Health inspection·January 19, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cards were then reviewed. The facility found an additional three narcotic cards containing oxycodone that had been tampered with belonging to Resident 188 and 189. Through their investigation the facility had identified 47 Claritin tablets (allergy medication) had been replaced for the oxycodone in the four identified tampered blister cards. Staff Schedules were reviewed and the facility interviewed Employee 4, LPN (license practical nurse), on September 22, 2023. At that time Employee 4 admitted to the NHA (nursing home administrator) and DON that she swapped out the residents' oxycodone tablets for Claritin tablets. A review of Employee 3's statement dated September 22, 2023, revealed that while the employee was working during 3:00 PM to 9:00 PM she noticed an issue with a resident's oxycodone. The employee indicated that when giving Resident 44's nighttime dose, one tablet popped easily out of the medication card and looked suspicious. The employee stated the tablet looked different from an oxycodone tablet and it was visible that the card had been tampered with. A review of Employee 4's statement dated September 22, 2023, revealed that the employee stated that she removed three residents' oxycodone (Residents 44, 188, and 189) from the medication cards and replaced them with Claritin. The employee indicated that she had a drug problem in the past and had been going through some rough times and found herself in a bad place. A review of a drug screen completed on Employee 4 dated September 22, 2023, revealed that the employee tested positive for oxycodone. Upon conclusion of the facility's investigation, Employee 4 was terminated on September 22, 2023, for misappropriation of Resident 44, 188, and 189's medication, oxycodone. An interview with the NHA on January 19, 2023, at approximately 11:30 AM confirmed the facility failed to ensure all residents were free from misappropriation of resident property. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: The ADON reviewed all controlled substances in the facility to see if changes in medications were made or back of blister cards were altered. A total of 4 blister cards for three residents were noted to be tampered. Pain assessments and head to toe assessments were completed on Resident 44, 188, and 189 with no issues identified. The physician and responsible parties were made aware. [NAME] police, Area on Aging, [NAME] Area DEA (Drug Enforcement Agency), The Department of State, and The Department of Health were made aware of the misappropriation. The pharmacy was notified and requested that additional cards be delivered for residents with identified issues and the facility was billed for the cost. Statements were obtained in the facility identified Employee 4 of drug diversion. To identify residents that have the potential to be affected, the social worker or designee will interview capable residents to ensure controlled substances were given per physician's order. Incapable residents will have pain assessments completed. To identify residents that have the potential to be affected the ADON or designee reviewed current residents that had drugs diverted to ensure residents did not have any allergies to the medications that were replaced in the prescribed medication blister cards. To identify any issues with the potential to affect residents the ADON or designee review narcotic blister packs to ensure they were checked for the right medication and the back of the blister pack was intact. To identify residents that have the potential to be affected the regional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some director of clinical services or designee reviewed all controlled substance logs to the medication administration record (MAR) for the last seven days to ensure narcotics were given and signed out on the MAR. To identify residents that have the potential to be affected the ADON or designee will review current resident manifestation sheets from the Omnicare and controlled substances to ensure controlled substances were received and accounted for. To identify residents that have the potential to be affected the ADON or designee will review the Omnicell to ensure narcotics pulled in the past seven days were signed out in the residents' MARs. To prevent this from happening again the regional director of clinical services or designee educated the ADON on an appropriate chain of custody of controlled substances. The receiving nurse from the delivery driver will sign the electronic manifestation sheet from the delivery driver. The nurse then will distribute controlled substances and pharmacy countdown sheets directly to the nurse authorized to access the controlled substances in the medication cart and document the receipt on the nursing unit. Once received by the medication cart nurse it will be logged in the facilities controlled medication inventory system immediately. The yellow sheet will then be placed under the ADON's door for comparison of inventory received and the electronic manifestation sheet to ensure all controlled substances were received and accounted for. The ADON or designee will educate all the licensed nurses. To prevent this from happening again the ADON or designee will educate the licensed nursing staff on ensuring when controlled substance is given and is documented on the MAR and the controlled substance log. If a resident refused the medication and the controlled substance was popped out of the blister pack, two nurses must destroy the medication and document appropriately. To prevent this from happening again the ADON or designee will educate the licensed nurses if a blister pack appears to be tampered with or the medication and the blister pack appears to be not the correct pill the DON or ADON one will be made aware immediately and remove the medication from the cart and alert Omnicare. The medication will be stored in a safe place until the DON or the ADON or the pharmacists are in the facility to review the medication. To prevent this from happening again the ADON or designee will educate current staff on the abuse policy specifically with misappropriation. To prevent this from happening again the ADON or designee will educate