Health inspection·January 16, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policies, observation, and staff interviews, it was determined that the facility failed to implement effective procedures to maintain accurate records of controlled medications to ensure timely acquisition and administration of prescribed medications for one resident (Resident 108) and failed to timely obtain and administer prescribed medications for one resident (Resident 115) out of 24 residents sampled. Findings include: A review of the facility policy titled Administration of Medication, Schedule II -V Controlled Drugs last reviewed by the facility on October 23, 2025, revealed the facility will comply with all federal and state laws and regulations, and other requirements related to handling, storage, disposal, and record keeping of Schedule II-V controlled narcotics. (Schedule II-V medications are drugs regulated by federal law due to their medical use and potential for misuse, with Schedule II medications having the highest risk. Narcotics are medications commonly used to treat moderate to severe pain and require strict monitoring due to the risk of dependence).The Licensed Nurse administering the medication immediately enters all the following on the administration recorder, the date and time of administration, amount administered, signature of the nurse administering the dose, and balance of remaining medication to ensure accurate tracking and accountability. A clinical record review revealed that Resident 108 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a condition involving reduced blood flow to the limbs caused by narrowed or blocked blood vessels) and methicillin-resistant Staphylococcus aureus (MRSA) infection (a bacterial infection resistant to many common antibiotics). A review of physician orders revealed that on June 30, 2025, Resident 108 was prescribed Oxycodone HCL oral tablet 5 mg (a schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse and requires strict documentation and accountability), with instructions to administer one tablet every six hours as needed for moderate to severe pain.A review of facility records revealed the facility utilized an Individual Resident's Controlled Substance Record to track the receipt, use, and remaining balance of controlled medications. The facility also utilized a Medication Administration Record (MAR), which serves as the legal record documenting the administration of medications, including the medication given, date and time administered, and the staff member administering the medication. A comparison of Resident 108's Controlled Substance Record and the MAR from August 1, 2025, through January 2026, revealed discrepancies. The Controlled Substance Record reflected six entries indicating Oxycodone 5 mg was removed or utilized, while the MAR lacked corresponding documentation indicating the medication was administered. The discrepancies occurred on the following dates and times:October 22, 2025, at 11:30 AMDecember 16, 2025, at 8:00 PMDecember 18, 2025, at 8:00 AMDecember 22, 2025, at 8:00 PMDecember 23, 2025, at 8:00 PMJanuary 7, 2026, at 8:00 PMThe absence of corresponding MAR documentation indicated the facility failed to maintain accurate and reconciled records for a Schedule II controlled medication, as required by facility (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 3 Event ID: 395324 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 395324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allied Services Meade Street Skilled Nursing 200 S. Meade Street Wilkes Barre, PA 18702 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)