Health inspection·November 21, 2024

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 review of clinical records, resident council meeting minutes, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of 21 sampled (Residents 25 and 74) and experiences reported by five out of the nine residents during a resident group interview (Residents 24, 28, 31, 55, and 57). Findings include: A review of Resident Council meeting minutes dated October 2, 2024, revealed that residents in attendance had concerns regarding call bell response wait times. The meeting minutes contained no further documentation regarding the residents' concerns. A grievance dated October 2, 2024, revealed residents had concerns regarding call bells not answered timely. The document indicated individual concerns would be addressed as needed and reviewed during resident council. A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that included chronic heart failure (a condition that occurs when the heart can't pump enough blood to meet the body's needs). A review of an annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 11, 2024, revealed that Resident 25 is moderately cognitively impaired with a BIMS score of 9 (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 08-12 indicates moderate cognitive impairment). During an interview on November 19, 2024, at 12:00 PM, Resident 25 indicated she experiences long wait times for care. She indicated she sometimes waits 20 minutes or longer for staff to respond to her call bell after she rings for assistance. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). Page 1 of 22 395265 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0550 Level of Harm - Minimal harm or potential for actual harm A review of an annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 4, 2024, revealed that Resident 74 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). Residents Affected - Some During an interview on November 19, 2024, at 12:55 PM, Resident 74 indicated that he experiences long wait times for care. He explained that he waits from 15 minutes to two hours for assistance. He explained that a few days ago he told the nurse aide that he was having pain and would like his medication, but he had to wait 2 hours before the nurse checked in on him. Resident 74 indicated he is frustrated regarding the wait times for assistance. During a resident council group interview on November 20, 2024, at 10:00 AM, five alert and oriented residents out of nine in attendance indicated they experience distress because of the long wait times for care (Residents 24, 28, 31, 55, and 57). During the group interview, Resident 24 indicated that she waits 20 to 30 minutes for staff to respond to her call bell after she rings for assistance. She expressed that she is frustrated and upset that it takes so long before someone responds to her when she needs help. During the group interview, Resident 28 indicated she waits 30 minutes for staff to respond to her call bell after she rings for assistance. She explained the wait time is the worst in the evening and indicated she is upset when no one responds when she needs to use the bathroom. During the group interview, Resident 31 indicated she often waits 30 minutes or more for staff to respond after she rings her call bell for assistance. Resident 31 explained that sometimes staff will initially respond and turn off her call bell, then tell her they will be right back to provide care but then do not return. Resident 31 expressed that she is upset when she must wait and wait for assistance. During the group interview, Resident 55 indicated she has been left on the toilet for 30 minutes before staff responded to her call bell for assistance. She explained that waiting that long for care is frustrating and upsetting. During the group interview, Resident 57 indicated she often waits 30 minutes for staff to respond to her call bell after she rings for assistance. She explained that she needs assistance to safely ambulate to the bathroom. Resident 57 indicated that when staff do not respond after 30 minutes, she transfers herself to the bathroom even though she knows it is not safe. During an interview on November 21, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect and provided care in a manner that promotes each resident's quality of life. The NHA and DON were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 395265 Page 2 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0550 28 Pa. Code 211.12 (d)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395265 Page 3 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility investigative reports, observation and resident and staff interview it was determined the facility failed to consistently provide care and services to prevent the development of a pressure sore for two residents out of 21 sampled (Residents 19 and 26). Residents Affected - Some Findings include: A review of facility policy titled Unavoidable Pressure Injury, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's risk factors demonstrate they were unavoidable. A clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included 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). