Health inspection·January 10, 2025

F 0641 Ensure each resident receives an accurate assessment. 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, the Resident Assessment Instrument, and staff interview, it was determined the facility failed to ensure that Minimum Data Set Assessments accurately reflected the status of three residents out of 21 sampled (Residents 34, 8, and 31). Residents Affected - Few Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section

K0300 Weight Loss the facility is to record loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A clinical record review revealed Resident 34 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 31, 2024, indicated in Section K0200 that the resident's height was 64 inches and weight was 163 pounds. Review of Section

K0300 indicated that Resident 34 did not experience a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of Resident 34's Weight Record revealed that on April 3, 2024, the resident weighed 181.2 pounds. On October 5, 2024, the resident weighed 163 pounds which is indicative of a 10.04 % significant weight loss in 6 months. During an interview on January 9, 2025, at 11:30 AM the Registered Dietitian (RD) confirmed that Resident 34 did experience a 10.04% weight loss between April 3, 2024, and the quarterly MDS assessment dated [DATE], Section K0300 was inaccurate. A clinical record review revealed that Resident 8 was admitted to the facility on [DATE]. A review of an annual MDS assessment dated [DATE], indicated in Section A1600 Most Recent Admission/Entry or Reentry into the facility noted the most recent entry date into the facility was July 4, 2024, and Section A 1700 Type of Entry indicated admission. Further review of the clinical record revealed that Resident 8 was transferred to the hospital on June 29, 2024, and readmitted to the facility on [DATE]. Page 1 of 7 395581 395581 01/10/2025 Allied Services Center City Skilled Nursing 80 E. Northampton Street Wilkes Barre, PA 18701

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview with the Registered Nurse Assessment Coordinator (RNAC) on January 10, 2024, at 10:30 AM confirmed that the annual MDS assessment dated [DATE], Section A 1700 Type of Entry was not accurate and was incorrectly coded as admission instead of reentry. A clinical record review revealed that Resident 31 was admitted to the facility on [DATE]. Residents Affected - Few A review of an admission MDS dated [DATE], Section N Medications N 0350, Insulin indicated Resident 31 received one insulin injection in the last seven days. Further clinical record review revealed no other documented evidence that Resident 31 was administered any insulin injections in the last seven days. The MDS was coded as the resident receiving insulin despite no physician order. During an interview on January 8, 2024, at 12:40 PM the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident 31 did not receive insulin as indicated in Resident 31's MDS assessment dated [DATE], Section N 0350 Medications, Insulin. The RNAC confirmed the admission MDS assessment dated [DATE], was coded in error as it relates to insulin. 28 Pa. Code 211.5(f)(i) Medical records. 28 Pa. Code 211.12(d)(3) Nursing services. 395581 Page 2 of 7 395581 01/10/2025 Allied Services Center City Skilled Nursing 80 E. Northampton Street Wilkes Barre, PA 18701

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 observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide person-centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, compression stockings, for one resident of 21 sampled (Resident 22). Residents Affected - Few Findings include: A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of cerebral infarction (a pathological process, also known as ischemic stroke, the result of disrupted blood flow to the brain) and essential hypertension (high blood pressure). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2024, revealed that Resident 22 is cognitively intact with a BIMS score of 14 (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 13-15 indicates intact cognition ). A review of Resident 22's clinical record revealed a physician's order dated October 22, 2024, for Ted Stockings (Thrombo-Embolus deterrent compression stockings, or anti-embolism stockings, which are specially designed to help reduce the risk of developing deep vein thrombosis (DVT) or blood clots in your lower leg after surgery) to be on in the morning and removed in the evening. During a resident interview on January 7, 2025, at 10:29 AM, Resident 22 reported that staff did not assist her with applying her TED stockings that day, despite a physician's order requiring their use. Observations made on January 7, 2025, at 10:29 AM and 1:39 PM revealed that Resident 22 was not wearing her TED stockings as ordered. A review of Resident 22's January 2025 Treatment Administration Record revealed that staff documented the TED stockings were applied at 6:00 AM on January 7, 2025. This documentation was inconsistent with the resident's statements and observed findings. On January 8, 2025, at 10:30 AM, Resident 22 stated she had to remind the nurse on duty to apply her TED stockings, indicating a lack of adherence to the prescribed care plan. She explained that if she does not tell the nurse, then they do not apply her TED stockings. On January 9, 2025, at 1:30 PM, the Director of Nursing confirmed that staff did not consistently follow the physician's orders regarding the application and removal of Resident 22's TED stockings. 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services 395581 Page 3 of 7 395581 01/10/2025 Allied Services Center City Skilled Nursing 80 E. Northampton Street Wilkes Barre, PA 18701

