Inspection·April 28, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and orderly resident environment in select resident rooms (resident rooms [ROOM NUMBER]). Findings include: An observation of the bathroom of resident room [ROOM NUMBER] on April 25, 2023, at 11:55 AM revealed that the floor of the bathroom dirty and debris present was on the floor. The red bin trash bag was removed from the red bin and leaning against the door frame with trash overflowing. Inside the red bin, which did not have a trash liner, was what appeared to be a plastic fast food cup with melted ice cream on the interior of the can. There was a bed pan half wrapped in plastic and directly on the bathroom floor under the sink. The toilet paper holder was not secured to the wall fully and was hanging from one side as the other side was not secured to the wall. An additional observation on April 27, 2023, at 11:15 AM of the bathroom in resident room [ROOM NUMBER] revealed that the bathroom floor remained dirty and debris remained on the floor. The bedpan, which was half wrapped in plastic remained on the floor under the sink and the toilet paper holder remained hanging from the wall. An observation of the bathroom in resident room [ROOM NUMBER] on April 27, 2023, at 12:25 PM revealed a 12 inch patch of missing dry wall on the area of the wall adjacent to the sink. There was debris on the floor behind the toilet. There was a plastic raised toilet seat lying directly on the floor next to the toilet. An observation in resident room [ROOM NUMBER] on April 28, 2023, at 9:30 a.m. revealed that the handle to the drawer of the bedside night stand was missing Interview with the administrator on April 28, 2023, at approximately 1:30 p.m., confirmed that the residents' rooms and bathrooms were maintained in a clean, functional and orderly manner. 28 Pa. Code 207.2 (a) Administrator's Responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 2 of 7 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 395636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at St Luke Village,the 1711 East Broad Street 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to assess and record changes in skin integrity to reflect the resident's current condition in accordance with standards of practice, for one resident out of 18 sampled residents (Resident 287). Residents Affected - Few Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: · Assessments · Clinical problems · Communications with other health care professionals regarding the patient · Communication with and education of the patient, family, and the patient ' s designated support person and other third parties. A review of the clinical record revealed that Resident 287 was admitted to the facility on [DATE], with diagnoses that included intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing and long-term use of anticoagulants. A review of Resident 287's paper baseline care plan dated April 16, 2023, at 11:00 AM, revealed a focus area of anticoagulant use and a goal in which the resident will have no complications related to anticoagulant use. Interventions include to monitor for sign/symptoms of internal/external bleeding and to protect from injury. Additionally, an electronic care plan dated April 17, 2023, revealed a focus area of anticoagulant therapy related to status post right hip hemi arthroplasty, DVT (deep vein thrombosis) popliteal vein LLE (left lower extremity) and Apixaban/Eliquis (anticoagulant medication). The goal was for the resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date of July 16, 2023. Interventions in place included: daily skin inspections, report abnormalities, monitor/document/report PRN (as needed) adverse reactions to anticoagulant therapy: bruising. Observation of Resident 287 on April 25, 2023, at 11:55 AM, revealed that the resident was in bed and was observed to have what appeared to be scratches on her right outer lower leg and bruising to her wrist, which extended under her sweatshirt. A review of the resident's clinical record on April 25, 2023, failed to reveal nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 3 of 7 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 395636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at St Luke Village,the 1711 East Broad Street 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation regarding the above observed skin injuries on the areas of the resident's skin, which were observed by the surveyor on April 25, 2023. In response to surveyor inquiry regarding the resident's skin injuries, at a 11:15 AM the Director of Nursing provided the surveyor a form entitled Skin evaluation prior to discharge/transfer/LOA with seven (7) locations on Resident 287's body, which had skin conditions noted. There were no measurements of these areas documented. The DON confirmed the form was completed on April 27, 2023, by the Assistant Director of Nursing following surveyor inquiry regarding Resident 287's scratches and bruises. Interview with the Director of Nursing on April 27, 2023 at 11:15 AM revealed that Resident 287 had been transferred to an acute care hospital on April 24, 2023, and returned to the facility on April 25, 2023. According to the DON nursing would not conduct a body audit or skin evaluation upon the resident's return unless the resident was admitted to the hospital and then returned to the facility. The DON confirmed that there was no documented evidence of a skin evaluation prior to the resident's transfer to the hospital. Observation of Resident 287's skin on April 27, 2023 at approximately 12:00 PM with the ADON revealed the following impaired skin areas and corresponding measurements: #1 = 4.5 cm x 3.5 cm noted as right calf scratches with purpura; #2 = small purple area was right upper arm was 4 distinct fading 1 cm x 1 cm bruise; #3 = purple area just below left AC (antecubital) area, and measured 5 cm x 5 cm; #4 = light purple area right wrist measuring 2 cm x 2 cm; #5 = purpura, area on right forearm with scattered areas, not measured; #6 - black heel which measured 3 cm x 2 cm and #7 a sacral slit, area not measured due to resident refusal. During an interview on April 28, 2023, at approximately 2:00 PM, with the Director of Nursing, confirmed there was no documented evidence of a nursing assessment or documentation of the record of resident's impaired areas of skin prior to surveyor inquiry during the survey. