Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allied Services Skilled Nursing Center during CMS and state inspections, most recent first.
An LPN left medications at the bedside for two residents who had been assessed as unable to safely self-administer meds. One resident had dementia and HTN, and the other had lymphedema and muscle weakness. The LPN did not remain present to supervise ingestion or verify the meds were swallowed, and one resident was observed pouring pills onto the bedside table and taking them individually without staff supervision.
MDS assessments were not accurately coded for three residents. One resident had a fall with a head laceration and acute-on-chronic subdural hematoma requiring staples, another had a fall with a right humerus fracture, and a third resident received Eliquis during the look-back period but the quarterly MDS did not reflect anticoagulant use. The RNAC confirmed each assessment was coded incorrectly.
A resident with Parkinson's disease and moderate cognitive impairment had a care plan that still listed discharge to home as the goal even after social services notes documented a change to long-term placement in the facility. The record showed the resident declined community discharge resources and planned to remain in the facility, but the active care plan continued outdated discharge planning interventions that did not match the resident's current preferences and needs.
Failure to Conduct Required Care Plan Conferences After MDS Assessments: A resident with Parkinson's disease and moderate cognitive impairment had quarterly and annual MDS assessments completed, but the record showed no evidence that care plan conferences were held afterward. The chart also lacked documentation of resident or representative participation, information exchange, or efforts to involve them in the care planning process, and the NHA confirmed the conferences were not conducted.
Improper Schizophrenia Diagnosis Documentation: The facility failed to use evidence-based criteria and accepted clinical standards before adding schizophrenia to a resident's record. The resident had prior diagnoses including anxiety disorder and Parkinson's disease, and the chart lacked psychiatric or psychological evaluations, physician documentation, behavioral assessments, diagnostic testing, or symptom evidence such as delusions, hallucinations, disorganized speech, grossly disorganized behavior, or negative symptoms. Schizophrenia was later coded as an active dx in the MDS and used in a physician order for perphenazine, but the facility could not provide supporting clinical evidence when questioned by surveyors.
Medication Administration Not Consistent With Physician Orders: Staff failed to follow physician-ordered BP and pulse parameters for two residents. One resident with HTN, a pacemaker, and severe cognitive impairment had Metoprolol held when ordered criteria were not fully met, including one instance where HR was not obtained before withholding. Another resident with CKD and hypertensive urgency received Amlodipine despite BP below hold parameters and was given PRN Clonidine when SBP did not exceed the ordered threshold.
The facility failed to maintain an effective staff training program to ensure an RN and an LPN had documented competency to initiate IV access. Two residents had one-time IV orders, and the RN and LPN each started IV access with a 24-gauge needle, but personnel records did not show the required three witnessed IV insertion attempts required by facility policy before they performed the procedure independently.
A resident with muscle weakness, difficulty walking, incontinence, and documented moisture-associated skin damage was admitted with hospital recommendations for a low air loss bed, barrier products, frequent repositioning, and use of a pressure-relieving cushion. Facility staff performed Braden Scale assessments that inaccurately scored the resident as low risk, documenting that the resident could move freely with minimal assistance despite therapy records showing extensive to maximal assistance needs for bed mobility and transfers. Admission skin findings of redness and rashes on the groin, buttocks, sacrum, coccyx, and heel were not documented with the detailed descriptions required by facility policy. Progress notes later acknowledged risk for skin breakdown but focused on educating the cognitively impaired, dependent resident to reposition himself, rather than ensuring staff-assisted repositioning and full implementation of pressure-relieving interventions. An unstageable pressure injury was subsequently identified on the resident’s right gluteal area, demonstrating that the facility failed to accurately assess pressure injury risk, perform thorough skin assessments, and implement appropriate preventive measures.
A resident with end stage COPD and a Foley catheter was admitted without documented clinical justification for the catheter's continued use. Facility policy requiring assessment and physician notification was not followed, and after the catheter was removed, required bladder assessments and a voiding trial were not documented. The resident subsequently experienced multiple falls while attempting to toilet, and there was no supporting documentation for the continence care plan.
A resident with malnutrition and dementia experienced significant weight loss, but staff did not complete a timely nutritional reassessment, reweigh, or care plan update as required by facility policy. The RD documented the weight loss more than two months later without recommending new interventions, and there was no evidence of prompt physician notification or care plan revision.
