Inspection·May 31, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some by the facility. He explained that she never had bed sores in the past, but she had been lying in bed for hours at the facility. During an interview on May 28, 2024, at 12:30 PM, Resident 298 stated that she had been in the facility for only a few days. She explained that sometimes she is in pain and needs the staff's assistance. Resident 298 stated that she has stopped ringing the call bell because it takes at least 20 minutes for staff to respond to her request for assistance. During a resident group interview with alert and oriented residents, on May 29, 2024, at 10:00 AM, all residents in attendance indicated that the facility doesn't have enough staff to take care of the residents and meet their needs timely. The residents explained that when the facility is short on staff, residents experience long waits for care and assistance. The residents stated that this has been discussed at resident group meetings with no resolution to date. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 23 stated that there is often only one nurse aide working on her hall. She explained that she had recently waited over an hour for staff to provide her care after she rings her call bell. She explained that she is frustrated and angry that no one in the facility addresses this issue. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 30 stated that she has recently waited one hour for staff assistance and has waited as long as two hours within the last two weeks. She explained that sometimes there is only one staff member assigned to her hall, causing long waits for care. Resident 30 explained that she and her husband are both dependent on staff for their care. She indicated that she attempts to help her husband because she does not like to see him waiting for assistance, even though she knows it is not safe for her to do so. During the resident group interview on May 29, 2024, at 10:00 AM, Resident 64 stated that he has soiled himself because the staff response is longer than his body is able to wait. During an interview on May 31, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and DON verified that all residents at the facility should be treated with dignity and respect, including timely staff responses to residents' requests for assistance. Refer F686 and F725 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 2 of 10 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 05/31/2024 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 a review of clinical records, select facility policy, and facility investigation reports, observation, and resident, staff, and resident family member interviews, it was determined that the facility failed to ensure that residents receive care consistent with professional standards of practice to prevent pressure sore development for one of 23 residents sampled (Resident 88). Residents Affected - Few Findings include: A review of facility policy titled Skin and Wound, last reviewed by the facility on March 25, 2024, revealed it is the facility's policy to provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries. A clinical record review revealed Resident 88 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and acute kidney failure (kidneys are suddenly not able to filter waste products from the blood). A baseline care plan dated February 19, 2024, indicated that Resident 88 has the potential for altered skin integrity, with a goal to prevent a skin breakdown or injury. The plan included an intervention to turn the resident every two hours and as needed, provide incontinence care as needed, apply preventative skin care each shift and as needed, apply barrier incontinence cream each shift and as needed, and report any skin breakdown to the charge nurse. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 21, 2024, revealed that Resident 88 was 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). Resident 88 was dependent on staff to roll from lying on the back to the left and right sides, to move from a sitting position to lying on the bed, to stand from a sitting position, to transfer to and from a bed to a chair, and to get in and out of a tub or shower. A Braden Scale for Predicting Pressure Sore {Ulcer} Risk dated February 26, 2024, indicated that Resident 88 was assessed and found to be at risk of developing pressure injuries. Braden Scale for Predicting Pressure Sore {Ulcer} Risk dated March 11, 2024, indicated that Resident 88 was assessed and found to be not at risk of developing pressure injuries. The assessment indicated that Resident 88 was rarely moist (skin is usually dry) and walked occasionally (walks during the day, but for very short distances). However, a review of the survey documentation reports dated February 2024 and March 2024 revealed that from February 19, 2024, through March 11, 2024, Resident 88 walked on only four out of 66 shifts and was found to be incontinent of urine 26 times from February 19, 2024, through March 11, 