer than 15 minutes) she had soiled herself on three different occasions. Resident 151 stated that it seems the facility does not have enough nursing staff. Resident 151 stated that the facility was aware of her concerns with her call bells not being answered timely and stated that they were to start offering toileting after meals. Resident 151 stated that she finished breakfast around 8:00 AM and, as of 9:30 AM nursing staff still had not offered her toileting. Resident 151 stated that she did have to go to the bathroom presently and the surveyor offered to seek out nursing staff assistance for the resident. Upon entering the hall and nurses station there were no staff available other than Employee 7 who stated that other nursing staff were busy helping other residents. Employee 7 (RN Supervisor) then assisted Resident 151 to the bathroom. Interview with the nursing home administrator (NHA) on July 19, 2024, at 10:30 AM confirmed that nursing staff are to make resident beds timely. The NHA confirmed that nursing staff are to answer call bells timely answered and offer Resident 151 after meals. The NHA confirmed that nursing staff call-offs were a problem, that negatively affected sufficient nurse staffing levels. A review of nurse staffing hours revealed the facility averaged 3.22 direct care hours for each resident with an average census of 98 residents for the week of June 24, 2024, through June 30, 2024. However, with an increase in their census, from June 11, 2024, through June 17, 2024, the facility averaged 3.06 direct care hours for each resident, with an average census of 104 residents. A review of the facility's nurse staffing from June 11, 2024, through July 17, 2024, revealed the facility failed to meet the required minimum state ratio for nurse aides on 18 of the 63 shifts reviewed. The facility failed to meet the required minimum state ratio for licensed practical nurses on 9 of the 63 shifts reviewed. The facility failed to meet the state minimum required nursing staff direct care hours per day for each resident on 10 out of 21 days reviewed. During an interview on July 19, 2024, at approximately 11:00 AM, the Nursing Home Administrator (NHA) confirmed that the facility failed to meet the state minimum requirements for nurse aides, licensed practical nurses, and nurse staff direct care hours for residents per day. The NHA was unable to provide evidence that additional direct care staff were provided to ensure residents needs were met with the increase in the resident census from the week of June 11, 2024 (98 residents) to the week of July 11, 2024 (104 residents). The NHA confirmed that it is the facility's responsibility to provide sufficient nursing staff to provide timely and quality care to each resident. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (c)(d)(4)(5)(f.1)(2)(4)(i)(1)(2) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395265 If continuation sheet Page 5 of 5