Staff failed to attempt or document non-pharmacological interventions before administering as-needed narcotic pain medication to a resident with lung cancer, and also gave the medication outside the prescribed pain level parameters, contrary to physician orders and facility policy.
An LPN was observed administering medications to two residents without following proper infection control practices. On several occasions, the LPN picked up tablets and capsules that had fallen onto the medication cart with bare hands and placed them into medication cups without performing hand hygiene or using gloves, contrary to facility policy.
A resident with end stage COPD and a history of falls did not receive timely and consistent implementation of planned fall prevention interventions, including post-catheter care, toileting schedules, and elimination tracking. Despite being identified as at risk for falls and having specific interventions in place, the resident experienced multiple falls, with documentation showing that key interventions were not effectively implemented or monitored.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a history of deep tissue injury. Despite physician orders for TruVue boots to prevent pressure sores, these were not included in the care plan or nurse aide Kardex. The resident was observed without the boots, and a nurse aide was unaware of the requirement due to its absence in the Kardex. The assistant DON confirmed the omission in the care plan.
The facility failed to ensure proper nursing practices for IV medication administration via PICC lines for three residents. LPNs, who were not authorized or trained, signed the MAR for administering medications through PICC lines. Interviews revealed LPNs were not educated on this task, and the DON confirmed that only RNs were allowed to administer medications through PICC lines, as per facility policy.
The facility failed to follow physician orders for PICC line management for two residents. Resident 270's PICC line care was not documented as performed weekly, and changes in catheter length were not reported to the physician. Similarly, Resident 105's PICC line care was not documented on multiple occasions. The Director of Nursing confirmed the lack of documentation and adherence to orders, resulting in a deficiency in nursing services.
The facility failed to securely store discontinued medications in three out of five medication storage rooms. Observations revealed that various medications were left unsecured in bins on countertops and floors. Staff interviews confirmed the medications were awaiting pharmacy pickup, but there was uncertainty about the pickup procedure. The DON acknowledged the need for timely return and secure storage of these medications.
A facility failed to update and implement a discharge plan for a resident with heart disease who wished to return to the community. Despite the resident's intact cognitive status and expressed desire for independent living, the discharge plan was not revised or acted upon, and there was no evidence of social services involvement in planning the transition.
The facility failed to follow physician orders for oxygen therapy and maintain sanitary conditions for respiratory equipment for two residents. One resident received less oxygen than prescribed, and another had uncovered nebulizer equipment on a cluttered nightstand. These issues were confirmed by staff interviews.
A facility failed to create a person-centered care plan for a resident with PTSD, neglecting to identify symptoms, triggers, and specific interventions to prevent re-traumatization. This deficiency was confirmed by the DON, highlighting a lack of culturally competent, trauma-informed care.
The facility failed to maintain infection control practices, as observed with a resident's supra pubic catheter tubing on the floor, a soiled brief on a clean linen cart, and clean briefs and other supplies stored directly on the floor. The DON confirmed that equipment should be stored sanitarily.
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and records for a resident. The resident had a physician order for Hydrocodone/Acetaminophen, but a review revealed discrepancies between the controlled substance records and medication administration records. The DON confirmed these inconsistencies.
A facility failed to develop and implement a care plan for a resident with a surgically implanted DRG stimulation therapy unit, used to manage chronic pain. Despite the resident's cognitive intactness and independence in daily activities, the care plan did not address the necessary management of the device during the resident's stay.
Unsupervised Medication Administration and Unattended Medications
Penalty
Summary
The facility failed to ensure residents were free from foreseeable accident hazards related to unattended medications and unsupervised medication administration for two residents. Facility policy required medications to be administered safely and in a timely manner, and the self-administration policy required residents to be reviewed to determine whether they could safely self-administer medications; if the interdisciplinary team determined self-administration was unsafe, that right was to be withdrawn. Clinical record review showed one resident had dementia and hypertension, and a self-administration assessment documented the resident could not state the purpose of medications, identify the correct dosage, or identify scheduled administration times. Another resident had lymphedema and muscle weakness, and a similar assessment documented the resident could not state the purpose of medications, identify the correct dosage, or identify scheduled administration times. During a medication pass observation, an LPN prepared medications for the first resident, placed the medication cup on the bedside table, instructed the resident to take the medications, and left the room without staying to supervise administration or verify the medications were swallowed. The LPN then prepared medications for the second resident, placed a cup containing five pills on the bedside table, and exited the room without supervising administration or verifying swallowing. The second resident was observed pouring the medications onto the bedside table and ingesting the pills individually without staff supervision. During interview, the LPN stated both residents could self-administer medications without assistance despite the facility assessments showing both residents were unable to safely self-administer medications.
