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 (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 5 Event ID: 396074 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 396074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allied Services Skilled Nursing Center 303 Smallacombe Drive Scranton, PA 18501 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)