licensed nurses on appropriate procedure and documentation on destruction of narcotics. To monitor and maintain ongoing compliance the social worker or designee will interview 10 capable residents weekly for four weeks then monthly for two months to ensure control substances were given per the physician's order. To monitor and maintain ongoing compliance the ADON or designee will assess 10 incapable residents weekly for four weeks then monthly for two months for pain or signs and symptoms of anxiety based off the controlled substance the resident is on. To monitor and maintain ongoing compliance the ADON or designee will audit 10 controlled substance blister packs weekly for four weeks then monthly for two months to ensure a blister pack does not appear to be tampered with or the medication in the blister pack is the correct pill. To monitor and maintain ongoing compliance the ADON or designee will complete an audit of 10 residents on controlled substances weekly for four weeks and monthly for two months to ensure that controlled substances are given and documented appropriately in the MAR and on the controlled substance log. To monitor and maintain ongoing compliance the ADON or designee will audit the chain of custody of narcotics weekly for four weeks and monthly for two months to ensure the electronic manifestation sheets matched the delivery sheet. To monitor and maintain ongoing compliance the NHA or designee will complete 5 interviews on random employees weekly for four weeks and monthly for two months to ensure that staff are confident in the abuse policy. To monitor and maintain ongoing compliance the ADON or designee will audit narcotics that are destroyed weekly for four weeks and monthly for two months to ensure appropriate destruction of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some narcotics. To monitor and maintain ongoing compliance the ADON or designee will review the Omnicell narcotic removal weekly times four weeks and monthly for two months to ensure all narcotics removed from the Omnicell were administered per the physician order. The facility's corrections were completed by September 25, 2023, as confirmed during the survey ending January 19, 2024. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on the review of the facility's abuse prohibition policy, clinical records and select facility investigations and staff interviews, it was determined that the facility failed to ensure that an allegation of abuse was reported timely for one of 18 residents reviewed (Resident 56). Findings include: The facility's abuse prohibition policy last reviewed by the facility January 25, 2023, indicated that all allegations of abuse shall be reported immediately to his or her supervisor. Facility investigation documents, dated December 14, 2023, included a statement from Employee 10, a nurse aide, indicated she witnessed an incident the last time she worked with Employee 11, a nurse aide, involving Resident 56. According to Employee 10's statement, Employee 10 and Employee 11 were providing care to Resident 56. Employee 10 stated that Employee 11 told Resident 56 don't f**ck with me and put a pillow over the resident's head. Employee 10 did not reveal the date in her written statement because she did not report the incident immediately. Information submitted by the facility revealed that the above incident allegedly occurred on December 5, 2023, but was not reported to the Director of Nursing until December 14, 2023. Interview with the Nursing Home Administrator on January 19, 2024, at 9:35 a.m. confirmed that Employee 10 did not report the allegation of abuse immediately as required. 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of select facility policy and interviews with residents and staff, it was determined that the facility failed to review and revise the resident's plan of care in response to a significant weight loss for one resident out 18 residents (Resident 30). Findings include: Review of the clinical record of Resident 30 revealed admission to the facility on April 11, 2019, with diagnoses to include diabetes. On December 5, 2023, the resident weighed 213.6 pounds and on January 3, 2024, the resident weighed 202.8 pounds, which was a 5.06% percent significant weight loss in approximately one month. A dietary progress note dated January 9, 2024, revealed that the dietitian recognized the significant weight loss and attributed the loss to a history of edema and noted that the weight loss was noted as beneficial. However, a review of Resident 30's care plan, dated last revised on January 18, 2022, revealed that the resident was identified to be at nutrition/hydration risk related to: Parkinson's disease, diabetes, therapeutic menu plan, obese BMI, mna 10, significant weight gain- edema. The facility failed to review and revise the resident's care plan reflect Resident 30's the desirable significant weight loss identified on Janaury 3, 2024. Interview on January 18, 2024, at 2:30 p.m. the Nursing Home Administrator (NHA) confirmed that Resident 30's care plan was not revised after the resident experienced a significant weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records and staff and resident interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to assure that licensed nurses promptly assessed and evaluated a resident's wound to ensure the resident timely received necessary care and treatment for one resident (Resident 188) and failed to follow acceptable nursing practices, by pre-pouring medications, resulting in a medication error for one resident (Resident 15), following which nursing staff failed to assess the resident's condition out of 18 sampled residents. Residents Affected - Some 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 Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. 