MDS assessments were inaccurately coded for falls with major injury and anticoagulant use
Penalty
Summary
The facility failed to ensure MDS assessments accurately reflected residents’ clinical status for three residents. For Resident 303, the record showed the resident was found on the floor in the room, sustained a 3.0 cm by 3.0 cm by 0.3 cm laceration to the back right side of the head with moderate bleeding, and was transferred to the community ED. ED records documented an acute-on-chronic subdural hematoma, and the resident returned with three staples placed in the back of the head. However, the discharge-return not anticipated MDS indicated the resident had not experienced a fall with major injury since the prior assessment, even though the RNAC later confirmed the fall involved a major injury and the MDS was not coded accurately. For Resident 302, the record showed the resident fell in the room, was transferred to the ED, returned from the hospital, and later had a documented non-operative right humerus fracture related to the fall. The discharge-return not anticipated MDS also indicated no fall with major injury, although fractures are considered falls with major injury for MDS coding purposes, and the RNAC confirmed the assessment was not coded accurately. For Resident 273, the record showed the resident had diagnoses including cerebral infarction and long-term anticoagulant use, physician orders for Eliquis 5 mg twice daily, and MARs showing the medication was administered during the look-back period. The quarterly MDS indicated the resident did not receive anticoagulant medication during the seven-day look-back period, and the RNAC confirmed the assessment was not coded accurately.
Care Plan Not Updated for Changed Discharge Goals
Penalty
Summary
The facility failed to develop and revise a resident-centered comprehensive care plan to reflect current discharge planning goals and preferences for one resident. The resident was admitted with Parkinson's Disease without dyskinesia and, on the quarterly MDS dated April 22, 2026, was documented as cognitively impaired with a BIMS score of 12. The comprehensive care plan dated February 13, 2025, identified the resident as a potential discharge to home and included interventions for discharge planning such as anticipating equipment and home health needs, involving the resident in discharge planning, providing written and verbal education, and evaluating community resources. Clinical record review showed social services progress notes documented the resident's goal to be discharged from the facility, but a later note stated the discharge plan had changed because the resident required ongoing care and supervision in the facility. That note also documented the resident declined referral to community discharge resources and planned to remain in the facility. Despite this change, the active care plan continued to identify discharge to home as the resident's goal and continued discharge planning interventions that did not match the resident's current preferences and needs. During interview, the Nursing Home Administrator stated the resident was initially considered for discharge to the community but was no longer able to be safely discharged and planned to remain in the facility, and acknowledged the care plan had not been revised in accordance with facility policy.
Failure to Conduct Required Care Plan Conferences After MDS Assessments
Penalty
Summary
The facility failed to ensure care plan conferences were conducted after required MDS assessments for one resident. Resident 93 was admitted with Parkinson's Disease without dyskinesia and had a quarterly MDS assessment completed on November 23, 2025, and an annual MDS assessment completed on January 20, 2026. The resident's quarterly MDS showed cognitive impairment with a BIMS score of 12, indicating moderate cognitive impairment. Review of the clinical record, including interdisciplinary progress notes and care plan conference attendance/signature documentation, did not show evidence that care plan conferences were held after either assessment. The record also did not include evidence of care plan conference participation, information exchange, resident involvement in care planning, or documented efforts to engage Resident 93 or the resident representative in the care planning process following the November 2025 quarterly MDS assessment and the January 2026 annual MDS assessment. The facility policy titled Resident Centered Comprehensive Care Plan stated that the comprehensive care plan would be reviewed after each comprehensive and quarterly assessment and that social services would invite residents, families, or resident representatives to participate in the plan of care conference. During interview, the Nursing Home Administrator confirmed that care plan conferences were not conducted after those two MDS assessments.