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility-provided manufacturers' medication information, and staff interviews, it was determined the facility failed to demonstrate the physician timely acted upon irregularities identified by pharmacy services during drug regimen reviews for one resident out of the five sampled (Resident 56). Findings include: A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis (a bone infection) and gastro-esophageal reflux disease (GERD- a digestive disorder that occurs when stomach acid flows into the esophagus). A clinical record review revealed a pharmacy note to the attending physician or prescriber dated November 4, 2024, indicating that Resident 56 was prescribed sucralfate (an antiulcer medication) one gram every six hours for GERD. The note indicated the medication is usually administered on an empty stomach prior to meals and/or bedtimes to assure disintegration in the stomach acid and binding to stomach mucosa, forming a protective layer. If clinically appropriate for this patient, consider altering times of administration. A physician's response to the pharmacist indicating disagreement that Resident 56 has a gastrointestinal bleed. However, the response failed to address the pharmacist's recommendation for medication administration times to match the medication's manufacturer's direction. A review of facility provided medication information for sucralfate revealed recommended instructions for medication administration was 1 hour prior to meals and given on an empty stomach 1 hour before meals. A medical record review revealed no changes to physician's orders following recommendations by the pharmacist. A physician's order for Resident 56 to receive Carafate tablet 1 GM (sucralfate-an anti-ulcer medication) with direction to give 1 gram by mouth every six hours for gastric protection was initiated on December 17, 2024. During an interview on January 9, 2025, at approximately 10:00 AM, Employee 3, CRNP, indicated she reviewed the recommendation made by the pharmacist note from November 4, 2024. Employee 3, CRNP, was not able to provide a clinical rationale for disagreeing to consider altering times of Resident 56's sucralfate administration. Following questions asked during the survey, Resident 56's physician's order for sucralfate was revised to include recommendations indicated by the pharmacist from November 4, 2024. A clinical record review revealed a physician's order for Resident 56 to receive Carafate tablet 1 GM (sucralfate-an anti-ulcer medication) with direction to give one gram by mouth before meals and at bedtime for gastric protection initiated on January 9, 2025. During an interview on January 10, 2025, at approximately 10:00 AM, the Nursing Home Administrator confirmed it is the facility's responsibility to ensure the physician timely acts upon 395581 Page 4 of 7 395581 01/10/2025 Allied Services Center City Skilled Nursing 80 E. Northampton Street Wilkes Barre, PA 18701

F 0756 irregularities identified by pharmacy services during drug regimen reviews. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.2 (d)(3)(9) Medical Director Residents Affected - Few 395581 Page 5 of 7 395581 01/10/2025 Allied Services Center City Skilled Nursing 80 E. Northampton Street Wilkes Barre, PA 18701