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 7, 2024, revealed that Resident 19 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 comprehensive care plan indicating Resident 19 has the potential impairment to skin integrity with a goal to maintain clean and intact skin was initiated on July 20, 2023. An intervention implemented by the facility to achieve this goal included ensuring oxygen tubing has ear padding to prevent skin breakdown, initiated on February 16, 2024. The care plan indicated the resident had a history of skin breakdown due to oxygen tubing rubbing against Resident 19's ear, including the development of a Stage II pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed and may also present as an intact, open, or ruptured blister) dated February 16, 2024. A Braden Scale for Predicting Pressure Sore Risk form dated June 6, 2024, identified Resident 19 as at risk for the development of pressure injuries. Further clinical record review revealed a skin impairment assessment report dated August 27, 2024, indicating staff observed a new Stage II pressure injury on the top of Resident 19's left ear due to oxygen tubing. The report indicated Resident 19 said that her left ear is tender from oxygen tubing rubbing. A pressure ulcer wound round report dated August 28, 2024, described Resident 19's left ear wound as a Stage II pressure injury measuring 1.5 cm x 1.5 cm x 0.0 cm with firm edges, no drainage, and a wound bed with slough (accumulation of dead cells usually yellow or white). The surrounding wound area was red with intact skin. A progress note dated September 12, 2024, at 11:04 AM indicated Resident 19's Stage II left ear wound was resolved and staff were continuing to ensure the oxygen tubing was padded to prevent further 395265 Page 4 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0686 skin breakdown. Level of Harm - Minimal harm or potential for actual harm A review of weekly skin integrity documentation dated November 16, 2024, at 4:25 PM indicated Resident 19 had no current skin conditions noted, and preventative treatment for skin breakdown was ongoing. Residents Affected - Some During an observation on November 21, 2024, at 10:40 AM, Employee 2, Licensed Practical Nurse (LPN), removed a 2.0-inch x 2.0-inch gauze pad from Resident 19's left ear in the area where the oxygen tubing would be present, revealing an open wound measuring 0.7 cm x 0.3 cm x 0.1 cm. The gauze pad contained yellow and brown discolorations. The wound bed had small amounts of clear yellow liquid present. The wound edges were intact. There was no odor from the wound detected. Resident 19 indicated she did not feel any pain associated with the wound. During an interview on November 22, 2024, at 11:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed it is the facility's responsibility to prevent the development of pressure injuries. The NHA and DON confirmed that the facility failed to consistently implement effective interventions such as consistently padding the oxygen tubing to prevent Resident 19 from developing a pressure injury to her left ear. A review of Resident 26's clinical record revealed the resident was most recently readmitted to the facility on [DATE], with diagnoses that include a left hip fracture, reduced mobility, and Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown). A review of the resident's significant change Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed the resident had a BIMS of 7, which indicated severe cognitive impairment, always incontinent of bladder and bowel, and dependent with substantial/maximum assistance for toileting, showering, upper and lower dressing, and personal hygiene. Additionally, she was dependent with partial to moderate assistance with bed mobility. A review of Resident 26's clinical record a form entitled Pressure Ulcer Wound Rounds completed by Employee 1, a Registered Nurse (RN), dated October 27, 2024, at 10:33 AM, indicated the resident had a pressure area to her left buttock that measured 0.5 cm in length by 0.5 cm in width and no documented depth Stage II pressure area (the sore has broken through the top layer of the skin and part of the layer below and typically results in a shallow, open wound and may appear as a shallow, crater-like wound or a blister containing a clear or yellow fluid), wound was bed pink, wound edges firm, no redness, no drainage. Further review of a Pressure Ulcer Wound Round documentation completed by Employee 1(RN) on October 27, 2024, at 11:14 AM, revealed a second pressure area to her sacrum that measured 1.0 cm in length by 1.0 cm in width with depth not noted, Stage II pressure area, wound bed pink, wound edges firm, no redness, no drainage, peri area intact. There was no documentation to determine if the physician or responsible party of the resident was notified at the time of discovering the new pressure ulcers. A facility investigation for skin impairment completed by Employee 2, a RN/Unit Manager, dated October 28, 2024, at 7:00 AM, revealed Resident 26 was assessed following a report of the aforementioned 395265 Page 5 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0686 Level of Harm - Minimal harm or potential for actual harm open area on the sacrum over the weekend. Stage II wound present 4.0 cm by 3.0 cm area measured as one area with three separate superficial openings. The treatment was changed to wound gel twice per day. Immediate action was to provide topical treatment initiated, turn and repositioning every two hours, and every two-hour check and change program. Noted predisposing factors included incontinence and Gait (walking pattern) imbalance. Residents Affected - Some A review of the resident's task summary reports (reports that capture care related tasks completed by nurse aides) dated August 28, 2024, through October 28, 2024, failed to reveal that staff performed pressure ulcer prevention tasks, such as scheduled turning and repositioning and more frequent incontinence care/management to prevent the development of pressure areas. Resident 26's clinical record review failed to reveal that licensed nursing staff developed and implemented interventions for prevention of the development of pressure areas related to the resident's declined mobility post left hip fracture. A review of a Pressure Ulcer Wound Round form completed by Employee 2, dated November 13, 2024, at 12:57 PM, revealed the Stage II on the resident's sacrum was showing a depth at 0.01 cm with granulation (formation of new tissue) present