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 An observation at 12:50 PM of resident grievance information posted in common areas throughout the facility revealed outdated information regarding the facility's current Grievance Official.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, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 395636 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 11/16/2023 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)