Health inspection·March 28, 2025

F 0610 Respond appropriately to all alleged violations. 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 facility policy, resident grievance documentation, clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure a thorough and complete investigation of an allegation of sexual abuse for 1 of 19 sampled residents (Resident 63). Residents Affected - Few Findings included: A review of a facility policy entitled Abuse, Neglect, Exploitation & Misappropriation revealed it is the policy of the facility to provide professional care and services in an environment that is free from abuse, neglect, mistreatment, exploitation, and/or misappropriation of property. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. Sexual abuse is defined as the nonconsensual sexual contact of any type with a resident which includes but is not limited to unwanted touching of any kind especially of breast or perineal area. Further review of the facility abuse policy revealed under the area of investigation that the Abuse Coordinator or designee will investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. Upon the allegation of abuse or neglect, the suspect will be immediately segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee will perform and document a thorough nursing evaluation and notify the attending physician. An incident report will be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. The Abuse Coordinator and/or Director of Nursing will take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she will also secure all physical evidence. Upon completion of the investigation, a detailed report will be prepared. Under the area of reporting, the facility should report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency within 5 working days of the incident. A review of Resident 63's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition where the heart does not pump blood as efficiently as it should) and chronic kidney disease (a condition where the kidneys cannot filter blood properly leading to waste buildup). A review of the facility grievance dated February 14, 2025, revealed that Resident 63 no longer wanted Employee 1 to care for her because of the way Employee 1 performed peri-care ((perineal care hygiene of the private areas) made Resident 63 uncomfortable. (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 8 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 03/28/2025 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)