in the wound bed, no drainage or odor. Wound gel was recommended by the physician. Additionally, a nurses' progress notes in Resident 26's clinical record dated November 18, 2024, at 10:45 AM, revealed the sacral wound progressed to an unstageable pressure area (full-thickness tissue loss with the base of the ulcer covered by slough a yellow, tan, gray, green, or brown substance) in the wound bed that measured 4.0 cm in length, by 4.5 cm in width, with 0.1 cm depth. A review of the facility's contracted wound nurse practitioner assessment dated [DATE], revealed Resident 26 was seen for a follow-up of a Stage II pressure area to the sacrum and indicated that staff reported the area had deteriorated throughout the week. Treatment was changed to Santyl (is a topical enzyme medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin). During an interview with the Director of Nursing (DON) on November 22, 2024, at 2:00 PM, confirmed the facility failed to implement consistent and appropriate measures to prevent the development and worsening of pressure sores for residents. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services. 395265 Page 6 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one out of 21 residents sampled (Resident 74). Findings include: A review of the facility policy titled Restorative Nursing Services, last reviewed by the facility on June 6, 2024, revealed the facility provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition and goals. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 4, 2024, revealed that Resident 74 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). Review of the comprehensive plan of care indicated Resident 74 is on the restorative nursing program for ambulation and active range of motion to maintain mobility, initiated on April 16, 2024, and discontinued on November 20, 2024. Interventions in place included encouraging the resident's participation in the restorative nursing program, monitoring progress, and referring the resident to therapy services as needed. A review of the documentation survey report from October 1, 2024, through November 20, 2024, revealed no documented evidence that Resident 74 received or was offered his scheduled restorative nursing program on 18 occasions: October 11, 12, 19, 20, 22, 23, 25, 26, 27, 28, 2024, or on November 2, 3, 5, 6, 7, 16, 17, or 19, 2024. A physical therapy Discharge summary dated [DATE], revealed Resident 74's prognosis to maintain the current level of function is excellent with participation in the restorative nursing program, and the discharge recommendations indicated discharge from the restorative nursing program. During an interview on November 19, 2024, at 12:55 PM, Resident 74 indicated that he is not receiving therapy or restorative nursing services. He explained it is frustrating because his goal is to regain his independence and ambulatory abilities. During an interview, on November 21, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure residents receive appropriate services and assistance to maintain or improve mobility. The NHA was unable to provide documented evidence that Resident 74 received restorative nursing services as planned. 28 Pa. Code 211.5(f)(xi) Medical records. 395265 Page 7 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0688 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395265 Page 8 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

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 BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policies, and staff interviews it was determined the facility failed to assess and implement individualized measures to meet the toileting needs of one resident out of 21 sampled residents. (Residents 26). Findings included: A facility policy entitled Bladder and Bowel Evaluation last reviewed by the facility June 6, 2024, indicated that residents are evaluated for continence on admission/readmission, quarterly, and with a significant change in status. Residents who are determined to be incontinent without a documented irreversible cause are to be further evaluated for potential bowel and/or bladder management and will have a Bowel and Bladder Evaluation completed and a Bowel and Bladder Elimination Pattern Evaluation completed. Based on the data collected from the patterning evaluation, residents are to be provided an individualized continence management program, a scheduled toileting program, a re-training program, or routine incontinence care which is to be documented on the resident's care plan. A review of Resident 26's clinical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown). A review of the resident's comprehensive person-centered plan for bladder and bowel incontinence last revised on August 13, 2024, indicated that Resident 26 had activity incontinence (stress incontinence when movement or activity puts pressure on the bladder causing urine to leak) and would remain free from skin breakdown due to incontinence. Planned interventions included to check and change the resident as required for incontinence and clean peri-area with each incontinence episode. Further review of the clinical record revealed that Resident 26 was transferred to the hospital on August 21, 2024, and readmitted to the facility on [DATE], with diagnoses of anemia with blood transfusion, left hip fracture, and reduced mobility. A review of the resident's significant change Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed the resident had a BIMS of 7, (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00-07 equates to being severely cognitively impaired), always incontinent of bladder and bowel, and dependent with substantial to maximum assistance for toileting, showering, upper and lower dressing, and personal hygiene. Additionally, she was dependent with partial to moderate assistance with bed