Health inspection·November 16, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of select facility policy, the minutes from Residents' Council meetings and grievances lodged with the facility and staff interviews it was determined that the facility failed to demonstrate their response to resident complaints/grievances raised at Resident Council meetings, including four of the four grievances raised at the October 2023 Resident Council meeting. Residents Affected - Few Findings include: A review of the facility policy titled Complaint/Grievances, last reviewed by the facility on January 1, 2023, revealed that the facility will make prompt efforts to resolve grievances and inform residents of progress towards resolution. The policy also indicates that the facility's Grievance Officer or designee shall act on the grievance and begin follow-up on the concern or submit it to the appropriate director for follow-up. Furthermore, the policy states that the grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. A review of Resident Council Meeting minutes dated October 10, 2023, indicated that residents in attendance voiced complaints regarding the length of time the second and third shifts take to administer medications; the towels from the laundry are rough and dirty; and the housekeeping staff are not cleaning every day. The Resident Council Meeting Minutes dated October 10, 2023, referred to the Resident Food Committee Meeting for concerns related to dietary services. A review of Food Committee Meeting Minutes dated, October 10, 2023 indicated that a resident raised concerns that vegetables are soggy, that salads lack flavor, and that too much pork is being served. A review of written grievances filed with the facility revealed no reference or record of the residents' complaints raised at the October 10, 2023 Resident Council Meeting. Further review of facility grievance records revealed no grievances filed after September 26, 2023. An observation at 12:50 PM of resident grievance information posted in common areas throughout the facility revealed outdated information regarding the facility's current Grievance Official. During an interview on November 16, 2023, at approximately 1:30 PM, the Nursing Home Administrator indicated that the facility Grievance Official's last day of employment with the facility was October 25, 2023. The Nursing Home administrator confirmed that the information posted regarding the facility's current grievance official was not accurate. The Nursing Home Administrator was unable to provide evidence that the facility had responded to the concerns raised at the October 10, 2023, Page 1 of 6 395636 395636 11/16/2023 Manor at St Luke Village,the 1711 East Broad Street Hazleton, PA 18201

F 0565 resident council and food committee meetings. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18 (e)(1) Management. 28 Pa. Code: 201.29 (a) Resident Rights. Residents Affected - Few 395636 Page 2 of 6 395636 11/16/2023 Manor at St Luke Village,the 1711 East Broad Street Hazleton, PA 18201

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 observation, review of clinical records and select facility policies, and staff interviews it was determined that the facility failed to ensure adequate staff supervision and effective safety measures were implemented to supervise wandering behavior resulting in an attempted/actual elopement and failed to evaluate the circumstances of an attempted elopement and the effectiveness of safety measures to prevent future elopement for one resident (Resident A1) with exit seeking behaviors out of three sampled residents. Findings include: Review of the facility Elopement/Wandering Risk Guideline Policy last reviewed by the facility January 2023, indicated staff are to evaluate and identify residents that are at risk for elopement and develop individualized interventions. Residents are to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. Initiate individualized interventions based on Resident's risk. Document individualized interventions in the resident Care Plan and [NAME]. If utilizing a wander monitoring system device check placement of the device every shift and functionality every day. Maintain the Elopement Risk Alerts in an easily accessible location. Review of the facility Missing Resident Policy last reviewed January 2023, indicated that staff will investigate cases of missing residents and possible elopement. An elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the resident at risk for harm or injury. Review and revise the interventions as indicated related to the elopement and wandering risk and update the care plan and [NAME]. A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], with diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and diabetes. Review of Resident A1's Elopement Risk Evaluations dated September 28 and October 4, 2023, indicated that the facility determined that the resident was not at risk for elopement. A nurses note dated October 21, 2023, at 5:59 PM indicated that a Wanderguard bracelet (a bracelet which triggers an alarm when within close range) was placed on the resident because the resident was verbalizing that she wants to go home to see her mom. Further review of the clinical record revealed no indication that the facility's Elopement/Wandering Risk Guidelines policy and procedures were fully implemented based on the placement of the Wanderguard bracelet and resident's expressed desire to go home to see her mom. An Elopement Risk Evaluation dated October 29, 2023 indicated that Resident A1 was not at risk for elopement despite the placement of the Wanderguard bracelet on October 21, 2023. A nurses note dated November 2, 2023 at 6:44 PM noted resident attempting elopement. States she has 395636 Page 3 of 6 395636 11/16/2023 Manor at St Luke Village,the 1711 East Broad Street Hazleton, PA 18201

