Health inspection·April 30, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement a person-centered plan to address one resident's surgically implanted device to treat chronic pain for one of five sampled residents (Resident 1) to ensure the resident's needs for pain control and device management are met. Findings include Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include below the knee amputation and chronic lower back pain. An admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 29, 2023, revealed that Resident 15 was cognitively intact, independent for activities of daily living and received opioid pain medication. admission documentation dated November 22, 2023, indicated that the resident was admitted with a Dorsal root ganglion (DRG) stimulation therapy unit (a surgically implanted neurostimulation therapy unit, designed to manage difficult-to-treat chronic pain). The DRG stimulation therapy system is made up of parts that are designed to work together to help manage pain: Generator: A small device that sends out mild electrical pulses and that contains a battery. This is implanted in your body. Leads: Thin insulated wires that carry the electrical pulses from the generator to your dorsal root ganglia. These are placed in your body in the area of the DRG. Patient controller: A handheld remote control that allows you to adjust the strength and location of stimulation or even turn stimulation off. A review of the resident's care plan initiated November 22, 2023, and discontinued with the resident's AMA (against medical advice) discharge January 6, 2024, revealed that during the resident's stay the resident's care plan did not address the resident's DRG stimulation unit or the required care and services associated with the device. Interview with the Nursing Home Administrator, on July 30, 2024, at approximately 2 PM, confirmed Page 1 of 5 396074 396074 04/30/2024 Allied Services Skilled Nursing Center 303 Smallacombe Drive Scranton, PA 18501

F 0656 Level of Harm - Minimal harm or potential for actual harm the facility failed to develop and or implement a person-centered plan to address Resident 1 Dorsal root ganglion (DRG) stimulation therapy unit. 28 Pa Code 211.12 (d)(3)(5) Nursing Services. Residents Affected - Few 396074 Page 2 of 5 396074 04/30/2024 Allied Services Skilled Nursing Center 303 Smallacombe Drive Scranton, PA 18501

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 controlled drug records and select facility policy and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one of five residents sampled (Resident 1 ). Finding include: Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include below the knee amputation and chronic lower back pain. An admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 29, 2023, revealed that Resident 15 was cognitively intact, independent for activities of daily living and received opioid pain medication. The resident had a physician order dated November 22, 2023, for Hydrocodone/Acetaminophen 5-325 mg ( a narcotic opiod pain medication) one, by mouth every 4 hours as needed for moderate pain rated 5-7) and give 2 tabs by mouth every 4 hours as needed for severe pain (pain rated 8-10) on a scale of 1 {least pain} to 10 {worst pain}). The resident's November 2023 and December 2023 individual resident controlled substance record accounting for Resident 1's supply of the controlled drug, and nursing staff's removal of doses for administration of Hydrocodone/Acetaminophen 5-325 mg revealed that nursing staff signed out doses of the controlled drug for administration to the resident on the following dates and times: November 23, 2023, at 9 PM November 25, 2023, - 4 PM November 26, 2023, - 8 AM November 26, 2023, - 4:40 PM November 26, 2023, - 8:44 PM November 27, 2023, - 8:12 PM November 28, 2023, - 9 AM November 29, 2023, - 4 PM November 30, 2023, - 8 PM December 1, 2023, - 6 AM December 2, 2023, - 10 AM 396074 Page 3 of 5 396074 04/30/2024 Allied Services Skilled Nursing Center 303 Smallacombe Drive Scranton, PA 18501

F 0755 December 2, 2023, - 2 PM Level of Harm - Minimal harm or potential for actual harm December 4, 2023, - 4 PM December 4, 2023, - 8 PM Residents Affected - Some December 5, 2023, - 8 AM December 13, 2023, - 9:30 AM December 13, 2023, - 1:30 PM December 13, 2023, - 10 PM December 14, 2023, - 6 PM December 15, 2023, - 8 AM December 15, 2023 - 12 PM December 15, 2023, - 8 PM December 16, 2023 - 8 AM December 16, 2023, - 8 PM December 18, 2023 - 10:45 PM December 21, 2023, - 12:45 AM December 22, 2023 - 9 PM December 26, 2023 - 4:15 PM December 29, 2023 - 12 PM December 30, 2023 - 8 PM December 31, 2023 - 4:45 AM December 31, 2023 - 5 PM December 31, 2023 - 11:40 PM A review of Resident 1's medication administration records for November 2023 and December 2023 revealed that the above doses of the Hydrocodone/Acetaminophen 5-325 mg were not documented as given to the resident on those dates and times. During an interview April 30, 2024 at 2 P.M., the Director of Nursing confirmed that the above 396074 Page 4 of 5 396074 04/30/2024 Allied Services Skilled Nursing Center 303 Smallacombe Drive Scranton, PA 18501

F 0755 inconsistencies between the controlled drug records and medication administration records. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa Code 211.9 (a)(1)(j.1)(4)(k) Pharmacy services. Residents Affected - Some 396074 Page 5 of 5