Inspection·August 31, 2023

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on a review of clinical records and the facility's bed hold policy and staff and family interview it was determined the facility failed to provide written notice of the specifics of the facility's bed hold policy, to include the duration and reserve bed payment, to a resident's resident's representative upon the resident's transfer to the hospital for one resident out of six sampled (Resident CR1). Findings include: A review Resident CR1's clinical record revealed admission to the facility on July 20, 2023. The resident was severely cognitively impaired with a BIMS score of 4 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information) and a diagnosed intellectual disability. Resident CR1 was transferred to the hospital on August 24, 2023. Interview with the resident's representative on September 11, 2023, that upon the resident's admission to the facility he was provided a copy of the facility's bed hold policy, but he was not provided a second notice at the time of Resident CR1's transfer, or within 24 hours. He confirmed that he was not provided written information that explained the duration of bed-hold, if any, the reserve bed payment policy and addressing permitting the return of resident to the next available bed in the facility. There was no documented evidence that the facility provided the representative of the cognitively impaired resident with an intellectual disability, written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) at the time of transfer, or within 24 hours, detailing the duration of bed-hold, if any, and the reserve bed payment policy and addressing permitting the return of residents to the next available bed. Interview with the business office manager (BOM) on September 11, 2023, indicated that the facility provides the bed hold information to residents and/or their representatives upon admission. However, the BOM stated she was unaware that the facility was required to provide a second notice at the time of transfer . Interview with the Nursing Home Administrator on September 11, 2023, at approximately 3:35 PM confirmed the facility did not provide written notice of the facility's bed hold policy to the resident's representative upon Resident CR1's transfer to the hospital. The NHA stated that a copy of the facility's bed hold policy is sent with the resident upon transfer, but is not provided to the resident's representative if the resident is cognitively impaired. responsible party if the resident is not (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 2 Event ID: 395581 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 395581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allied Services Center City Skilled Nursing 80 E. Northampton Street Wilkes Barre, PA 18701 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)