F 0880 Provide and implement an infection prevention and control program. 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, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to implement enhanced barrier infection control procedures for three residents out of the 21 residents sampled (Residents 28, 33, and 56) and failed to properly store resident hygiene and personal products in two out of three resident shower rooms (3rd and 4th floor shower rooms). Residents Affected - Some Findings include: A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on December 30, 2024, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug resistant organisms (MDROs) to staff hands and clothing. The policy indicates nursing home residents with wounds and indwelling medical devices are especially high risk for both the acquisition of and colonization with MDROs. The policy indicates any resident who requires enhanced barrier precautions will have a blue circle sticker on their door (indicating gowns and gloves are required when providing any high-contact resident care activities). A clinical record review revealed Resident 28 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and chronic kidney disease (gradual loss of kidney function). A physician's order for Resident 28 to have isolation precautions-contact (interventions implemented to reduce the risk of spreading healthcare-associated infections) related to staphylococcus aureus MRSA (methicillin-resistant staphylococcus aureus- a bacteria resistant to antibiotic therapies) in urine initiated on December 29, 2024. An observation of Resident 28's room on January 7, 2025, at 11:15 AM, revealed no signs or postings identifying that Resident 28 was on enhanced barrier precautions or contact precautions. A clinical record review revealed Resident 33 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body). A physician's order for Resident 33 to have enhanced barrier precautions related to percutaneous endoscopic gastrostomy (PEG- an indwelling device that allows for the delivery of fluids, drugs, and nutrition to patients who are unable to eat orally) tube. An observation of Resident 33's room on January 7, 2025, at 11:59 AM, revealed no signs or postings identifying that Resident 33 was on enhanced barrier precautions. A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis (a bone infection). A physician's order for Resident 56 to have enhanced barrier precautions {related to indwelling urinary catheter} initiated on December 18, 2024. 395581 Page 6 of 7 395581 01/10/2025 Allied Services Center City Skilled Nursing 80 E. Northampton Street Wilkes Barre, PA 18701

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation of Resident 56's room on January 7, 2025, at 12:20 PM, revealed no signs or postings identifying that Resident 56 was on enhanced barrier precautions. During an interview on January 8, 2025, at 8:25 AM, Employee 1, Registered Nurse (RN), confirmed there was no signage or postings in Resident 28, 33, and 56's rooms or doorways indicating to staff that gown and gloves are required when providing any high-contact resident care activities. Employee 1, RN, indicated the rooms should be marked with a blue dot to indicate precautions are ordered and in place to prevent the spread of infections. During an interview on January 10, 2025, at approximately 9:00 AM, Employee 2, Infection Preventionist (IP), confirmed that Residents 28, 33, and 56's rooms should be identified to notify facility staff that additional personal protective equipment is required when providing any high-contact resident care activities in order to reduce the risk of spreading infections. During an interview on January 10, 2025, at approximately 10:00 AM, the Nursing Home Administrator confirmed it is the facility's responsibility to fully implement infection control procedures, including transmission-based precautions, and enhanced barrier precautions. An observation on January 7, 2025, at 11:09 AM in the 3rd-floor shower room, revealed two packages of resident incontinence briefs, a hair dryer, and sanitizing wipes stored on the shower room floor. An observation on January 7, 2025, at 12:08 PM in the 4th-floor shower room revealed three packages of resident incontinence briefs and one package of opened resident sanitizing wipes stored in the shower room bathtub. Also, four packages of resident incontinence briefs, multiple loose incontinence briefs, and a hairdryer were observed on the shower room floor. During an interview on January 7, 2025, at 12:10 PM, Employee 1, Registered Nurse (RN), confirmed the resident briefs and wipes should not be stored directly on the shower room floors or in the shower room bathtub. During an interview on January 10, 2025, at approximately 10:00 AM, the Nursing Home Administrator confirmed it is the facility's responsibility to fully implement infection control procedures, including the proper storage of resident hygiene and personal products to reduce the risk of spreading infections. The facility failed to ensure proper storge of these products by storing them on the floor. This practice poses a significant risk of contamination from dirt, dust and microbial pathogens compromising the cleanliness of these items. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa code 211.12 (d)(1)(5) Nursing services. 395581 Page 7 of 7