Health inspection·October 26, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff and resident interviews, it was determined that the facility failed to assess and treat wounds for one of 13 sampled residents. (Resident 94) Residents Affected - Few Findings include: Review of the facility policy entitled, Wound Prevention and Wound Care, last reviewed January 6, 2023, revealed that information regarding increased risk for skin breakdown should be obtained prior to resident admission and upon admission a skin assessment would be completed weekly for one month to assess changing risk for skin breakdown. The registered nurse would assess, document, and notify the physician of a new wound. Clinical record review revealed that Resident 94 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, end stage renal disease, and hypertension. Review of Resident 94's discharge documentation from the hospital revealed that he had wounds to his left elbow and sacrum. In an interview on October 24, 2023, at 11:30 a.m., Resident 94 stated that he was concerned with pain in his left elbow and wound treatments to his sacrum. He stated that no one has looked at his wounds or provided treatments to them since admission. Resident 94's left elbow was observed at that time and revealed a bandage dated October 19, 2023. Resident 94 further stated that the bandage was placed on his elbow at the hospital prior to admission. There was no documented evidence that the facility assessed Resident 94's wounds, notified the physician, or provided treatments until October 24, 2023, for his sacral wound and October 25, 2023, for his left elbow. In an interview on October 26, 2023, at 9:15 a.m. the Director of Nursing stated that staff were to assess a resident's skin on admission and that there was no documentation to support that Resident 94's wounds were assessed or treated prior to October 24 and 25, 2023. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395916 If continuation sheet Page 2 of 4 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 395916 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkland Village One Kirkland Village Circle Bethlehem, PA 18017 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 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 clinical record review, review of facility documentation, observation, and staff interview, it was determined that the facility failed to implement safety interventions for one of three sampled residents at risk for falls. (Resident 11) Findings include: Clinical record review revealed that Resident 11 was admitted to the facility on [DATE], and had diagnoses that included Parkinson's disease. On August 5, 2023, the resident fell out of bed and was found on the floor. On August 7, 2023, the risk team reviewed the incident and implemented fall mats to each side of the bed as an intervention to prevent injury. Review of the current care plan revealed that the resident was at risk for falls and an intervention for staff to apply fall mats to each side of her bed was implemented on August 7, 2023. On August 17, 2023, Resident 11 was found lying next to her bed on the floor. A nurse's note dated August 17, 2023, revealed that the facility had contacted hospice for fall mats. On September 7, 2023, Resident 11 was found lying on her back beside her bed on the floor. On September 22, 2023, Resident 11 was found on the floor next to her bed. Review of the facility's incident documentation for Resident 11's falls from August 17, 2023, through September 22, 2023, revealed no documented evidence that the fall mats to both sides of the resident's bed were in place at the time of the falls. Observations on October 24, 2023, from 11:00 a.m. through 2:00 p.m., and on October 25, 2023, from 9:15 a.m through 9:40 a.m., revealed Resident 11 in bed without fall mats to each side of her bed. In an interview on October, 26, 2024, at 11:00 a.m. Registered Nurse 1 stated that there was no documented evidence that fall mats were in place during the time of Resident 11's falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395916 If continuation sheet Page 3 of 4 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 395916 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkland Village One Kirkland Village Circle Bethlehem, PA 18017 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for two of 13 sampled residents. (Residents 7, 42) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included diabetes. A physician's order dated [DATE], directed staff to administer six units of a diabetes medication (insulin aspart) with each meal when blood glucose level (BGL) (the measurement of sugar found in one's blood) was greater than 100 milligrams per deciliter (mg/dL). A physician's order dated [DATE], directed staff to administer an additional number of insulin aspart units with each meal based on a scale of how much over 150 mg/dL the BGL was at that time. A review of Resident 7's medication administration record revealed that the staff documented the total amount of insulin aspart given to Resident 7 in two places in the administration record 51 of 143 times. In an interview on [DATE], at 1:20 p.m., the Director of Nursing confirmed that staff did not properly document the amount of insulin they gave in the clinical record. Clinical record review revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses that breast cancer and congestive heart failure. A nurse's note dated [DATE], indicated that the resident was resting in bed and had no pain. In an interview on [DATE], at 9:05 a.m., the Director of Nursing stated that the resident died in the facility on [DATE], on hospice. There was a lack of evidence to support that facility staff documented Resident 42's change in condition and notification to the physician and resident representative. In an interview on [DATE], at 9:06 a.m., the Director of Nursing stated that the facility had no documentation to support that staff documented the change in condition for Resident 11 or notification to the physician and resident representative. 28 Pa. Code 211.5(f) Medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395916 If continuation sheet Page 4 of 4