Allied Services Skilled Nursing Center

Inspectors wroteBased on observations, clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to assess and determine whether a resident could safely self-administer medications before permitting medications to be left at the bedside without staff supervision for one of 10 residents reviewed (Resident 1).

Inspectors wroteBased on observations, clinical record review, select facility policy review, and staff interviews, it was determined the facility failed to ensure residents were free from foreseeable accident hazards related to the unattended placement and unsupervised administration of medications for 2 of 21 residents reviewed (Resident 116 and Resident 136) on 1 of 4 units observed.

Inspectors wroteBased on clinical record review, review of the Resident Assessment Instrument (RAI) Manual, Minimum Data Set (MDS) assessments, and staff interviews, it was determined the facility failed to ensure Minimum Data Set assessments accurately reflected the clinical status of three of 37 residents reviewed (Residents 273, 302, and 303).

Inspectors wroteBased on clinical record review, review of facility policies, and staff interviews, it was determined the facility failed to develop and revise a resident-centered comprehensive care plan to accurately reflect current discharge planning goals and preferences for one of 37 residents reviewed (Resident 93).

Inspectors wroteBased on a review of clinical records, care plan conference attendance documentation, facility policy, and staff interview, it was determined the facility failed to ensure comprehensive care plan conferences were conducted following Minimum Data Set (MDS) assessments for one of 37 residents reviewed (Resident 93).

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to ensure evidence-based diagnostic criteria and accepted professional standards of clinical practice were utilized to establish a diagnosis of schizophrenia for one of 37 residents reviewed (Resident 13).

Inspectors wroteBased on select facility policy, a review of clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure licensed nurses administered medications according to physician ordered parameters for 2 of 21 residents reviewed (Resident 9 and Resident 258).

Inspectors wroteBased on a review of clinical records, employee personnel records, facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and demonstrated competencies necessary to safely initiate intravenous (IV) access for two of 37 residents reviewed (Resident 14 and Resident 290).

Inspectors wroteBased on a review of clinical records, hospital records prior to admission, select facility policies and procedures, facility-provided investigative documentation, and staff interview, it was determined the facility failed to accurately assess pressure injury risk, failed to implement appropriate preventative interventions, and failed to conduct timely and thorough skin assessments to prevent the development of pressure injuries for one resident (Resident CR1) of five residents reviewed.

Inspectors wroteBased on a review of clinical records, facility-provided investigation reports, staff interviews, and facility policies, it was determined the facility failed to implement and monitor planned fall prevention interventions for one of 32 sampled residents (Resident 70), resulting in multiple falls. Clinical record review revealed that Resident 70 was admitted to the facility on [DATE], with diagnosis to include, end stage COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease), and was receiving hospice services. A review of a five-day admission Minimum Data Set (MDS a federally required standardized assessment) dated June 16, 2025, documented a Brief Interview for Mental Status (BIMS a cognitive assessment tool) score of 13 (a score of 13 to 15 indicates the resident is cognitively intact). [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to evaluate the clinical necessity of an indwelling urinary catheter and failed to follow its own policies for catheter removal and bladder assessment for one of 35 sampled residents (Resident 70). A review of the facility's policy titled Urinary Catheter Insertion, Care, Irrigation, and Removal, last reviewed August 2024, indicated that indwelling bladder catheterization may only be used to relieve urinary retention not treatable by other means or to collect a urine specimen when a resident is unable to provide one midstream. The facility will attempt catheter removal, if medically able, and establish a toileting plan to address incontinence or urinary frequency. [...]

Inspectors wroteBased on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to complete a comprehensive nutritional assessment and monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement appropriate interventions to address weight loss for one of thirty-five residents reviewed for nutritional status and weight loss. (Resident 75). A review of the facility policy titled Weighing Residents/Reporting Significant Weight Changes, last reviewed in March 2025, indicated that when a resident experiences a weight change of 5% or more in one month, nursing and/or the dietitian will reweigh the resident within 48 hours to verify the change. [...]

Inspectors wroteBased on select facility policy, clinical record review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis and failed to ensure the physician orders were followed for one residents (Resident 166) of 35 residents reviewed. A review of the clinical record revealed that Resident 166 was admitted to the facility on [DATE], with diagnoses to include malignant neoplasm of the lung (a form of cancer affecting lung tissue). [...]

Inspectors wroteBased on observation, review of select facility policy, and staff interviews, it was determined the facility failed to ensure staff followed appropriate infection control practices during the administration of medications for two of four residents observed during the administration of medications. (Residents 26 and 99) on the One North nursing unit. A review of facility policy titled Infection Control Policy and Procedure last reviewed by the facility on August 12, 2024, indicated the Infection Control Intervention Protocol is established and maintained for the detection, control and prevention healthcare associated infections. The elements of the protocol consist of infection criteria, standard and transmission-based precautions, hand hygiene, surveillance, infection control and prevention. [...]

Inspectors wroteBased on review of clinical records and staff interview it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address the resident's needs for adaptive equipment to ensure the prevention of the development of potential skin impairment for one out 35 residents sampled. (Resident 250).

Inspectors wroteBased on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for three of six residents reviewed (Resident 334, 105 and 270).

Inspectors wroteBased on observations, review of select facility policy and clinical records, and staff interviews it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs, and failed to follow physician orders for management of a PICC line for two residents out of 35 sampled (Residents 270, and 105).

Inspectors wroteBased on review of select facility policy, observation, and staff interview it was determined the facility failed to store drugs and pharmacy supplies in a safe manner and failed to remove medications awaiting final disposition in a timely manner in three medication storage rooms out of five medication storage rooms first floor, second floor, north, and third floor, south.

Inspectors wroteBased on clinical record review and resident and staff interview it was determined the facility failed to develop and implement an individualized discharge plan for one of 25 residents sampled (Resident 251). Findings Include: A review of the clinical record of Resident 251 revealed admission to the facility on February 24, 2024, with diagnoses including heart disease. A quarterly Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic intervals to plan resident care) dated August 1, 2024, revealed the resident had a BIMS (brief interview to aid in detecting cognitive impairment) score of 15, indicating that her cognition was intact. Interview with Resident 251 on September 18, 2024, revealed the resident was hoping to return to the community to live independently. [...]

Inspectors wroteBased on review of clinical records, observation, and staff interview, it was determined the facility failed to follow physician orders for oxygen therapy and failed to to maintain oxygen equipment in a functional and sanitary manner for two residents out of 35 sampled (Residents 227 and 176).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 35 residents reviewed (Resident 156).

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to maintain infection control practices to prevent the spread of infection for one of 35 sampled residents. (Resident 337)

Inspectors wroteBased 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 ).

Inspectors wroteBased 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.