Improper Schizophrenia Diagnosis Documentation
Penalty
Summary
The facility failed to ensure evidence-based diagnostic criteria and accepted professional standards of clinical practice were used before identifying one resident as having schizophrenia. Resident 13 was admitted with diagnoses including anxiety disorder and Parkinson's disease, and a PASRR form dated October 8, 2020, identified one serious mental illness as personality disorder. The resident's admission MDS dated May 18, 2025, did not list schizophrenia as an active diagnosis, but a PASRR Identification form dated May 11, 2025, added schizophrenia after admission and was signed by the Social Services employee. A physician order for Perphenazine 4 mg twice daily for mood disorder was initiated on May 11, 2025, discontinued on May 23, 2025, and a later physician order for Perphenazine 4 mg twice daily for schizophrenia was entered on November 27, 2025. The clinical record review did not reveal psychiatric evaluations, psychological evaluations, physician documentation, diagnostic testing, behavioral assessments, or symptom documentation supporting schizophrenia. The record also did not show documentation of delusions, hallucinations, disorganized speech, grossly disorganized behavior, or negative symptoms consistent with DSM-5-TR criteria for schizophrenia. During an interview with the NHA on May 1, 2026, the facility was unable to provide physician documentation, psychiatric evaluation, psychological evaluation, behavioral assessments, or other clinical diagnostic evidence supporting the diagnosis. The resident's quarterly MDS also coded schizophrenia as an active diagnosis in Section I.
Medication Administration Not Consistent With Physician Orders
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for two residents. Facility policy required medications to be given as ordered and vital signs, including blood pressure and pulse, to be obtained when ordered by the physician. The deficiency involved Resident 9 and Resident 258, based on review of clinical records, physician orders, eMAR documentation, and staff interviews. Resident 9 was admitted with hypertension and a cardiac pacemaker and was severely cognitively impaired with a BIMS score of 0. The resident had an order for Metoprolol Succinate ER 25 mg, one-half tablet by mouth every morning and at bedtime, with instructions to hold only if systolic blood pressure was less than 100 mm/Hg and heart rate was less than 60 beats per minute. The eMAR showed the medication was withheld on several occasions when the documented vital signs did not meet both hold criteria, including times when either the blood pressure or heart rate was outside the parameter but not both. On one occasion, the heart rate was not obtained before the medication was withheld. Resident 258 was admitted with chronic kidney disease and hypertensive urgency and was cognitively intact with a BIMS score of 15. The resident had an order for Amlodipine Besylate 2.5 mg twice daily, to be held if systolic blood pressure was less than 110 mm/Hg or heart rate was less than 60 beats per minute, and an order for Clonidine 0.1 mg every 8 hours as needed for systolic blood pressure greater than 160 mm/Hg. The eMAR showed Amlodipine was administered on multiple occasions despite blood pressure readings below the hold parameter, and Clonidine was administered on multiple occasions when systolic blood pressure did not exceed 160 mm/Hg. The Nursing Home Administrator acknowledged the findings during interview.
Missing IV Competency Validation for Nursing Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff had the knowledge and demonstrated competency to safely initiate IV access for two residents. Federal requirements and Pennsylvania nursing regulations were cited as requiring staff training and competency validation before independently performing IV therapy, and the facility policy titled Intravenous Therapy required an RN or LPN to complete three witnessed IV insertion attempts before initiating IV access. For Resident 14, a physician ordered a one-time IV for an upper respiratory infection and elevated white blood cell count, and an RN initiated IV access with a 24-gauge needle in the resident’s right forearm. For Resident 290, a physician ordered a one-time IV for hydration, and an LPN initiated IV access with a 24-gauge needle in the resident’s right forearm. Review of both employees’ personnel records did not show documentation of the required three supervised IV insertion attempts, and the Nursing Home Administrator acknowledged the facility could not provide evidence that either staff member completed the required competency validation before independently initiating IV access.