2024. A documentation survey report for March 2024 indicated that staff did not turn and reposition Resident 88 every two hours as indicated in her baseline care plan. The report indicated that turning and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 3 of 10 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 05/31/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few repositioning began on March 18, 2024, the date the resident was first assessed to have a pressure injury. The medical record failed to indicate if staff turned or repositioned the resident every two hours prior to the resident developing a pressure injury on March 18, 2024. A pressure ulcer wound round document dated March 18, 2024, revealed that the resident was assessed to have an unstageable pressure ulcer wound on her coccyx measuring 3.0 cm x 2.0 cm x 0.2 cm. The assessment indicated that an unstageable pressure injury is full-thickness tissue loss in which the base of the ulcer is covered by slough (dead skin tissue that is yellow, tan gray, green, or brown) and/or eschar (dead tissue that is tan, brown, or black) in the wound bed. The assessment further noted that the wound was not present on admission. The wound bed was observed to have a yellow slough. The wound edges were rolled. The assessment indicated that the wound had a small amount of serous drainage. Furthermore, the assessment indicated that the wound began as two scratch-like areas that combined and opened the coccyx area. A review of pressure ulcer wound round documentation revealed the following progress of the resident's coccyx wound: On March 18, 2024, the wound measured 3.0 cm x 2.0 cm x 0.2 cm. On March 20, 2024, the wound measured 2.2 cm x 1.5 cm x 2.0 cm. On March 27, 2024, the wound measured 2.3 cm x 1.5 cm x 2.0 cm. On April 3, 2024, the wound measured 2.5 cm x 2.0 cm x 2.0 cm. On April 10, 2024, the wound measured 2.5 cm x 2.0 cm x 2.0 cm. On April 17, 2024, the wound measured 2.5 cm x 2.0 cm x 2.0 cm. On April 24, 2024, the wound measured 3.5 cm x 2.5 cm x 3.8 cm. On May 1, 2024, the wound measured 2.8 cm x 3.0 cm x 3.3 cm. On May 8, 2024, the wound measured 2.1 cm x 1.4 cm x 0.8 cm. On May 15, 2024, the wound measured 2.5 cm x 1.5 cm x 0.7 cm On May 22, 2024, the wound measured 1.7 cm x 1.0 cm x 0.3 cm. On May 29, 2024, the wound measured 1.5 cm x 1.0 cm x 0.3 cm. A physician's order for Resident 88 to be admitted to Hospice Services related to a diagnosis of heart failure dated March 25, 2024. During an interview on May 28, 2024, at 12:10 PM, Resident 88 was not able to recall staff turning or repositioning her during her first month of admission. Resident 88 stated that she sometimes waits 30 minutes for staff to respond when she rings her call bell for assistance. The resident explained that the wait time is longer on the weekends. Resident 88 stated that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 4 of 10 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 05/31/2024 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 ends up soiling herself when staff are not able to respond. Level of Harm - Minimal harm or potential for actual harm During an interview on May 28, 2024, at 12:15 PM, Resident 88's family member explained that Resident 88 was not being turned or repositioned by staff regularly from the time of admission until the development of her pressure injury. He explained that he was upset that there were not enough facility staff to properly care for his family member. The family member stated that before hospice services began providing care to Resident 88 on March 25, 2024, the facility would often leave her in bed until 11:00 AM or later. The family member explained that now, hospice services are coming daily, Monday through Friday, and the hospice staff get her out of bed each morning. Residents Affected - Few A clinical record review revealed no documentation indicating what time of day Resident 88 was assisted out of bed each morning from her admission on [DATE], until the assessment of an unstageable pressure ulcer wound on her coccyx on March 18, 2024. During an observation on May 30, 2024, at 1:50 PM, the wound was measured at 1.5 cm x 1.0 cm x 0.8 cm. The wound was observed with edges intact, no odor, and no drainage noted. The wound dressing was clean, with no color noted. The resident indicated that she was not experiencing pain related to her injury. During an interview on May 31, 2024, at approximately 11:15 PM, the Director of Nursing and Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that residents receive care consistent with professional standards of practice to prevent pressure injuries and ensure pressure injuries do not develop. The DON or NHA were unable to provide evidence that Resident 88 was turned or repositioned as indicated in her baseline plan of care to prevent the development of pressure injuries. Refer F550 and F725 28 Pa. Code 211.5 (f)(ii)(iii)(iv) Medical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 5 of 10 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 