mobility. A review of Resident 26's Potential for Bowel and Bladder Retraining form dated September 3, 2024, at 12:45 PM, revealed that the resident was always incontinent of bowel and bladder and a retraining program was not recommended. A facility investigation for skin impairment completed by Employee 2, a RN/Unit Manager, dated October 28, 2024, at 7:00 AM, revealed Resident 26 was assessed following a report of an open area on the sacrum over the weekend. Stage II wound present 4.0 cm by 3.0 cm area. Immediate action taken was to provide topical treatment turn and reposition the resident every two hours, and check and change 395265 Page 9 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0690 the resident every two-hours. Level of Harm - Minimal harm or potential for actual harm Further review of Resident 26's survey documentation reports (a report that summarizes recorded tasks that staff document based on resident individualized care needs) dated September 2024 through October 28, 2024, failed to reveal that staff performed more frequent incontinence checks and incontinence care. Residents Affected - Few The facility could not provide documented evidence that staff performed more frequent incontinence checks and incontinence care to prevent the development of pressure ulcers. Additionally, the facility failed to revise Resident 26's comprehensive person-centered plan to reflect her individualized incontinence needs with interventions such as frequent incontinence checks and incontinence care to prevent the development of pressure ulcers. Interview with the Nursing Home Administrator on November 21, 2024, at approximately 1:00 PM, confirmed the facility was unable to provide evidence the facility had consistently provided timely care for the resident's toileting needs, including incontinence management, to prevent Resident 26 from developing pressure ulcers. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies 395265 Page 10 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services in acquiring medication to meet the needs of one resident out of 21 sampled (Resident 9). Findings include: A review of facility policy titled, 4.1 New Orders for Controlled Substances, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that all controlled substance orders should be communicated to the pharmacy. If the medication is needed before the next scheduled delivery, facility staff should indicate the exact time by which the medication is needed. If the controlled substance is needed before the pharmacy can make arrangements for a timely delivery, then the facility should fax a request to remove a controlled substance from the emergency medication supply to the pharmacy. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included neuropathy (a nerve condition that can cause pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). Further clinical record review revealed a physician order for Resident 9 to receive Lyrica Oral Capsule 25 mg (pregabalin-an anticonvulsant drug used to treat neuropathic pain) with instructions to give 25 mg by mouth three times a day for pain management, initiated on February 22, 2024, and discontinued on November 6, 2024. A clinical record review revealed Resident 9 was in the community hospital from [DATE], through her readmission to the facility on November 8, 2024. A physician order for Resident 9 to receive Pregabalin Oral Capsule 25 mg with instructions to give 25 mg by mouth three times a day for pain management was initiated on November 8, 2024. A Medication Administration Record for November 2024 revealed Resident 9 did not receive six doses of Pregabalin Oral Capsule 25 mg from November 8, 2024, through November 10, 2024. A review of progress notes from November 8, 2024, through November 10, 2024, revealed communication between the facility and pharmacy services indicating the Pregabalin Oral Capsule 25 mg medication was not administered to Resident 9 because the pharmacy did not send the medication to the facility. A progress note dated November 9, 2024, at 8:30 AM, revealed a call was made to the pharmacy regarding delivery of Lyrica {Pregabalin Oral Capsule 25 mg}. The facility requested a STAT (immediately) delivery of the medication and verified receipt of the prescription from the physician with the pharmacy. The request was approved, and the nurse was assured of STAT delivery of ordered medication. However, further clinical review revealed Resident 9 did not receive Pregabalin Oral Capsule 25 mg until November 10, 2024, at 9:00 PM. During an interview on November 21, 2024, at approximately 11:00 AM, the Director of Nursing (DON) 395265 Page 11 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0755 Level of Harm - Minimal harm or potential for actual harm confirmed Resident 9 did not receive six doses of Pregabalin Oral Capsule 25 mg as prescribed by her physician because the medication was not provided by the pharmacy until November 10, 2024, at 9:00 PM. The DON confirmed it is the facility's responsibility to ensure pharmacy services acquire and provide medication to meet each resident's need. Residents Affected - Few 28 Pa Code 211.12 (d)(3) Nursing services. 28 Pa Code 211.9(k) Pharmacy services. 