Failure to Accurately Assess and Prevent Pressure Injuries for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess a resident’s pressure injury risk, implement appropriate preventive interventions, and conduct timely and thorough skin assessments, which contributed to the development of an unstageable pressure injury. Upon admission, the resident had multiple risk factors, including muscle weakness, difficulty walking, dependence on staff for bed mobility and transfers, incontinence, and moisture-associated skin issues. The admission nursing evaluation documented redness and rashes on the penis, groin, buttocks, sacrum, coccyx, and heel, but the clinical record did not include required details such as type of skin impairment, size, drainage, odor, or tissue characteristics, contrary to the facility’s wound management policy. Hospital records prior to admission had already identified moist, macerated skin with bleeding in the groin and penis area, blanchable redness on the coccyx, buttocks, and gluteal folds, and high risk for further skin breakdown, with specific recommendations for a low air loss bed, barrier products, avoidance of briefs, frequent repositioning, and use of a waffle cushion. The facility’s Braden Scale assessments were inconsistent with the resident’s documented functional status and known risk factors. On admission, staff scored the resident at low risk (Braden score 18), documenting no sensory impairment, the ability to move freely with minimal assistance, and only often moist skin, despite other records showing the resident required maximal assistance for bed mobility and transfers and could not independently reposition in bed or chair. A subsequent Braden assessment again scored the resident as low risk (score 16), indicating the resident could make occasional position changes without assistance and move freely with minimal help, even though therapy evaluations documented extensive to maximal assistance needs for sit-to-stand transfers, bed mobility, and transfers. Based on the resident’s actual condition and the presence of moisture-associated skin damage, the Braden categories for mobility, moisture, and activity should have reflected greater impairment, and a more accurate score would have placed the resident in a high-risk category. Progress notes later documented that the resident was at risk for skin breakdown due to moisture-associated skin areas, limited mobility, and incontinence, yet the interventions focused on educating the resident to reposition himself frequently, despite documentation that he was moderately cognitively impaired and unable to reposition without staff assistance. These notes did not reflect a change in approach to account for the resident’s dependence on staff. Eventually, a progress note documented the discovery of an unstageable pressure injury on the right gluteal area measuring 3 cm x 3 cm x 0.1 cm, with 100% purple, non-blanching tissue. At that time, the record referenced a low-air loss mattress order and continued two-hour repositioning, but prior to the development of this wound, the facility had not accurately assessed the resident’s pressure injury risk or fully implemented the recommended pressure-relieving and moisture-management interventions identified in the hospital records and required by facility policy. The facility’s own wound management/pressure reduction policy required comprehensive risk assessment using the Braden scale on admission and weekly for four weeks, weekly body checks by CNAs, and detailed documentation of any skin impairment, including location, size, description, drainage, odor, and necrosis. The policy also required specific actions when an unstageable pressure ulcer is identified, such as moist saline dressings, consultation with the wound nurse, physician, and dietician, and use of prevention or specialty mattresses as needed. In this case, the initial and subsequent Braden assessments did not reflect the resident’s true risk level, the admission skin findings were not documented in the detailed manner required, and the preventive interventions recommended by the hospital wound care provider were not fully implemented prior to the development of the unstageable pressure injury. These actions and omissions formed the basis of the cited deficiency under 28 Pa. Code 211.10(d) and 211.12(c)(d)(1)(3)(5).
Failure to Assess Catheter Necessity and Follow Post-Removal Protocols
Penalty
Summary
The facility failed to evaluate the clinical necessity of an indwelling urinary catheter and did not follow its own policies regarding catheter removal and bladder assessment for a resident. Upon admission, the resident, who had end stage COPD and was receiving hospice care, had a Foley catheter in place. The facility's policy required the use of an assessment tool to determine the need for an indwelling catheter and mandated physician notification if criteria were not met. However, there was no documented diagnosis or clinical justification for the continued use of the catheter in the clinical record, and the required assessment was not completed. The care plan indicated assistance with toileting, but there was no supporting documentation for a toileting plan or continence pattern. After the hospice nurse recommended discontinuing the Foley catheter, the physician was contacted and the catheter was removed. Despite facility policy requiring a bladder assessment and initiation of a voiding trial following catheter removal, there was no documentation that these steps were completed. Subsequently, the resident experienced three falls while attempting to get to the bathroom. A later bladder assessment noted mixed urinary continence and a toileting schedule, but there was no documented bladder tracker to support this plan. The DON confirmed the lack of documentation and acknowledged that facility policy was not followed.
