Health inspection·March 7, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a resident group interview with residents on March 6, 2024, at 10:00 AM, three of the five residents in attendance (Residents 1, 7, and 23) stated that they have experienced long wait times for staff to respond to their call bells and requests for assistance. During the resident group interview on March 6, 2024, Resident 1 stated that she frequently experienced long waits for staff to respond to her requests for assistance via the nurse call bell system. She explained that it is a problem when she needs to go to the bathroom because she is unable to remain continent when she feels the urge to go. Resident 1 stated that she has waited 35 to 40 minutes for staff to respond to requests for assistance. Resident 1 also stated that after staff assist her to the toilet, it may take another 35-40 minutes for them to come back to assist her from the toilet. She explained that staff response is the worst during the day shift of nursing duty. During the resident group interview on March 6, 2024, Resident 7 stated that she waits 25 to 30 minutes for staff assistance after ringing her call bell. Resident 7 explained that she experiences the longest wait times on the night shift. During the resident group interview on March 6, 2024, Resident 23 stated that she experiences long waits for staff to respond to her call bell and provide needed assistance. She explained that she sometimes waits for 20 minutes before staff respond to her call bell and the longest wait times occur on the night shift. During an interview on March 7, 2024, at 12:00 PM, the Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect, including timely response to their requests for assistance The DON was unable to explain why multiple residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(4)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 2 of 13 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 03/07/2024 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean environment on one of two nursing units (Nursing Unit 2). Findings include: An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:26 AM revealed a 2-inch brown/tan stain on the wall in the resident's bathroom, near the call bell and several brown/tan substance droplets on the wall to the left of the call bell. Brown/red stains were observed on the floor to the left of the toilet. A buildup of dirt and debris was observed along the edge of the bathroom floor. An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:35 AM revealed tan discolored rings on two ceiling blocks with and a black and gray substance on one ceiling block An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:40 AM revealed tan discolored stains on nine ceiling blocks. An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:55 AM revealed tan discolored stains on three ceiling blocks and two ceiling blocks stained with a black and gray substance. An observation in resident room [ROOM NUMBER] on March 5, 2024, at 11:00 AM revealed brown stains on the window blinds. An observation in the Unit 2 resident shower and bathing room on March 5, 2024, at 11:48 AM revealed strands of white and black hair were observed in the drain in the large white bathtub. Multiple strands of hair and debris were also observed in the tub basin. A light gray pool of water and debris was observed on the shower floor. Hair strands were observed in the first shower floor drain. A clump of hair and a tan piece of paper were observed in a second shower floor drain. Dark hair strands were also observed on the tile shower floor. An observation of resident room [ROOM NUMBER] on March 5, 2024, at 11:55 AM revealed dark tan discolored stain rings on five ceiling blocks During an interview on March 6, 2024, at approximately 11:15 AM, the Facility Maintenance Manager explained that the ceiling tiles were discolored and stained due to condensation on the piping above the residents' rooms that was dripping onto the ceiling tiles. During an interview on March 7, 2024, at approximately 12:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility should be maintained in a clean and sanitary manner. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 3 of 13 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 03/07/2024 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)

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and a staff interview, it was determined that the facility failed to ensure necessary resident information was communicated to the receiving health care provider for four transferred residents out of five sampled residents (Residents 11, 13, 36, and 45). Findings include: A review of Resident 36's clinical record revealed that the resident was transferred to the hospital on September 16, 2023, and returned to the facility on September 17, 2023. A review of Resident 11's clinical record revealed that the resident was transferred and admitted to the hospital on [DATE], and returned to the facility on September 22, 2023. A review of Resident 13's clinical record revealed the resident was transferred from the facility and admitted to the hospital on [DATE], and returned to the facility on January 15, 2024. A review of Resident 45's clinical record revealed the resident was transferred from the facility and admitted to the hospital on [DATE], and returned to the facility on February 8, 2024. Further review of the above clinical records revealed no documented evidence of the information communicated to the receiving health care facility upon the residents' transfer to the hospital. An interview with the director of nursing on March 6, 2024, at 9:00 AM, confirmed that the facility was unable to provide documented evidence that all special instructions or precautions for ongoing care, as appropriate, and comprehensive care plan goals were communicated to the receiving health care facility. 