05/31/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of nurse staffing, clinical records, grievances lodged with the facility and the minutes from Residents Council meetings and staff, resident and family interviews, it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality of care to residents, and in accordance with each resident's plan of care, to meet individualized needs and promote the resident's health and well-being. Findings included: A review of grievances filed with the facility revealed a grievance dated March 9, 2024, indicating that Resident 199 was not offered a shower because facility staff told her that they were too short {of staff} to give her a shower. Resident Council Meeting minutes dated April 9, 2024, revealed that the Director of Nursing (DON) explained to residents in attendance that they are trying to find workers to hire. Residents in attendance indicated that they had concerns about needing more help in the facility to provide their care. Resident Council Meeting minutes dated May 7, 2024, revealed that the DON explained to residents that there will be a nurse aide class beginning next month and that three new nurse aides were hired to increase facility staffing. During an interview on May 28, 2024, at 12:10 PM, Resident 88 stated that she sometimes waits 30 minutes for staff to respond when she rings her call bell for staff assistance. The resident explained that the wait time is longer on the weekends. Resident 88 stated that she ends up soiling herself when staff are not able to respond promptly. Resident 88 further explained that the facility staff are nice and work hard, but when there is only one person assigned to her hall, then that person can't help everyone. During an interview on May 28, 2024, at 12:15 PM, Resident 88's family member explained that he is upset that there is not enough staff working in the facility to properly care for his family member. The family member stated that until hospice services began for Resident 88 on March 25, 2024, the facility staff would often leave her in bed until 11:00 AM or later. He explained that she was in bed until 2:00 PM on a few occasions. The family member explained that now that staff from the hospice agency are coming daily Monday through Friday, the hospice staff get her out of bed each morning. He stated that the lack of care is likely because of the low nurse staffing in the facility. The family member stated that he believes his mother developed a pressure injury because of the lack of care by the facility. He explained that she never had bed sores in the past, but she had been lying in bed for hours at the facility. During an interview on May 28, 2024, at 12:30 PM, Resident 298 stated that she had been in the facility for only a few days. She explained that sometimes she is in pain and needs the staff's assistance. Resident 298 stated that she has stopped ringing the call bell because it takes at least 20 minutes for staff to respond to her request for assistance. During a resident group interview with alert and oriented residents, on May 29, 2024, at 10:00 AM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 6 of 10 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 05/31/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many all residents in attendance indicated that the facility doesn't have enough staff to take care of the residents and meet their needs timely. The residents explained that when the facility is short on staff, residents experience long waits for care and assistance. The residents stated that this has been discussed at resident group meetings with no resolution to date. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 23 stated that there is often only one nurse aide working on her hall. She explained that she had recently waited over an hour for staff to provide her care after she rings her call bell. She explained that she is frustrated and angry that no one in the facility addresses this issue. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 30 stated that she has recently waited one hour for staff assistance and has waited as long as two hours within the last two weeks. She explained that sometimes there is only one staff member assigned to her hall, causing long waits for care. Resident 30 explained that she and her husband are both dependent on staff for their care. She indicated that she attempts to help her husband because she does not like to see him waiting for assistance, even though she knows it is not safe for her to do so. During the resident group interview on May 29, 2024, at 10:00 AM, Resident 64 stated that he has soiled himself because the staff response is longer than his body is able to wait. During an interview on May 31, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and DON verified that all residents at the facility should be treated with dignity and respect, including timely staff responses to residents' requests for assistance. A clinical record review revealed Resident 88 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and acute kidney failure (kidneys are suddenly not able to filter waste products from the blood). A baseline care plan dated February 19, 2024, indicated that Resident 88 has the potential for altered skin integrity, with a goal to prevent a skin breakdown or injury. The plan included an intervention to turn the resident every two hours and as needed, provide incontinence care as needed, apply preventative skin care each shift and as needed, apply barrier incontinence cream each shift and as needed, and report any skin breakdown to the charge nurse. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 21, 2024, revealed that Resident 88 was 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). Resident 88 was dependent on staff to roll from lying on the back to the left and right sides, to move from a sitting position to lying on the bed, to stand from a sitting position, to transfer to and from a bed to a chair, and to get in and out of a tub or shower. A Braden Scale for Predicting Pressure Sore {Ulcer} Risk dated February 26, 2024, indicated that Resident 88 was assessed and found to be at risk of developing pressure injuries. Braden Scale for Predicting Pressure Sore {Ulcer} Risk dated March 11, 2024, indicated that Resident 88 was assessed and found to be not at risk of developing pressure injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 7 of 10 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 05/31/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The assessment indicated that Resident 88 was rarely moist (skin is usually dry) and walked occasionally (walks during the day, but for very short distances). However, a review of the survey documentation reports dated February 2024 and March 2024 revealed that from February 19, 2024, through March 11, 2024, Resident 88 walked on only four out of 66 shifts and was found to be incontinent of urine 26 times from February 19, 2024, through March 11, 2024. A documentation survey report for March 2024 indicated that staff did not turn and reposition Resident 88 every two hours as indicated in her baseline care plan. The report indicated that turning and repositioning began on March 18, 2024, the date the resident was first assessed to have a pressure injury. The medical record failed to indicate if staff turned or repositioned the resident every two hours prior to the resident developing a pressure injury on March 18, 2024. A pressure ulcer wound round document dated March 18, 2024, revealed that the resident was assessed to have an unstageable pressure ulcer wound on her coccyx measuring 3.0 cm x 2.0 cm x 0.2 cm. The assessment indicated that an unstageable pressure injury is full-thickness tissue loss in which the base of the ulcer is covered by slough (dead skin tissue that is yellow, tan gray, green, or brown) and/or eschar (dead tissue that is tan, brown, or black) in the wound bed. The assessment further noted that the wound was not present on admission. The wound bed was observed to have a yellow slough. The wound edges were rolled. The assessment indicated that the wound had a small amount of serous drainage. Furthermore, the assessment indicated that the wound began as two scratch-like areas that combined and opened the coccyx area. A physician's order for Resident 88 to be admitted to Hospice Services related to a diagnosis of heart failure dated March 25, 2024. During an interview on May 28, 2024, at 12:10 PM, Resident 88 was not able to recall staff turning or repositioning her during her first month of admission. Resident 88 stated that she sometimes waits 30 minutes for staff to respond when she rings her call bell for assistance. The resident explained that the wait time is longer on the weekends. Resident 88 stated that she ends up soiling herself when staff are not able to respond. During an interview on May 28, 2024, at 12:15 PM, Resident 88's family member explained that Resident 88 was not being turned or repositioned by staff regularly from the time of admission until the development of her pressure injury. He explained that he was upset that there were not enough facility staff to properly care for his family member. The family member stated that before hospice services began providing care to Resident 88 on March 25, 2024, the facility would often leave her in bed until 11:00 AM or later. The family member explained that now, hospice services are coming daily, Monday through Friday, and the hospice staff get her out of bed each morning. A clinical record review revealed no documentation indicating what time of day Resident 88 was assisted out of bed each morning from her admission on [DATE], until the assessment of an unstageable pressure ulcer wound on her coccyx on March 18, 2024. During an observation on May 30, 2024, at 1:50 PM, the wound was measured at 1.5 cm x 1.0 cm x 0.8 cm. The wound was observed with edges intact, no odor, and no drainage noted. The wound dressing was clean, with no color noted. The resident indicated that