395265 Page 12 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued administration of an antipsychotic medication for one resident out of five sampled residents for unnecessary medication use. (Resident 96). Findings included: A clinical record review revealed Resident 96 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and generalized anxiety disorder (a mental health disorder characterized by the presence of excessive anxiety and worry about a variety of topics, events, or activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 20, 2024, revealed Resident 96 is severely cognitively impaired with a BIMS score of 3 (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 01-07 indicates severe cognitive impairment). A physician's order for Resident 96 to receive quetiapine fumarate oral tablet 25 mg (Seroquel-an antipsychotic medication) with directions to give 25 mg by mouth at bedtime for anxiety was initiated on July 11, 2024. A review of a nursing progress note dated September 17, 2024, at 5:57 PM indicated the resident was noted to be restless. She was walking in the hall and attempting to go in other residents' rooms. She denied any pain or discomfort. The resident's call bell was in reach. A progress note dated September 18, 2024, at 6:01 PM indicated the resident had restless behaviors this evening. She was walking in the hall, and staff supervision continued. No complaint of pain or discomfort. A progress note dated September 19, 2024, at 9:21 PM indicated the resident was redirected throughout the evening when attempting to go into other residents' rooms. Resident denies any pain or discomfort. Resting in bed now. A medication administration record (MAR) dated September 2024 revealed behavior tracking for anxiety initiated on July 11, 2024. The record indicated that Resident 96 displayed no maladaptive behaviors related to the resident's anxiety (i.e., agitation, crying, calling out, combativeness, screaming hallucinations) from September 1, 2024, through September 30, 2024. A progress note dated September 20, 2024, at 12:01 PM, indicating the physician recommended increasing Seroquel to 25 mg twice a day due to a recent increase in behaviors. A physician's order for Resident 96 to receive quetiapine fumarate oral tablet 25 mg (Seroquel-an 395265 Page 13 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few antipsychotic medication) with directions to give 25 mg by mouth two times a day for anxiety initiated on September 20, 2024. A medication administration record (MAR) dated September 2024 revealed Resident 96 received seventeen doses of quetiapine fumarate oral tablet 25 mg (Seroquel-an antipsychotic medication) from September 22, 2024, through September 30, 2024. A medication administration record (MAR) dated October 2024 revealed Resident 96 received sixty-one doses of quetiapine fumarate oral tablet 25 mg (Seroquel-an antipsychotic medication) from October 1, 2024, through October 31, 2024. A medication administration record (MAR) dated October 2024 revealed behavior tracking for anxiety initiated on July 11, 2024. The record indicated that Resident 96 displayed no maladaptive behaviors related to the resident's anxiety (i.e., agitation, crying, calling out, combativeness, screaming hallucinations) from October 1, 2024, through October 31, 2024. A pharmacy consultation report dated October 2024 revealed Resident 96 receives an antipsychotic medication (quetiapine) without adequate indication for use in the medical record. The pharmacy consultation report contains recommendations to the physician, including (1) if the antipsychotic order is to continue, please update the medical record to include the specification diagnosis/indication requiring treatment that is based upon an assessment and therapeutic goals, a list of the symptoms of target behaviors (e.g., hallucinations) including their impact on the resident, and documentation that other causes and medications have been considered and individualized nonpharmacological interventions are in place. In response to the October 2024 pharmacy consultation report, the physician's note dated November 6, 2024, indicated a plan to reduce Resident 96's Seroquel 25 mg from twice daily to once daily at bedtime, with a complete discontinuation of the antipsychotic medication after 14 days. A medication administration record (MAR) dated November 2024 revealed Resident 96 received twelve doses of quetiapine fumarate oral tablet 25 mg (Seroquel-an antipsychotic medication) from November 1, 2024, through November 7, 2024. A physician's order for Resident 96 to receive quetiapine fumarate oral tablet 25 mg (Seroquel-an antipsychotic medication) with directions to give 25 mg by mouth at bedtime for anxiety was initiated on November 7, 2024, and discontinued on November 21, 2024. A medication administration record (MAR) dated November 2024 revealed behavior tracking for anxiety initiated on July 11, 2024. The record indicated that Resident 96 displayed no maladaptive behaviors related to the resident's anxiety (i.e., agitation, crying, calling out, combativeness, screaming hallucinations) from November 1, 2024, through November 21, 2024. Further clinical record review revealed Resident 96's plan of care had no documented evidence that anxiety or individualized behavioral symptoms due to anxiety were identified as a problem. Resident 96's plan of care had no documented evidence that individualized nonpharmacological interventions were developed or implemented to assist the resident with anxiety-related behaviors. During an interview on November 21, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide documented evidence necessitating the 395265 Page 14 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0758 Level of Harm - Minimal harm or potential for actual harm use of an antipsychotic medication to treat Resident 96's anxiety. The DON and NHA were unable to provide documented evidence the facility attempted to develop and implement individualized non-pharmacological interventions to address resident 96's anxiety. 28 Pa. Code 211.2 (d)(3) Medical Director Residents Affected - Few 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (d)(5) Nursing services. 