28 Pa. Code 211.5 (f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 4 of 13 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 03/07/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records and select incident reports and resident and staff interviews it was determined that the facility failed to timely and effectively monitor a resident's use of a therapeutic device to preserve skin integrity and prevent pressure sore development, which resulted in the development of an avoidable pressure sore by one resident out of three reviewed (Resident 53). Residents Affected - Few Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of Resident 53's clinical record revealed she was admitted to the facility on [DATE], with diagnoses of included motor vehicle collision, fractures of the nasal bone, multiple right sided rib fractures, left thumb, patella (knee), right bimalleolar (ankle) fractures. An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 12, 2024, revealed that the resident was cognitively intact, had impairment on both lower extremities with functional range of motion, and was dependent on staff for toileting, lower body dressing, and putting on/taking off footwear. The resident's care plan indicated she was at risk for potential for or actual skin breakdown related to alteration in mobility, initiated January 5, 2024, with a goal that the resident will comply with therapeutic regimen, including preventative measures and nutritional interventions through next review, with a target date of April 18, 2024. Planned interventions included pressure redistribution cushion to chair as ordered, pressure redistribution mattress to bed, turn and re-position per schedule, employ good transfer technique to avoid friction, and skin checks at least weekly on scheduled bathing days, date initiated, January 5, 2024. The resident's care plan also indicated that a skin breakdown or interference with structural integrity of layers of skin on left inner heel, caused by pressure from device worn by resident initiated January 11, 2024, and resolved on February 21, 2024. The goal was that the area will improve with no signs of infection by April 18, 2024, resolved on February 21, 2024. Planned interventions, included suspected deep tissue injury (DTI) left inner heel with treatment as ordered, remove immobilizer left lower extremity for skin check, initiated January 11, 2024, and treatment to area, which will provide padding and protect area until healed initiated January 12, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 5 of 13 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 03/07/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Braden Scale (a tool used to determine/predict pressure sore development) dated January 5, 2024, revealed that the resident scored a 19, indicating the resident was very low or no risk for pressure sore development. A review of a nursing note, a late entry by a CRNP, dated January 9, 2024, 5:48 PM, reflecting an admission visit with the resident indicated that the resident has a brace LLE (left lower extremity) and a soft cast to the right ankle. The entry noted that the resident required assistance with activities of daily living. A nursing note dated January 10, 2024, 2:31 PM, revealed that during routine wound rounds by nurse, the resident complained of a burning feeling to the left heel. The immobilizer was removed for a skin check and the nurse found a discolored area to the left inner heel. A physician order dated January 10, 2024, was noted for staff to remove the immobilizer left lower extremity for skin check every shift. Cleanse left inner heel with soap water, pat dry, apply skin prep and dry dressing daily and as needed for soiling or dressing displacement. An incident report dated January 10, 2024, at 2:25 PM, revealed that the resident was complaining of burning feeling to left heel. Immobilizer removed for skin check, discolored area noted left inner heel. Immobilizer removed and deep tissue injury (DTI) was noted to the inner aspect of her heel. New treatment order received. The facility noted, however, that the pressure area was unavoidable as the immobilizer necessary for bone healing. New treatment will provide padding and protect area while immobilizer is in place. Review of witness statement, pressure injury/MASD by Employee 4 (Licensed Practical Nurse - LPN), dated January 11, 2024, revealing that vascular checks had been performed, and no area noted at time. The witness statement pre-typed question asked: did you see anything in the environment that could have contributed to the area? If yes, explain: immobilizer. A review of the resident's Treatment Administration Record (TAR), for January 2024, revealed the task of removing the left lower extremity (LLE) immobilizer for skin checks, was not initiated until January 10, 2024, five days after the resident's admission and the day the resident's pressure sore was discovered. A review of facility wound-skin healing record, dated February 14, 2024, indicated that the resident's pressure injury, DTI, left inner heel, measured 4.0 (cm) x 2.0 cm x 0 cm. No exudate (drainage), no odor, no s/s infection. Two small areas of intact purple/maroon discolored skin separated by flesh tone skin edges, normal in appearance, surrounding skin normal in temp. A review of a wound consultant note dated February 20, 2024, indicated the resident's left heel pressure sore was s now resolved. Interview with Employee 5 (Registered Nurse, Assistant Director of Nursing) on March 7, 2024, at approximately 9:50 AM, confirmed the resident's January 2024 TAR failed to identify the removal of the left lower extremity immobilizer, to check the integrity of the resident's skin to prevent pressure sore development, until after the pressure ulcer/injury was identified. Interview with Resident 53 on March 7, 2024, at approximately 11:05 AM, indicated she had been experiencing discomfort in her left heel, for a brief period of time, so she alerted staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 6 of 13 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 03/07/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of the left inner heel on March 7, 2024, at approximately 11:10 AM, with the resident's approval, and in the presence of Employee 6 (LPN), revealed an intact, slightly reddened, small, circular area. The area measured 1 cm x 1.5 cm (as measured by Employee 6 LPN). During the observation the resident displayed and vocalized no pain and or discomfort. The facility was unable to provide documented evidence that staff had timely and consistently conducted skin integrity checks under the brace prior to the development of this unstageable DTI to promptly identify declines in skin integrity and prevent the development of the deep tissue injury. During an interview with the Director of Nursing (DON) on March 7, 2024, at approximately 10:15 AM, confirmed that the facility was unable to demonstrate that staff had timely implemented consistent removal of the immobilizer to conduct checks the integrity of the resident's skin and there was no evidence that this task was completed until after the pressure ulcer/injury was identified. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 7 of 13 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 03/07/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services to maintain the mobility and functional abilities of one of the 17 residents sampled (Resident 15). Findings included: A clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness) and pneumonia. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care, dated January 25, 2024, revealed that Resident 15 is severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 severe cognitive impairment. During an interview on March 5, 2024, at 11:00 AM, Resident 15 stated that she was not currently receiving restorative nursing services. A clinical record review revealed a Physical Therapy (PT) Discharge summary dated [DATE], which indicates that Resident 15 was discharged from skilled physical therapy at this time because her highest practical level of functioning was achieved. The PT discharge summary indicated that Resident 15 was provided skilled services to improve the resident's ability to transfer, balance, ambulate, and improve her overall functional status. The PT discharge summary further noted that to maintain Resident 15's current level of performance and to prevent decline, development of, and instruction in an ambulation restorative nursing program, was completed with the resident's interdisciplinary team. Further review of the resident's clinical record, conducted during the survey ending March 7, 2024, revealed no documented evidence that restorative nursing program was developed and implemented for Resident 15 following discharge from skilled therapy. During an interview on March 7, 2024, at 12:00 PM, the Director of Nursing (DON) confirmed that the failed to provide restorative nursing services to Resident 15 as recommended upon discharge from skilled therapy. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 8 of 13 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 03/07/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 review of select facility policy and controlled drug records, observation and staff interview, it was determined that the facility failed to implement procedures to promote accurate medication administration, and records accounting for controlled drugs for one of three residents sampled (Resident 57), and reconciliation of controlled drugs on three of three medication carts (4th, 2 east, and 2 west). Finding include: A review of the facility policy Medication storage, controlled medication last reviewed by the facility [DATE], indicated that at each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on the controlled substances accountability record. Observation of the medication administration pass, on [DATE], at approximately 9:50 AM, revealed Employee 1, Licensed Practical Nurse (LPN), on the 4th floor medication cart. A review of the shift-to-shift accountability forms, titled controlled substance signature sheet, for the 4th floor, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: [DATE], and 9, 2024, and February 22, 2024. Interview with Employee 1, LPN, on [DATE], at approximately 9:59 AM, confirmed the above observation that the shift to shift, controlled substance record was not signed, and that the expectation is that it should have been signed by nursing staff according to facility policy During the observation of the medication administration pass, on [DATE], at approximately 10:10 AM, revealed Employee 2, Licensed Practical Nurse (LPN), on the 2nd floor East medication cart. A review of the shift-to-shift accountability forms, titled controlled substance signature sheet, for the 2nd floor East, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: February 23, 2024. Interview with Employee 2, LPN, on [DATE], at approximately 10:21 AM, confirmed the above observation that the shift to shift, controlled substance record was not signed to verify that nursing staff had counted the controlled drugs. During the observation of the medication administration pass, on [DATE], at approximately 10:38 AM, revealed Employee 3, Licensed Practical Nurse (LPN), on the 2nd floor [NAME] medication cart. A review of the shift-to-shift accountability forms, titled controlled substance signature sheet, for the 2nd floor West, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: February 29, 2024, and [DATE]. Interview with Employee 3, LPN, on [DATE], at approximately 10:46 AM, confirmed the above observation that the shift to shift, controlled substance record was not signed by nursing staff A review of Resident 57's clinical record revealed admission to the facility on [DATE], with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 9 of 13 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 03/07/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses to include anxiety, and hypertensive heart disease. The resident had a physician order dated [DATE], for admission to hospice care for a diagnosis of end stage hypertensive heart disease. The resident had a physician orders dated, [DATE], for Dilaudid (Hydromorphone HCL -an opioid pain medication) oral liquid, 1 milligram (mg)/ milliliter (ml), give 1 ml by mouth every 6 hours for pain management and Lorazepam (an antianxiety medication) oral concentrate 2 mg/ml. Give 0.25 ml by mouth every 6 hours for anxiety/restlessness. A nursing note dated [DATE], 0135 hours (1:35 AM), indicated that the resident had expired. The individual resident's controlled substance record, accounting for Resident 57's supply of Lorazepam, 0.25 ml revealed 30 mls had been received from pharmacy for the resident's use. On [DATE], 0000 hours (12:00 AM), a dose given 0.25 ml was given with the amount remaining 25.75 ml. The disposition of the remaining doses, and quantity was not recorded. The individual resident's controlled substance record, accounting for Resident 57's supply of Dilaudid, Hydromorphone HCL, give 1 ml by mouth every 6 hours for pain management, revealed 120 mls was received from pharmacy for the resident's use. The record revealed no evidence that a dose had been administered. The controlled substance record did not identify the disposition of the amount and doses remaining upon the resident's discharge. During an interview with the Director of Nursing (DON) on [DATE], at approximately 10:15 AM, that the controlled substance record should accurately reflect accounting, use and amount awaiting final disposition/disposal. 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 10 of 13 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 03/07/2024 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)

F 0851 Level of Harm - Potential for minimal harm Residents Affected - Some Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on record review and interview, it was determined that the facility failed to submit accurate staffing information in the Payroll-Based Journal (PBJ) system for two of the four quarters reviewed (October 1, 2023, through December 31, 2023, and July 1, 2023, through September 30, 2023). Findings include: A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 4 2023 (July 1 - September 30) revealed that the facility's data triggered for no registered nurse (RN) hours on August, 5, 2023, August 6, 2023, August 27, 2023, September 2, 2023 and September 4. 2023. A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 1 2024 (October 1 - December 31) revealed that the facility's data triggered for no registered nurse (RN) hours on October 1, 2023, October 14, 2023, November 18, 2023, November 19, 2023, November 23, 2023, and November 25, 2023. A review of staffing time sheets and daily nurse assignment sheets revealed that the facility had RN staffing working on each date that triggered for no RN hours on the PBJ Staffing Data Reports. During an interview on March 7, 2024, at approximately 10:00 AM, the facility [NAME] President of Skilled Nursing Operations indicated that the PBJ trigger for no RN hours was due to a coding error that occurred when the facility updated their system to identify charge nurses. He explained that charge nurses were added to the facility's reporting system in July of 2023, but the facility failed to code the charge nurses as registered nurses for submissions through the PBJ system. 28 Pa. Code 201.18 (e)(2) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 11 of 13 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 03/07/2024 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)

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. 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 clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure each resident room is designed and equipped to assure full visual privacy for two out of the 17 residents sampled (Resident 15; Resident room [ROOM NUMBER], Resident 13 room [ROOM NUMBER]). Residents Affected - Few Findings include: A clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness) and pneumonia. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 25, 2024, revealed that Resident 15 is severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 severe cognitive impairment. Observation on March 5, 2024, at 11 AM revealed that Resident 15 did not have a roommate and resided in resident room [ROOM NUMBER]. During an interview and observation on March 5, 2024, at 11:00 AM, Resident 15 stated that she was worried that people could see in through her room window at night and when staff were assisting her with clothing changes or providing personal care. She explained that she was concerned that her window blinds would not close completely. An observation at the time of the interview in resident room [ROOM NUMBER] revealed a window that measured approximately 5.0 feet tall x 10.0 feet wide, covered by multiple 3-inch vertically hanging blinds. When in the closed position, some of the blind slats remained open, creating a line of sight into and out of the room. A courtyard and other facility windows were visible through the opening in the blinds. Further observation revealed that the window blinds were missing slats. During an additional observation on March 7, 2024, at 8:35 AM, Employee 2, Licensed Practical Nurse, confirmed that the vertical blinds in resident room [ROOM NUMBER] would not fully close allowing for a line of sight into and out of the room. Observation of Resident room [ROOM NUMBER] on March 6, 2024, at approximately 10:00 AM revealed that the vertical window blinds were partially opened and one of the slats was twisted. Observation at this time also revealed that when the blinds were fully closed the middle slat was missing. Interview with Resident 13 at this time revealed that the middle slat has been missing for a while. Resident 13 stated that the missing slat prevented her from having full privacy (from the outside) when the blinds are closed. During an interview on March 7, 2024, at 9:00 AM, the Director of Nursing (DON) confirmed that each resident room should be designed and equipped to assure privacy. The DON indicated that action would be taken to ensure Resident 15 and Resident 13's room window blinds were functioning properly and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 12 of 13 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 03/07/2024 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)

F 0914 providing full privacy. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 201.18 (e)(2.1) Management Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395581 If continuation sheet Page 13 of 13