Dunmore Health Care Center

Based on a review of controlled drug shift count records, facility policies, and staff interviews, it was determined that the facility failed to ensure accurate documentation of controlled (Schedule II) medications (controlled medications are drugs regulated under the federal Controlled Substances Act due to their potential for abuse or dependence, with Schedule II drugs having a high potential for abuse but accepted medical use) by both the oncoming and off-going nurses (the licensed nurses assuming or ending responsibility for a medication cart at the change of shift) for two of two medication carts observed (First Floor [NAME] Hall and First Floor East Hall).Findings include:A review of the facility policy entitled Inventory Control of Controlled Medications, last reviewed May 29, 2025, revealed that controlled drugs (medications regulated under federal and state law due to their potential for abuse) must be inventoried and documented under proper security and in accordance with state and federal regulations. The policy further indicated that Schedule II controlled medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the attending physician failed to document a clinical rationale for declining the pharmacist ' s identified irregularities in the medication regimen for one resident (Resident 49) out of five sampled residents reviewed for unnecessary medications.Findings include:A review of the clinical record revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia without behavioral disturbance (a condition characterized primarily by memory loss and cognitive decline without significant behavioral changes), encephalopathy (a general term describing brain disease or malfunction that can cause symptoms ranging from mild confusion to severe cognitive impairment or coma), respiratory failure (a serious condition in which the lungs cannot adequately oxygenate the blood), and a history of multiple falls.A review of a consultation report completed by the facility ' s consultant pharmacist dated July…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (1 East Hall).Findings include:A review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, last reviewed by the facility on May 29, 2025, indicated that if a multi-use medication vial/injectable (containers intended for multiple uses for one or more patients that require puncture of the rubber stopper or seal to withdraw doses on different occasions) has been opened and accessed, the vial is to be dated and discarded within 28 days unless the manufacturer specifies a different expiration timeframe for that opened vial.An observation of the medication cart located on the 1 East Hall unit, conducted on October 1, 2025, at 8:22 AM in the presence of Employee 3 (Licensed Practical Nurse), revealed one (1) multi-dose insulin pen of Insulin Aspart (a short-acting insulin medication used to lower blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records, select resident incident report, and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to thoroughly conduct and document the results of a professional nursing assessment regarding the clinical status of a resident following a change in condition for one resident (Resident 1) out of 8 residents reviewed. Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: · Assessments · Clinical problems · Communications with other health care professionals regarding the patient · Communication with and education of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one resident out of 18 sampled (Resident 6). Findings include: A review of policy entitled Restorative Nursing Referral and Process Policy last reviewed by the facility on December 4, 2024, revealed it is the policy of the facility that Residents who could benefit from the nursing restorative program can be identified at the following times: -on admission -when other assessments are required, such as an MDS assessment -from the 24 hour report and the change of shift report -at morning stand up meeting -at care plan meeting and other resident-focused meetings -at risk management meetings such as behavior management, nutrition at risk -during restorative weekly meetings. The procedure to include, a referral from the therapy department, goals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, clinical records, and staff interviews it was determined that the facility failed to develop and implement individualized measures for the toileting needs of two residents out of 18 sampled residents for bowel and bladder management (Residents 27 and 74). Findings included: A facility policy entitled Continence Management Programs last reviewed by the facility December 2, 2024, indicated that the facility will design a plan to manage incontinence that is developed according to the resident's needs and capabilities. Upon admission, the admitting Nurse will complete a head-to-toe assessment which includes interview of resident and review of underlying conditions such as potential or actual diagnoses that may affect the ability to participate in a continence management program. The nursing staff will identify each resident who is incontinent, assess, and plan appropriate treatment and services to achieve or maintain as much normal urinary and/or bowel function as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for two out of 18 residents (Resident 18 and 19). Findings include: A review of Resident 18's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 18's admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 23, 2024, revealed the resident was severely cognitively impaired. A review of the resident's current care plan, initially dated November 21, 2024, revealed no documented evidence the facility had developed an individualized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued administration of an antidepressant medication for one resident out of five sampled residents for unnecessary medication use. (Resident 19). Findings included: A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life). A review of Resident 19's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 21, 2024, revealed the resident was severely cognitively impaired. A review of current Physicians orders dated April 4, 2024, revealed orders for Mirtazapine 15 mg (an antidepressant medication) by mouth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to maintain accurate clinical records for one of 18 residents sampled (Resident 19). Findings include: A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life). A review of a care plan initiated July 18, 2022, for cognitive deficit revealed the resident has a diagnosis of Dementia with Lewy Bodies (Lewy body dementia causes a decline in mental abilities that gradually gets worse over time. People with Lewy body dementia might see things that aren't there. This is known as visual hallucinations. They also may have changes in alertness and attention). The facility was noted to have changed clinical record systems on April 8, 2024. The above noted care plan was not completely transferred, to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review clinical records and facility provided documents it was determined the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to complete and accurate medical records. Findings include: A review of a facility policy for Quality Assurance and Performance Improvement (QAPI) program reviewed December 4, 2024, revealed the purpose of QAPI in the facility is to take a proactive approach to continually improving delivery of care and services and to engage residents, caregivers, and other clinical/operational partners in maximizing quality of life and quality of care. The facility will conduct performance improvement projects to examine and improve care and services which have been identified as opportunities for improvement. A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute dementia (a chronic condition that causes a decline…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the facility's infection control tracking logs, the infection control and prevention policy, and staff interviews it was determined the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases including scabies for two of 18 residents reviewed (Resident 56 and Resident CR1). Findings include: A review of the current facility policy for Infection Prevention and Control, last reviewed December 4, 2024, revealed it is the policy of the facility to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors and contract healthcare workers, to conduct surveillance of communicable disease and infectious outbreaks and to monitor employee health. A review of a facility policy entitled Scabies Management reviewed December 4, 2024, revealed, the purpose of the policy is to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy and staff interview, it was determined the facility failed to demonstrate it had ascertained if a resident had an advance directive upon admission and whether the resident would like information to formulate an advance directive for two out of 18 sampled residents (Residents 74 and 18). Findings included: A review of a facility entitled Advance Care Planning meeting Protocol last reviewed by the facility on December 2, 2024, indicated that it was the policy of the facility that upon admission to the facility, the appropriate team member would meet with the resident and offer to formulate an advance directive to ensure their preferences (Living Wills, Medical [NAME] of Attorney, etc.) are recorded in their medical record and further used to develop their plan of care. Social Services, along with other team members as needed, will meet with the resident and family members within a reasonable timeframe (3-5 days from admission) to discuss pertinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 18 sampled (Resident 49). Findings include: A review of the clinical record revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses to have included cardiovascular disease, depression, and diabetes. A review of Resident 49's quarterly review Minimum Data Assessment (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 2, 2024, revealed in Section P - P0100 Restraints was coded D Other to indicate the resident had a form of restraints in place. A review of Resident 49's clinical record failed to reveal that the resident had restraints in place. An interview with the Director of Nursing (DON) on December 12, 2024, at 10:00 AM, revealed that Resident 49 did not have physician's orders for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of clinical records, and resident and staff interviews it was determined the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for one resident (Resident 59) out of 18 residents reviewed to promote normal bowel activity to the extent practicable. Findings include: According to the American Academy of Family Physicians (The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine) the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week. A review of the clinical record revealed that Resident 59 had physician orders dated May 1, 2024, for the following bowel regimen: - Milk of Magnesia (MOM) Suspension 400 mg/5ML (Magnesium Hydroxide), Give 30 ml by mouth as needed for constipation if no BM (bowel movement) after the third day. -Bisacodyl…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined 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 18 residents reviewed (Resident 78). Findings include: A review of Resident 78's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). The resident's current care plan, in effect at the time of review on December 11, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of select facility policy, clinical records, and select incident/accident reports and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards to prevent accidental ingestion and misuse of substances not intended for oral use and to prevent access to resident personal care supplies, treatment products, and medications that may be mishandled or consumed by residents for whom the medications were not prescribed, for two residents out of eight sampled (Resident A1 and A2) and observed on two of two nursing units. Findings include: A review of an undated facility policy titled General Dose Preparation and Medication Administration indicated that facility staff should not leave medications or chemicals unattended. Facility staff should enter the date opened on the label of the medication with shortened expiration dates for example insulins and irrigation solutions. A review of an undated facility policy titled Storage and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select reports, facility policy, and 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 demonstrate that licensed nurses thoroughly assessed and consistently monitored a resident after the resident ingested a potentially harmful substance for one resident out of eight sampled (Resident A1). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of grievances lodged with the facility, and staff interview, it was determined that the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as evidenced by four out of 11 residents sampled (Residents 1, 8, 9, and 10). Findings include: A review of a grievance submitted by Resident 4's representative dated January 23, 2024, revealed that the resident's representative had to physically call facility herself and ask for someone to answer her mother's call bell since no staff had answered the call bell. Review of the facility's resolution revealed that on January 24, 2024, nursing staff were provided written and/or verbal education via telephone to please be attentive to answering call bells. A resident call bell should be answered within 5-10 minutes. It is everyone's job to answer call bells, not just CNAs (nurse aides). Please do not walk by a call bell without addressing the resident's needs. Observations performed on the second-floor resident care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and grooming of residents' dependent on staff for assistance with these activities of daily living for three out of 11 residents reviewed (Residents 2, CR1, and CR2). Findings include: A review of a facility policy for Resident Bath/Showering/Scheduling Policy, dated as last revised September 9, 2022, indicated that residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. According to the policy, each resident will be asked about his/her bathing preferences upon admission (type of bath, preferred days and times). Each resident will be scheduled to receive bathing a minimum of two times per week, unless they prefer less frequent baths. The procedures were that If the bath/shower cannot be given or the resident refuses, the nursing assistant will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, grievances lodged with the facility and nurse staffing levels and staff interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely care, including assistance with activities of daily living, to meet the physical needs and promote the psychosocial well-being of each resident including Resident 4, Resident 2, Resident CR1 and CR2). Findings include: A review of a grievance submitted by Resident 4's representative dated January 23, 2024, revealed that the resident's representative had to physically call facility herself and ask for someone to answer her mother's call bell since no staff had answered the call bell. Review of the facility's resolution revealed that on January 24, 2024, nursing staff were provided written and/or verbal education via telephone to please be attentive to answering call bells. A resident call bell should be answered within 5-10 minutes. It is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.