395265 Page 15 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility's infection control tracking logs and infection control and prevention policy and staff interviews it was determined the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases including scabies for two of 21 residents reviewed (Resident 7 and Resident 54) and failed to maintain an environment conducive to infection prevention. Residents Affected - Many Findings include: A review of the current facility policy for Infection prevention and control, last June 6, 2024, revealed, the infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health and safety. Outbreak management to include the following: a. Outbreak management is a process that consists of: 1. determining the presence of an outbreak 2. managing the affected residents 3. preventing the spread to other residents 4. documenting information about the outbreak 5. reporting the information about the outbreak 6. educating the staff and public 7. monitoring for recurrences 8. reviewing the care after the outbreak has subsided 395265 Page 16 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0880 9. recommending new or revised policies to handle similar events in the future. Level of Harm - Minimal harm or potential for actual harm b. Specific criteria will be used to help differentiate sporadic cases from true outbreaks or epidemics. Residents Affected - Many c. The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. A review of the facility's infection control data conducted during the survey ending November 21, 2024, revealed the facility's infection control tracking did not reflect evidence of a functional tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a system which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. A review of infection control data revealed the following infections were tracked as noted: August 2024: 5 urinary tract infections (UTI), 2 eye infections, 1 ear infection, 2 skin infections and 5 upper respiratory infections (URI). September 2024: 3 UTI, 1 ear infection, 8 upper respiratory infection and 1 skin infection. A separate tracking log for September 2024 revealed 16 residents tested positive for COVID-19. There was no tracking or trending for the noted COVID-19 positive residents. October 2024: 3 UTI, 3 upper respiratory infections, 8 skin infections and 1 unidentified infection. November 2024: 4 UTI, 2 upper respiratory infection, 3 skin infection and 2 GI (gastro-intestinal infection) and 1 unidentified infection and 2 residents notes as rash/scabies and 8 additional with rash. A review of November 2024 tracking and trending documentation did not include any further information or documentation of any treatments. The facility's infection control log revealed no documented evidence of detailed data collection that could be used by the facility to track these infections and to identify any potential trends contained in the tracking data. The data did not include resident room location, the infectious organism or treatment. There was no documented evidence at the time of the survey that based on the available tracking data the facility had identified any possible trends to implement specific interventions to prevent the spread of any of the infections. There was no documentation by the facility of the any of the infection start dates, resolution date, symptoms, complete culture information for any of the infections noted in the facility's monthly infection control tracking logs and the treatments required, if any. It could not be determined if any of the noted infections required isolation protocols to be implemented. There was no indication the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of the infections. During an interview conducted on November 20, 2024, at approximately 1:00 PM the Director of 395265 Page 17 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Nursing confirmed the infection control tracking was incomplete and failed to include the necessary details to conduct routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections (i.e., HAI healthcare associated infections and community-acquired), infection risks, communicable disease outbreaks, and to maintain or improve resident health status and to track staff for adherence to infection control policies and procedures and the potential need to for corrective action. A review of a facility policy entitled Scabies Identification, Treatment and Environmental Cleaning reviewed June 6, 2024, revealed, the purpose of the policy and procedure is to treat residents infected with scabies and to prevent the spread of scabies to other residents and staff. Scabies is an itchy skin rash caused by a tiny burrowing mite called Sarcoptes scabiei. Intense itching occurs in the area where the mite burrows. The need to scratch may be stronger at night. Scabies is contagious and can spread quickly through close person-to-person contact. The policy indicated Scabies is spread by skin to skin contact with the infected area through contact with bedding, clothing, privacy curtains and some furniture. Diagnosis may be established by recovering the mite from its burrow (under the skin) and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because on one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings, although scrapings are preferred. Affected residents should remain on Contact precautions (used in addition to routine infection control practice for residents known or suspected to be infected with microorganisms that can be transferred by direct or indirect contact to include, wearing gown, gloves, and a mask during care) until 24 hours after treatment. Family and friends of residents who have had close contact should be notified and given instructions regarding self-examination and treatment. Staff members who may have been exposed should report any rashes developing on their bodies to the Infection Preventionist or Director of Nursing Services. A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved. During a scabies outbreak among residents and/or personnel, the infection Preventionist or Committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. Control of an