Failure to Timely Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment and consistently monitor weights to identify and address significant weight loss for a resident with moderate calorie-protein malnutrition and dementia. According to facility policy, a weight change of 5% or more in one month requires a reweigh within 48 hours, reassessment by the dietitian, and care plan adjustments as needed. The resident experienced a 6.5% weight loss over a 33-day period, but there was no evidence of a timely reweigh, reassessment, or care plan revision following this significant change. The care plan, which already identified the resident as at risk for nutritional deficits, was not updated to reflect the new weight loss, and there was no documentation of physician notification or new interventions. Further review showed that the Registered Dietitian did not document the significant weight loss until over two months after it occurred, and at that time, no new interventions were recommended. The delay in identifying and responding to the resident's nutritional decline was inconsistent with the facility's policy and did not demonstrate timely reassessment or mitigation of nutritional risk. These findings were confirmed during an interview with the Nursing Home Administrator.
Failure to Follow Pain Management Protocols and Physician Orders
Penalty
Summary
Facility staff failed to follow established pain management protocols for a resident with a diagnosis of malignant neoplasm of the lung. The resident had a physician order for hydrocodone-acetaminophen to be administered as needed for moderate pain, specifically for pain levels rated between 5 and 7 on a numeric pain scale. However, clinical record review showed that staff administered the narcotic pain medication 19 times in June and 5 times in July without attempting or documenting non-pharmacological interventions prior to medication administration, as required by standard nursing practice and pain management guidelines. Additionally, the medication was administered outside the parameters of the physician's order on several occasions, including for pain levels categorized as severe, mild, or even when the resident reported no pain. These findings were confirmed through review of the Medication Administration Record and staff interviews, indicating that the facility did not ensure pain medications were administered according to physician orders and failed to consistently attempt or document non-pharmacological interventions prior to the use of as-needed narcotic pain medications.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
Staff failed to follow appropriate infection control practices during medication administration for two residents on the One North nursing unit. During the administration of medications, an LPN was observed picking up medications that had fallen onto the medication cart with his bare hands and placing them into the residents' medication cups without performing hand hygiene or wearing gloves. This occurred multiple times with different medications, including Vitamin D2, Senna, Lorazepam, and Furosemide, for two separate residents. A review of the facility's Infection Control Policy and Procedure indicated that standard precautions, including hand hygiene, are required to prevent healthcare-associated infections. Despite this, the LPN did not wash his hands or use gloves after handling medications that had come into contact with potentially contaminated surfaces. These findings were confirmed during an interview with the Nursing Home Administrator.
Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and monitor planned fall prevention interventions for a resident with end stage COPD who was receiving hospice services and had an indwelling Foley catheter. The resident was identified as being at risk for falls, and the care plan included maintaining a hazard-free environment, keeping the bed in the lowest locked position, ensuring the call bell and needed items were within reach, reinforcing call bell use, and using non-slip footwear. Despite these interventions, the resident experienced multiple falls. After the first fall, new interventions such as referrals to occupational and physical therapy and issuance of a reacher device were added. However, following the removal of the Foley catheter, nursing staff failed to complete a bladder assessment or initiate a voiding trial as recommended by the hospice nurse and physician. Subsequent falls occurred when the resident attempted to go to the bathroom without assistance, indicating that interventions such as offering toileting assistance and implementing a bowel and bladder tracker were either not documented or not effectively carried out. There was no evidence that the facility implemented or monitored the effectiveness of planned interventions, including toileting schedules, elimination tracking, and post-catheter care, to prevent repeated falls. The Director of Nursing confirmed that planned interventions were not timely implemented to prevent falls for this resident.
Failure to Implement Comprehensive Care Plan for Pressure Sore Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of deep tissue injury. The resident, who requires extensive assistance for activities of daily living and is at risk for pressure sores, was admitted with diagnoses including Down syndrome, seizure disorder, and severe intellectual disorder. Despite physician orders and previous interventions to prevent pressure injuries, such as the application of TruVue boots to the resident's heels, these interventions were not included in the resident's care plan or the nurse aide Kardex. During an observation, it was noted that the resident was not wearing the prescribed TruVue boots, which were found on the floor behind the bed. A nurse aide, unfamiliar with the resident's specific care needs, confirmed that the intervention was not listed in the Kardex she reviewed at the start of her shift. The assistant Director of Nursing acknowledged that the care plan did not include the necessary intervention for pressure sore prevention, as ordered by the physician, and there was no documented evidence of a care plan to prevent potential skin impairment.
