Health inspection·January 28, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many provide evidence of a functional method for monitoring and investigating infections. The logs did not document trends, clusters, changes in prevalent organisms, or increases in infection rates in a timely manner. There was no documentation indicating that residents with upper respiratory symptoms were tested for viral illnesses such as COVID-19, Influenza, or RSV. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include metabolic encephalopathy (a change in how the brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and diabetes. A significant change minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 10, 2025, revealed that Resident 1 had a BIMS score (a test used to get a quick snapshot of how well you are functioning cognitively at the moment, a score of 13 to 15, cognitively intact) of 15. The resident was noted to be cognitively intact. A review of nursing documentation dated December 27, 2024, at 2 A.M. revealed Resident 1 exhibited symptoms of an upper respiratory infection, coughing. The resident was administered cough medication and evaluated via telemedicine but was not tested for any respiratory virus. On December 28, 2024 at 8:15 A.M., the resident was experiencing shortness of breath and the resident's oxygen saturation level dropped to 84% (normal 95% to 100%) on 4 liters of oxygen. , Documentation revealed the residents needs could not be met at the facility and the resident was transferred to the hospital, and tested positive for RSV (Respiratory Syncytial Virus, a common respiratory virus that infects the nose, throat, and lungs. RSV symptoms make it difficult to distinguish it from the common cold or other respiratory viruses like the flu or COVID-19). There was no documented evidence the facility assessed, tested, or implemented isolation precautions for the resident prior to hospitalization. Interviews conducted on January 28, 2025, with Employee 1 (LPN), Employee 2 (LPN), and Employee 3 (RN Supervisor) confirmed that while COVID-19 testing supplies were available, testing was not routinely conducted for residents exhibiting symptoms unless indicated by the facility's COVID-19 assessment form. Employees confirmed that the facility no longer implemented isolation precautions for COVID-19, and testing for other respiratory illnesses such as RSV or Influenza was not part of the routine protocol. A review of infection control data revealed the following infections were tracked as noted: December 2024: 5 urinary tract infections (UTI), 1 eye infections, 1 ear infection, 2 skin infections and 8 upper respiratory infections (URI). January 2025: 6 UTI, 2 ear infection, 19 upper respiratory infection and 3 skin infection, 4 eye infections. The facility tracking logs were noted to be comprehensive, noting all the infections on each monthly log. The logs did not indicate if the residents with noted upper respiratory symptoms were tested for COVID-19, Influenza or RSV (viral illnesses). Further review of the facility's infection control logs revealed the data collected was incomplete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 2 of 3 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 01/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and did not include resident room locations, infectious organisms, or treatments provided. There was no documented analysis of infection trends, interventions, or follow-up measures to prevent the spread of infections. Additionally, there was no documentation of infection resolution dates, complete culture information, or whether isolation precautions were implemented when necessary. During an interview on January 28, 2025, at approximately 1:00 PM, the Infection Preventionist confirmed that the facility's tracking system was incomplete and did not support routine, ongoing surveillance to identify healthcare-associated infections, communicable disease outbreaks, or infection risks. She further stated that she had been using corporate forms that did not allow for the inclusion of detailed infection data. The facility failed to develop and implement a comprehensive infection control program, including effective tracking, monitoring, and response measures. This failure had the potential to place residents at increased risk for infection transmission and prevent the implementation of appropriate infection prevention practices. 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395636 If continuation sheet Page 3 of 3