she was not experiencing pain related to her injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 8 of 10 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 05/31/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm During an interview on May 31, 2024, at approximately 11:15 PM, the Director of Nursing and Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that residents receive care consistent with professional standards of practice to prevent pressure injuries and ensure pressure injuries do not develop. The DON or NHA were unable to provide evidence that Resident 88 was turned or repositioned as indicated in her baseline plan of care to prevent the development of pressure injuries. Residents Affected - Many A review of the clinical record of Resident 75 revealed admission to the facility on June 30, 2022, with diagnoses to include reduced mobility, muscle wasting, muscle weakness, and unsteadiness on feet. A physician's order dated was March 22, 2024, for the resident to receive RNP ambulation. During interview with the alert and oriented Resident 75, on May 28, 2024, at approximately 12:45 PM, the resident stated staff are not walking her. Resident 75 further stated she kept track and in the past 29 days she was walked once. The resident further stated she had told staff that she is not being ambulated as ordered and nothing was done about it. A review of Resident 75's Physical Therapy Discharge summary dated [DATE], indicated that the resident was receiving services from March 12, 2024, to April 24, 2024, and that the discharge recommendations were to receive Restorative Nursing Program (RNP, with no indication of the specifics of the restorative nursing program. A review of a facility provided document entitled Rehab Services Restorative Nursing/Functional Maintenance Referral form dated April 24, 2024, indicated that the resident was to receive ambulation, to preserve functional mobility skills. Instructions indicated RNP with a restorative nursing assistant (RNA) for ambulation with a wheeled walker for up to 300 feet contact guard (CG) assist with close wheelchair (WC) follow. A physician orders dated May 23, 2024, was noted for physical therapy (PT) 5X/week for 30 days for gait training, therapeutic exercises, therapeutic activities, neuromuscular re-education. During an interview on May 29, 2024, at approximately 11:45 AM, with the Director of Therapy Services, confirmed Resident 75 should have received RNP, with a restorative nursing assistant for ambulation, from April 24, 2024, through May 23, 2024. A review of the Documentation Survey Report v2 for April 2024, and May 2024, revealed that Resident 75's RNP for ambulation was not implemented, as recommended by in the PT discharge summary, Rehab Services Restorative Nursing/Functional Maintenance Referral, and as prescribed by the physician. Interview with the Director of Nursing (DON) on May 29, 2024, at 12:45 PM failed to provide documented evidence that Resident 75 was provided with the physician prescribed RNP program. A review of the facility's staffing levels revealed that on the following dates the facility failed to provide state minimum nurse staffing of 2.87 hours of general nursing care to each resident: March 21, 2024 - 2.46 direct care nursing hours per resident March 22, 2024 - 2.39 direct care nursing hours per resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 9 of 10 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 05/31/2024 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 0725 March 23, 2024 - 2.30 direct care nursing hours per resident Level of Harm - Minimal harm or potential for actual harm March 24, 2024 - 2.33 direct care nursing hours per resident March 25, 2024 - 2.39 direct care nursing hours per resident Residents Affected - Many March 26, 2024 - 2.51 direct care nursing hours per resident March 27, 2024 - 2.82 direct care nursing hours per resident March 31, 2024 - 2.24 direct care nursing hours per resident April 1, 2024 - 2.72 direct care nursing hours per resident April 2, 2024 - 2.64 direct care nursing hours per resident April 3, 2024 - 2.79 direct care nursing hours per resident April 4, 2024 - 2.84 direct care nursing hours per resident April 5, 2024 - 2.81 direct care nursing hours per resident April 6, 2024 - 2.55 direct care nursing hours per resident May 24, 2024 - 2.45 direct care nursing hours per resident May 25, 2024 - 2.35 direct care nursing hours per resident May 26, 2024 - 2.27 direct care nursing hours per resident May 27, 2024 - 2.65 direct care nursing hours per resident May 28, 2024 - 2.48 direct care nursing hours per resident May 29, 2024 - 2.67 direct care nursing hours per resident May 30, 2024 - 2.25 direct care nursing hours per resident An interview with the Director of Nursing (DON) on May 31, 2024, at 12: 30 p.m., confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily. Refer F550, F686, F688 28 Pa. Code 211.12 (c)(d)(4)(5)(f.1)(2)(4) Nursing services 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 10 of 10