Deficiency in IV Medication Administration via PICC Lines
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality as per the Pennsylvania Code Title 49, Professional and Vocational Standards. Specifically, the facility did not implement proper nursing practices for the administration of intravenous medication via central venous catheters for three residents. The deficiency was identified through clinical record reviews, facility policy reviews, and staff interviews. Resident 334, admitted with a PICC line for orthopedic aftercare and infection, had orders for Vancomycin administration via the PICC line. However, LPNs, who were not authorized or trained to administer medications through PICC lines, signed the Medication Administration Record (MAR) as having administered the medication. Similarly, Resident 105, admitted with a MRSA infection and a PICC line, had orders for Vancomycin, and multiple LPNs signed the MAR for administration. Resident 270, with osteomyelitis and a PICC line, had orders for Zosyn, and again, LPNs signed the MAR for administration. Interviews revealed that LPNs were not educated on administering medications through PICC lines and would call an RN to perform the task, yet still signed the MAR. The Director of Nursing confirmed that LPNs did not receive education on PICC line medication administration and that facility policy restricted this task to RNs. The facility lacked evidence of education or supervision regarding IV administration and PICC line usage for LPNs, leading to the deficiency.
Failure to Follow PICC Line Management Orders
Penalty
Summary
The facility failed to provide person-centered care and follow physician orders for the management of PICC lines for two residents. Resident 270, who was admitted with osteomyelitis and immunodeficiency, had a PICC line placed for IV antibiotic therapy. The facility's policy required weekly dressing changes and measurement of the external catheter length, with physician notification if migration occurred. However, there was no documented evidence that these procedures were performed weekly as ordered. The external catheter length changed from 0 cm to 2 cm and then to 1.5 cm, but the physician was not notified of these changes. Resident 105, who was readmitted with a right AKA, osteomyelitis, and sepsis, also had a PICC line. The physician ordered weekly dressing changes and external catheter length measurements. However, the Medication Administration Record (MAR) showed no documentation of these procedures being completed on several occasions. The facility could not provide evidence that the PICC line treatments and measurements were performed as ordered by the physician. Interviews with the Director of Nursing confirmed the lack of documentation and adherence to physician orders for both residents. The facility's failure to perform and document the required PICC line care and notify physicians of changes in catheter length constituted a deficiency in nursing services as per 28 Pa. Code 211.12 (c)(d)(1)(3)(5).
Failure to Securely Store Discontinued Medications
Penalty
Summary
The facility failed to store drugs and pharmacy supplies in a safe manner and did not remove medications awaiting final disposition in a timely manner across three out of five medication storage rooms. The facility's policy on the disposition of medications, last reviewed on July 24, 2024, requires that discontinued medications be marked and stored in a locked, secure area until they are destroyed or picked up by the pharmacy. However, observations revealed that discontinued medications were left unsecured in clear storage bins on countertops and floors in the first, second, and third-floor medication storage rooms. These bins contained various medications, including prescription medication cards, pill packages, nebulizer treatments, IV bags, and insulin pens. Interviews with staff members, including registered nurses and a licensed practical nurse, confirmed that the medications in the bins were discontinued and awaiting pharmacy pickup. The staff members were unsure of the procedure or frequency for pharmacy pickup. The Director of Nursing confirmed that the medications should have been returned to the pharmacy in a timely manner and stored securely to prevent unauthorized access and potential drug diversion. The facility's failure to adhere to its policy and ensure the secure storage of discontinued medications resulted in a deficiency under 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services and 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Failure to Implement Individualized Discharge Plan
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 251, who was admitted with a diagnosis of heart disease. The resident, with an intact cognitive status as indicated by a BIMS score of 15, expressed a desire to return to the community and live independently. Despite this, the facility did not update the resident's discharge plan, which was initially noted on February 29, 2024, as requiring training and instruction for transitioning home. There was no documented evidence of social services working on the discharge plan or updating it with new goals and interventions to facilitate the resident's discharge to the community. This deficiency was confirmed by the Nursing Home Administrator during an interview on September 20, 2024.