F 0689 to go home. Found at East Wing back door. Level of Harm - Minimal harm or potential for actual harm Observation of the East Wing back door on November 16, 2023 at 12:00 PM in the presence of Employee 1 (RN) revealed that a Wanderguard alert system on the wall approximately six feet from the exit door to alert staff by an alarm if a resident with a Wanderguard approaches the area. The exit door is also alarmed and will sound if opened. Residents Affected - Few Interview with employee 1 (RN) at this time confirmed that she was working the evening of the incident and that both alarms sounded when Resident A1 attempted to exit the building. Further review of the clinical record revealed no further details related to the incident including if the resident was found inside or outside the exit door based on the exit door alarming which would indicate that Resident A1 had opened the door. There was no documented evidence of an investigation was completed as per facility policy. Review of Resident A1's October 21, 2023, through November 15, 2023 Treatment Administration Records revealed no documented evidence that the placement of the resident's Wanderguard was being checked every shift or that the function was being checked daily per facility policy. Review of Resident A1's care plan related to the resident being an elopement risk/wanderer initially dated October 23, 2023 revealed no indication that the care plan was reviewed/revised following the incident on November 2, 2023. Review of the facility's Elopement Risk Binder and photographs of residents at risk for elopement revealed that Resident A1's name and photograph was not added to the list until November 3, 2023 (13 days after Resident A1's Wanderguard bracelet was initially placed). The facility failed to provide consistent necessary supervision, at the frequency and level required, by a resident displaying exit seeking behavior to prevent a potential/actual elopement. Interview with the nursing home administrator on November 16, 2023, at approximately 1:30 PM, confirmed the potential/actual elopement on November 2, 2023 should have been investigated as per facility policy. The administrator failed to provide documented evidence that the facility's elopement policy was implemented, and safety measure were evaluated related to Resident A1's wandering and risk for elopement. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies 395636 Page 4 of 6 395636 11/16/2023 Manor at St Luke Village,the 1711 East Broad Street Hazleton, PA 18201

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on review of scheduled meal delivery times and resident and staff interviews it was revealed that the facility failed to ensure sufficient staffing to support the operations of the food and nutrition service department and timely meal service to residents. Findings include: During an interview on November 16, 2023, at 9:15 AM, Resident A2 stated that meal delivery times vary and are not consistent with the established schedule. Resident A2 stated that breakfast arrived on time today, but other times the meals are delivered over 30 minutes late. Resident A2 did not know why the meals were sometimes delivered late. During an interview on November 16, 2023, at 9:20 AM Resident A3 stated that meal delivery times have been from 45 minutes to an hour late recently. Resident A3 stated that the facility is understaffed and there are not enough workers to pass out the meals on time. Review of the facility's meal delivery schedule to residents revealed that established meal delivery times were in place for breakfast, lunch, and dinner. Interview with the food service director (FSD) on November 16, 2023, at 1:00 PM revealed that new dietary staff were recently hired and that the food and nutrition services department was still looking to hire additional staff. The FSD confirmed that meal delivery times are monitored and that meals have been greater than 30 minutes late at times, mostly at dinner, due to staffing issues in the food and nutrition services department. Review of recorded meal delivery times from October 30 through November 15, 2023 revealed that meals were at least 30 minutes late on the following dates: October 30, 2023 dinner for the bottom East nursing unit was 35 minutes late October 30, 2023 dinner for the bottom [NAME] nursing unit was 35 minutes late October 31, 2023 dinner for the top [NAME] nursing unit was 39 minutes late October 31, 2023 dinner for the middle East nursing unit was 56 minutes late October 31, 2023 dinner for the bottom East nursing unit was one hour late October 31, 2023 dinner for the bottom [NAME] nursing unit was 1 hour and 6 minutes late November 5, 2023 breakfast for the bottom East nursing unit was 30 minutes late November 5, 2023 breakfast for the bottom [NAME] nursing unit was 30 minutes late November 6, 2023 breakfast for the middle East nursing unit was 30 minutes late November 6, 2023 breakfast for the bottom [NAME] nursing unit was 30 minutes late 395636 Page 5 of 6 395636 11/16/2023 Manor at St Luke Village,the 1711 East Broad Street Hazleton, PA 18201

F 0802 November 8, 2023 dinner for the top [NAME] nursing unit was 37 minutes late Level of Harm - Minimal harm or potential for actual harm November 8, 2023 dinner for the middle East nursing unit was 50 minutes late November 8, 2023 dinner for the middle [NAME] nursing unit was 1 hour 10 minutes late Residents Affected - Some November 8, 2023 dinner for the bottom East nursing unit was 1 hour 25 minutes late November 11, 2023 dinner for the middle [NAME] nursing unit was 33 minutes late November 11, 2023 dinner for the bottom East nursing unit was 35 minutes late November 11, 2023 dinner for the bottom [NAME] nursing unit was 34 minutes late November 13, 2023 dinner for the bottom East nursing unit was 32 minutes late November 13, 2023 dinner for the bottom [NAME] nursing unit was 35 minutes late Interview with the nursing home administrator on November 16, 2023, at approximately 2:15 PM failed to provide documented evidence that sufficient staffing to support the operations of the food and nutrition service department were consistently available daily to ensure the timely arrival and delivery of meals to residents as scheduled. 28 Pa. Code 201.18(e)(1)(3)(6) Management 395636 Page 6 of 6