epidemic depends on treating all residents at risk. Specific drug selection for each resident will depend on that individual's risk factors, possible medication interactions etc. Treatment with Permethrin (Scabicide): Bathe the resident. Allow the body to cool. 395265 Page 18 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0880 Apply Permethrin cream into the skin from the chin to the soles of the feet. Level of Harm - Minimal harm or potential for actual harm Dress the resident in clean clothing. Use freshly laundered bed linens and towels. Residents Affected - Many Leave the cream on for at least 8 hours but no more than 12 hours, and then shower or bathe the resident in warm water. Put on clean clothing. Re-launder towels and bed linens used during treatment. Environmental Control: Typical Scabies Place residents with typical scabies on contact precautions during the treatment period. Place bed linens, towels and clothing used by an affected person during the 4 days prior to initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for at least 10-20 minutes. Use the hot cycle of the dryer for at least 10-20 minutes. Place non-washable blankets and articles in a plastic bag for at least 72 hours. Vacuum mattresses, upholstered furniture, and carpeting. Documentation: The date and time the care was provided. The name and title of the individual who assisted with the care. If the resident refused the treatment, the reasons why and the interventions taken. The signature and title of the person recording the data. Infection control documentation revealed that on October 29, 2024, 13 residents and 3 nursing staff members presented with itchy rashes. A review of infection control documentation dated October 28,2024 indicated Resident 54 was noted with a rash on his trunk. There was no further description of the area. The Physician was called and ordered Triamcinolone cream, a glucocorticoid, steroid used to treat certain skin diseases, allergies, and rheumatic disorders. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnosis to include heart disease and chronic kidney disease. A review of an annual (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 8, 2024, revealed, the resident to be cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. A score of 13-15 indicates intact cognition) and required staff assistance for activities of daily 395265 Page 19 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0880 living. Level of Harm - Minimal harm or potential for actual harm A review of a care plan dated October 29, 2024, revealed, the resident had a rash on body. Interventions to include, avoid scratching and keep hands and body parts from excessive moisture., give anti-pruritic medication as ordered by the Physician, monitor skin rashes for increased spread or signs of infection, seek medical attention if skin becomes bloody or infected. Residents Affected - Many Nursing documentation dated October 25, 2024, at 12:05 P.M., revealed, Resident 7 made nursing aware of itch to her upper back, lower abdomen, bilateral upper legs, and all over her abdomen. The rash was described as red raised areas. Nursing documentation dated Friday October 25, 2024, at 1:29 P.M. revealed, the Physician was notified of a rash on Resident 7 and indicated nursing to continue to monitor the resident until seen again on October 28, 2024. Nursing documentation dated October 28, 2024, at 12:28 P.M., revealed, the Physician was in to see the resident and ordered triamcinolone Acetonide External cream (Triamcinolone is a glucocorticoid used to treat certain skin diseases, allergies, and rheumatic disorders among others) 0.1%, apply to itchy body rash, topically every 12 hours, as needed for body rash for 2 weeks. The resident was placed on contact precautions and isolation precautions related to the rash. Nursing documentation dated October 29, 2024, November 2, 2024, November 3, 2024, revealed the itchy rash continued all over Resident 7's body. A physician's order dated November 4, 2024, at 10:40 A.M. revealed a new order for, Cetirizine (an antihistamine medication, used to treat allergies and allergic reactions) HCL oral tablet, 10 mg, 1 tablet by mouth one time a day for pruritus (itching) for 2 weeks. Nursing documentation dated November 4, 2024, at 1:07 P.M., indicated that contact precautions were discontinued by the infection control Preventionist. Further documentation at 6:46 P.M. that day indicated that Resident 7 complained of itchy skin. Nursing documentation dated November 7, 2024, at 1:49 P.M., revealed that Resident 7 still complained of itch despite treatment and new order for Cetirizine. Nursing documentation dated November 8, 2024, revealed, Resident 7 continues to complain of itchy rash. The resident placed back on contact precautions and a dermatology consult appointment was ordered. A review of a dermatology consult dated November 14, 2024 (no time indicated) revealed, the resident was seen for complaint of rash, located on the arms and trunk. The rash is itchy and mild in severity. The rash has been present for one month. The resident reports no household contacts (people in close contact with the resident) with similar rash, no new medications, no new personal care products, and no recent infections. She is not currently on any treatment. Patient was treated for scabies at the facility 2 weeks ago with Permethrin treatment. The diagnosis included, Scabietic nodules (lumps that appear after scabies treatment, may be 395265 Page 20 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0880 Level of Harm - Minimal harm or potential for actual harm secondary to persistent infection). Recommended treatment to include, Permethrin cream applied neck down to feet, leave on for 8 hours, shower off and repeat in one week. Facility expectations to include, household contacts should be treated. Contaminated