Failure to Follow Oxygen Therapy Orders and Maintain Equipment Sanitation
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy and did not maintain oxygen equipment in a functional and sanitary manner for two residents. Resident 227, who was admitted with respiratory failure and required continuous supplemental oxygen, was observed on two occasions receiving only 2 liters per minute of oxygen instead of the prescribed 3 liters per minute. This discrepancy was confirmed by a licensed practical nurse during an observation. Resident 176, admitted with acute respiratory failure and pneumonia, had a physician's order for nebulizer treatment that ended on September 2, 2024. However, during an observation, the resident's nebulizer equipment was found uncovered and not bagged on a cluttered bedside nightstand, which included opened beverages and other personal items. The Director of Nursing confirmed that respiratory equipment should be bagged when not in use to prevent contamination, indicating a failure to maintain sanitary conditions for the equipment.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Upon review, it was found that the resident's care plan did not identify symptoms or triggers related to PTSD, nor did it include specific interventions to minimize these triggers and prevent re-traumatization. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the facility's inability to provide culturally competent, trauma-informed care in accordance with professional standards of practice. The resident was admitted with PTSD, a condition that requires careful management to promote emotional well-being and safety, which was not adequately addressed in the care plan.
Infection Control Deficiency in Resident Care Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed in several instances involving resident care equipment and supplies. Resident 337 was found with a supra pubic catheter and tubing lying directly on the floor, which poses a risk of contamination. Additionally, a soiled brief was observed on top of a clean linen cart, emitting a malodorous smell. In another room, seven clean briefs were placed directly on the floor next to a bedside table, and three heel lift boots were also found on the floor behind a bedside table. Furthermore, a box of tube feeding bottles and multiple boxes of briefs and bed pads were stored directly on the floor, with some boxes open and exposing the contents to the air. These observations were confirmed by the Director of Nursing, who acknowledged that resident care equipment should be stored in a sanitary manner.
Failure to Reconcile Controlled Drug Records
Penalty
Summary
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one resident. Resident 1, who was admitted with diagnoses including below the knee amputation and chronic lower back pain, had a physician order for Hydrocodone/Acetaminophen 5-325 mg to be administered as needed for pain. However, a review of the resident's controlled substance records and medication administration records for November and December 2023 revealed discrepancies. Nursing staff signed out doses of the controlled drug for administration on specific dates and times, but these doses were not documented as given to the resident in the medication administration records. During an interview, the Director of Nursing confirmed the inconsistencies between the controlled drug records and the medication administration records. This failure to properly document the administration of controlled substances indicates a lapse in the facility's pharmacy procedures and nursing services, as required by the relevant state codes.
Failure to Develop and Implement Care Plan for Pain Management Device
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with a surgically implanted Dorsal Root Ganglion (DRG) stimulation therapy unit, which is used to manage chronic pain. The resident, who was admitted with diagnoses including below the knee amputation and chronic lower back pain, had a DRG stimulation unit that required specific care and services. Despite the resident being cognitively intact and independent in activities of daily living, the care plan did not address the management of the DRG stimulation unit or the necessary care associated with it during the resident's stay from November 22, 2023, to January 6, 2024, when the resident was discharged against medical advice (AMA). The deficiency was confirmed through a review of clinical records and an interview with the Nursing Home Administrator. The admission documentation and Minimum Data Set (MDS) assessments indicated the presence of the DRG stimulation unit, but the care plan failed to include any measures for its management. This oversight was identified during a survey conducted on July 30, 2024, highlighting the facility's failure to meet the resident's needs for pain control and device management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Scranton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allied Services Transitional Rehab Unit | 0.2 mi | ★★★★★ | 3 | 0 |
| Green Ridge Care Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Marywood Heights | 2.3 mi | ★★★★★ | 7 | 0 |
| Gino J Merli Veterans Center | 2.5 mi | ★★★★★ | 5 | 0 |
| Embassy Of Scranton | 2.5 mi | ★★★★★ | 24 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.