Health inspection·February 21, 2025

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 a review of clinical records, select facility policy, and staff interview, it was determined the facility failed thoroughly assess and timely implement treatments to an identified skin impairment for one resident out of 14 sampled residents (Resident 18). Residents Affected - Few Findings included: 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 a facility policy entitled Wound Management Pressure Reduction last reviewed by the facility on October 24, 2024, indicated that it was the policy of the facility to assess each resident's potential for skin breakdown based on clinical risk factors. On admission and readmission, a body check will be completed by the licensed nurse and documented on the Dermatological Evaluation form. The dermatological sheet will reflect the type of skin impairment and location, size, description, shape, drainage, odor, and color. A review of Resident 18's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a left femur fracture (is a breakage in the thigh bone (femur), the longest, strongest and heaviest bone in the human body that usually requires surgical repair) with left artificial hip joint (a left artificial hip refers to a hip replacement surgery where a damaged hip joint is replaced with an artificial one made of metal, ceramic, and plastic to reduce pain and improve mobility), type II diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and chronic kidney disease (is a condition characterized by a gradual loss of kidney function where in early stages can be show no symptoms and the disease progression occurs slowly over a period of time). Page 1 of 4 396135 396135 02/21/2025 Allied Services Transitional Rehab Unit 475 Morgan Highway Scranton, PA 18508

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A clinical record review revealed that a wound-skin healing record form was completed by the Director of Nursing (DON) on January 10, 2025, and signed on January 13, 2025, revealed that Resident 18 had a pressure injury identified as a suspected deep tissue injury [(DTI) The National Pressure Ulcer Advisory Panel (NPAUP) defines a deep tissue injury as a pressure-related injury to subcutaneous tissues under intact skin and initially appear like a deep bruise but subsequent progress and development into a Stage III or IV pressure ulcer] to the right heel, no measurements noted, described as red/purple. Resident 18's baseline plan of care that was initiated on January 11, 2025, identified that the resident was at risk for alteration in skin integrity related to immobility and skin breakdown as evidence by rash with a resident goal for the resident's skin integrity to be maintained as evidenced by no skin breakdown. Planned interventions included to administer wound treatment as ordered and assess and record details of wound and notify physician of any changes in wound condition. Further review of Resident 18's clinical record revealed a nurse's progress note completed by a Registered Nurse (RN) dated January 13, 2025, at 6:48 AM, that indicated the resident had a 3 by 3 cm blister on right heel. Skin prep applied and elevated off the bed. A review of physician's orders in Resident 18's clinical record revealed an order dated January 13, 2025, at 6:54 AM, to apply skin prep to bilateral heels every shift and elevate heels off the bed whenever in bed every shift for right heel blister/ left heel prevention for blister right heel and prevention left heel. Resident 18's clinical record failed to reveal that a RN performed a thorough assessment of the resident's noted DTI to her right heel and that a treatment was applied to the impaired area upon identification. The facility could not provide documented evidence that Resident 18's noted DTI to her right heel was measured and thoroughly assessed upon admission to the facility. Additionally, the facility could not provide documented evidence that a treatment was applied to the resident's right heel DTI upon initial identification. During an interview with the Director of Nursing (DON) on February 21, 2025, at 10:35 AM, confirmed that the facility failed to thoroughly assess Resident 18's right heel DTI upon admission and timely apply effective treatments for wound management. 8 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services. 396135 Page 2 of 4 396135 02/21/2025 Allied Services Transitional Rehab Unit 475 Morgan Highway Scranton, PA 18508

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on a review of clinical records, controlled drug medication records, controlled drug shift count records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate controlled medication records by not ensuring the completion of required narcotic shift counts on two of two medication carts observed. Findings include: A review of the facility's current policy titled Administration of Medication Schedule II-V Controlled Drugs, last reviewed on October 24, 2024, revealed that a physical inventory of controlled medications must be conducted at the end and beginning of each shift by two licensed nurses. The policy specifies that both the oncoming and off going nurses must view the medication together, validate the count, and document their verification with signatures. A review of the facility's Narcotic Count Sheets for January 2025 for the [NAME] Wing medication cart (located on the [NAME] Hall of the nursing unit) was conducted on February 19, 2025, at approximately 7:10 PM. The review revealed that on multiple occasions, either the oncoming or off going nurse failed to sign the sheet, indicating a lack of verification of the controlled drug count during shift change. Specifically, missing signatures were noted on the following dates: January 7, 2025 - Third shift off going nurse January 9, 2025 - Third shift oncoming nurse January 10, 2025 - Second shift oncoming nurse January 13, 2025 - Third shift oncoming nurse January 19, 2025 - Third shift oncoming nurse January 20, 2025 - Third shift oncoming and off going nurses January 31, 2025 - Third shift off going nurse A review of the Narcotic Count Sheets for February 2025 for the East Wing medication cart (located on the East Hall of the nursing unit) was conducted on February 19, 2025, at approximately 7:15 PM. Similar discrepancies were identified where the required shift count verification signatures were missing. Specifically, missing signatures were noted on: February 14, 2025 - Third shift off going nurse February 15, 2025 - Second shift oncoming nurse and third shift off going nurse 396135 Page 3 of 4 396135 02/21/2025 Allied Services Transitional Rehab Unit 475 Morgan Highway Scranton, PA 18508

F 0755 February 19, 2025 - Third shift oncoming nurse Level of Harm - Minimal harm or potential for actual harm During an interview on February 21, 2025, at approximately 3:00 PM, the Director of Nursing confirmed the facility failed to ensure consistent implementation of procedures to maintain accurate controlled drug records. Residents Affected - Few 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services 396135 Page 4 of 4