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(g)(h) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 4 of 7 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 395636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at St Luke Village,the 1711 East Broad Street 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 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 observation, review of clinical records and staff interview, it was determined that the facility repeatedly failed to implement interventions and services designed to preserve skin intergrity and prevent pressure sores for one resident out of 18 sampled residents (Resident 287). Residents Affected - Some Findings include: A review of the clinical record revealed that Resident 287 was admitted to the facility on [DATE], with diagnoses, which included intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, pressure ulcer sacral region and pressure ulcer right heel, unstageable. A review of Resident 287's baseline plan of care, initially dated April 16, 2023, revealed that Resident 287 was identified with the potential for altered skin integrity with a goal of prevent any skin breakdown or injury and heal/improve current skin issues. Interventions planned: follow facility skin protocol, turn every 2 hours and as needed, immediately report any skin redness to nurse, report any skin breakdown to the charge nurse, preventative skin care every shift, pressure reducing mattress, treatments as orders and right heel lifter in and out of bed. Observation of Resident 287 on April 25, 2023, at 11:55 AM revealed that the resident was in bed, lying in a supine position (lying horizontally with the face and torso facing up). Both of the resident's heels were directly on the mattress. The heel lifter was observed on a chair located at the foot of the resident's bed. Observation on Resident 287 on April 26, 2023, at 9:30 AM revealed that the resident was in bed, lying in a supine position. Both of the resident's heels were directly on the mattress. The heel lifter was observed on a chair located at the foot of the resident's bed. Observation of Resident 287 on April 27, 2023, at 9:15 AM revealed that the resident was in bed, lying in a supine position. Both of the resident's heels were directly on the mattress. The heel lifter was observed on a chair located at the foot of the resident's bed. Interview with the Assistant ADON on April 28, 2022, at 9:15 a.m. confirmed that the heel lifter should have been in place during the above observations. A review of Resident 287's clinical record revealed a physician order dated April 16, 2023, at 1729 (5:29 PM) to turn and reposition the resident every 2 hours while in bed. Further review of Resident 287's clinical record failed to reveal documented evidence that the facility was turning and repositioning the resident as ordered. Interview with the Director of Nursing on April 28, 2023, at approximately 1:30 PM confirmed the facility failed to implement and document interventions developed to prevent skin breakdown. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 5 of 7 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 395636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at St Luke Village,the 1711 East Broad Street 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility incident reports and investigative reports, and staff interview, it was determined that the facility failed to provide necessary staff assistance and effective safety measures with activities of daily living to prevent falls for one resident out of three sampled (Resident 22). Findings include: A review of the clinical record of Resident 22 revealed admission to the facility on July 29, 2019, with diagnoses that included polyneuropathy (damage or disease affecting peripheral (hands/feet) nerves which may cause weakness, numbness and burning pain), respiratory failure, atrial fibrillation (irregular heart rhythm). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 28, 2023, revealed the resident had a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 15 indicates intact cognitive response). The resident required extensive assistance of two persons for bed mobility and total dependence with assistance of two persons for transfers. The resident's plan of care for ADL self-care performance deficits, dated as revised February 10, 2023, revealed that the resident required extensive assistance of two for bed mobility. A review of the resident's [NAME] (a nursing information system used to obtain specific care information for each resident) dated as of April 27, 2023, (during the survey) revealed the resident required extensive assistance of two for bed mobility. A review of a facility incident report dated April 9, 2023, at 12:48 AM, revealed that Resident 22 rolled out of bed during care. A witness statement by Employee 2 (nurse aide) noted that During patient care, she turned toward her right side of the bed in a sitting position, as she turned, she continued to roll off the side of the bed. I tried to catch her, unfortunately it was too late. I immediately call for the nurse and supervisor on duty. Interventions in place at the time of the fall were The resident requires Ext (Assist) of two for bed mobility as per Resident 22's care plan. Further review of the facility incident investigation dated April 11, 2023, revealed that Resident 22 was too close to the edge of the bed when she rolled over resulting in a fall. The facility's Fall Investigation included the planned interventions that the facility educated Resident not to turn too far and position self in center of bed before rolling. Resident offered scoop mattress. However, the resident was dependent on the assistance of two staff for bed mobility. During an interview on April 27, 2023, at 11:19 AM, the Director of Nursing (DON) confirmed that Resident 22's MDS, Care Plan and [NAME] indicate that Resident 22 requires extensive assistance of two persons for bed mobility. The DON also confirmed that only Employee 2 (nurse aide) witnessed the resident's fall from bed. The facility investigation indicated that only one nurse aide was in the resident's room at the time of the resident's fall. The DON confirmed that a second staff member should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 6 of 7 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 395636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at St Luke Village,the 1711 East Broad Street 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have been present during the resident's care because the resident required the assistance of two staff assist for bed mobility. The DON confirmed that the facility did not obtain a statement from the resident to obtain the resident's account of the fall as part of their investigation process, although the resident is cognitively intact. The DON confirmed staff reeducation was not provided on proper positioning of a resident prior to providing care in bed for dependent residents. The DON verified that Employee 2 was not reeducated and failed to address the employee's failure to provide the necessary level of supervision and assistance to prevent the resident's fall from bed. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services 28 Pa. Code 211.11 (d)(e) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 7 of 7