clothing should be isolated for 72 hours and wash and dried on high heat. Contact the dermatology office if scabies fails to resolve after several weeks of treatment. Residents Affected - Many Nursing documentation dated November 14, 2024, at 9:05 P.M. revealed, Resident 7 had Permethrin cream applied. There was no documentation of the removal (bathing or shower) 8 hours after the application of the Permethrin cream application. There was also no documentation of environmental interventions, linen change, washing clothing etc. Nursing documentation dated November 16, 2024, at 4:06 A.M., revealed Resident 7's rash remains unchanged. An interview with Resident 7 on November 21, 2024, at approximately 12 P.M., revealed she still had a rash on her abdomen, back and arms and complained of an itch. An observation of the resident's skin at the time of the observation revealed a red rash on her abdomen, back and bilateral arms. The areas on her back were noted to have crusted with fresh scabbed areas. The resident stated that her skin is very itchy, and she scratches sometimes until the areas bleed. She stated the itching is very distressing to her. A review of a medication administration record for October 2024 and November 2024 revealed that Resident 7 received the steroid cream (Triamcinolone) twice daily as ordered. A review of weekly skin integrity forms (completed by nursing staff on resident shower days) dated October 28, 2024, October 31, 2024, November 4, 2024, November 18, 2024, indicated that Resident 7's skin was intact with a rash. A review of Infection control documentation, (a line listing of residents with body rashes) dated October 29, 2024, revealed 12 additional residents were noted with itchy body rashes. Nursing documentation dated October 29, 2024, at 2:53 P.M. revealed, the Medical Director was contacted and deemed it necessary to treat all the residents who were symptomatic and preventative treatment to all the residents in the facility due to the current rash outbreak. The facility census on October 29, 2024, was 104. Infection control documentation indicated, -October 29, 2024, 17 residents were treated with Permethrin cream -October 30, 2024, 31 residents were treated with Permethrin cream -October 31, 2024, 40 residents were treated with Permethrin cream -November 1, 2024, 11 residents were treated with Permethrin cream The infection control documentation indicated that 5 residents were newly admitted to the facility or hospitalized at that time. 395265 Page 21 of 22 395265 11/21/2024 Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201

F 0880 Level of Harm - Minimal harm or potential for actual harm Infection control documentation indicated that on October 29, 2024, after the initial 12 residents presented with the itchy rash, the Infection Preventionist informed the facility nursing staff of the resident rashes and offered staff Permethrin cream treatment. At that time, three nursing staff stated to the Infection Preventionist that they had itchy rashes and these staff along with an additional 5 nursing staff accepted the Permethrin cream treatment. Residents Affected - Many There was no evidence at the time that any staff were examined by a physician during or after treatment for scabies. Nursing documentation for all the above treated residents indicated the residents and or responsible party were notified of the rash outbreak in the facility, however there was no evidence that possible side effects and or a consent for treatment was obtained. An interview with the DON (director of nursing) on November 21, 2024, at 1:00 PM, confirmed the unresolved rashes have been discussed with the Medical Director and the decision was made to treat all residents at the facility. She stated that staff did not come forward with rashes until after residents had been treated. She could not confirm that residents or responsible party's or staff were presented with possible side effects or the opportunity to consent to treatment. She further confirmed there were no consistent nursing assessments regarding resident rashes as well as no documentation regarding staff rashes and treatments. An interview with the DON on November 21, 2024, at approximately 1:00 PM also verified the facility failed to implement proper infection control practices, including the facility's established policy and procedures, to prevent and mitigate further spread of scabies after Resident 7 began treatment for scabies and the other residents' rashes continued. An environmental tour of the facility central supply room (a storage area for resident care supplies, over the counter medication storage as well as clean resident care equipment) on November 20, 2024, at approximately 12 P.M., in the presence of the central supply clerk, revealed the floor to be dirty with visible dirt and paper and plastic debris. There were leaves on the floor near the exit door. There were cardboard boxes directly on the floor. There were 4 unbagged oxygen concentrators, 5 tube feeding poles with dried liquid on the bottom. There were 9 unbagged mattresses piled up in the middle of the floor. Holiday decorations in a box as well as on a metal shelving. There was a shopping cart with 2 cardboard boxes containing unbagged plastic suction canisters and an opened bag of resident briefs. There were multiple commode chairs as well as additional unclean tube feeding poles in this area. There were 3 unbagged suction machines on a shelving unit. There was an open cardboard box which contained multiple pieces of Styrofoam directly on the floor. An interview with the DON on November 21, 2024, at approximately 1:00 PM confirmed that infection control practices were not maintained in the facility central supply area. 28 Pa Code 211.10 (c)(d) Resident Care Policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 395265 Page 22 of 22