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 the patient, family, and the patient ' s designated support person and other third parties. A review of the clinical record review revealed that Resident 188 was admitted to the facility on [DATE], with diagnoses which include peripheral vascular disease and venous insufficiency. A review of an admission Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of an admission wound assessment dated [DATE], revealed that the resident had six arterial wounds on the left lower extremity: -Left fourth toe measuring 1 cm x 1.6 cm x 0.1 cm 100% eschar (black dead tissue) -Left medial foot measuring 1 cm x 1.5 cm x 0.1 cm 50% granulation (healthy pink color) and 50% dried serous crust (yellow). -Left foot measuring 2 cm x 1.7 cm x 0.1 cm 50% granulation and 50% dried serous crust. -Left lateral foot measuring 1.5 cm x 2.4 cm x 0.1 cm 100% dried serous crust. -Left distal leg measuring 3 cm x 2.7 cm 100% dried serous crust. -Left proximal leg measuring 12 cm x 13 cm x 0.1 cm 100% dried serous crust. The admission wound assessment revealed that the resident also had an arterial wound to his right great toe measuring 0.4 cm x 0.3 cm 100% eschar. A nursing note dated September 6, 2023, at 1:20 PM revealed that the resident was transported to an outside wound care provider and was now to receive Silvadene and a dry dressing to his left lower extremity wounds as result of that consultation. There was no documentation of the status and condition of the resident's wounds at that time, describing any improvement, declines, measurements and description of appearance. A review of the resident's clinical record revealed no documented evidence that the facility had assessed resident's wound during the week after the resident's admission and documented the wounds' appearance, size, and characteristics. A review of wound assessments revealed that the resident's wounds were not assessed again until September 20, 2023, 19 days after the first and only documented assessment completed by the facility. A review of the wound assessment dated [DATE], revealed only 4 wounds now were being tracked: -Left upper shin measuring 12 cm x 13 cm x 0.1 cm with serous drainage, a pink and yellow wound bed and had a faint odor. -Left pedal area measuring 5 cm x 9 cm x 0.1 cm with serous drainage, a pink and yellow wound bed and had a faint odor. -Left fourth toe measuring 2 cm x 2.5 cm x 0.1 cm with serous drainage, slough(thick yellow material) in the wound bed and had a faint odor. Left inner ankle measuring 1 cm x 1.5 cm x 0.1 cm with serous drainage and a pink wound bed. The facility failed to document the status of the wound on the resident's right great toe on September 20, 2023, and there was no documentation if it was still present or the date it had healed. The facility staff did not assess the resident's wounds again until two weeks later on the October (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 4, 2023. Level of Harm - Minimal harm or potential for actual harm A review of a facility wound assessment dated [DATE], revealed now only assessed two wounds instead of the seven present on admission: Residents Affected - Some -Left fourth toe had deteriorated and is now measuring 4 cm x 3 cm with the depth not measured. The wound had a moderate amount of serous drainage, wound bed was black, and had a moderate odor. -Left leg knee to ankle deteriorated and now is being measured as one wound measuring 36 cm x 11 cm x 0.2 cm. The wound had a moderate amount of serous drainage, a yellow and pink wound bed, and a moderate odor with the area surround the wounds macerated. A facility incident report dated October 6, 2023, revealed that during wound rounds with the facility's contracted wound consultant, staff identified an undetermined number of suspected maggots in the resident's wound of the resident's left fourth toe. The resident's toe was necrotic. The area was cleansed with Dakin's solution, but the wound physician was unable to remove all the maggots. The resident was sent out to the hospital at that time. There was no documented evidence of the presence of maggots in the resident's left toe wound during the assessment on October 4, 2023. There was no documented evidence that the facility's licensed and professional nursing staff had timely and fully assessed the resident's multiple wounds, at least weekly, to timely identify changes potentially requiring new or altered treatments. An interview with the director of nursing (DON) on January 19, 2024, at approximately 11:30 AM confirmed that there was no evidence to show that licensed nuring staff had timely and thoroughly assessed the resident's wounds and documented the status and condition of the wounds at least weekly to track healing, progression, and changes. A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses, which included anxiety and persistent mood disorder. Resident 15 had a current physician order dated April 18, 2023, for Ativan (an anti-anxiety medication) 0.5 milligrams (mg) by mouth two times a day for anxiety. The medication was scheduled for administration at 9:00 AM and 10:30 PM. A review of the resident's Controlled Medication Utilization Record dated from December 23, 2023, through January 11, 2024, revealed that on December 29, 2023, Employee 1, LPN, and Employee 2, LPN, signed the utilization record both signed out a dose of Ativan at 10:30 PM for administration to the resident. A review of Resident 15's Medication Administration Record (MAR) dated December 2023, revealed that on December 29, 2023, Employee 1, LPN, administered the Ativan .5 mg dose at 10 PM. A review of an incident report revealed that Employee 2 LPN pre-poured the Resident 15's scheduled 10:00 PM medications on December 29, 2023, and then Employee 1 LPN administered the medications, not realizing that the Ativan was included, then signing out an additional dose, which then resulted in the administration of an additional dose of Ativan 0.5 mg to the resident on the night of December (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 29, 2023. Level of Harm - Minimal harm or potential for actual harm A review of the resident's clinical record revealed that there was no documented evidence of that a licensed and professional nursing staff had fully assessed the resident's physical status and condition in response to the resident receiving an additional dose of Ativan on December 29, 2023, or had monitored the resident after the double dose of Ativan was erroneously administered to the resident. Residents Affected - Some There was no documentation that a physician or nursing supervisor were notified. A review of Resident 15's Medication Administration Record (MAR) dated January 2024, revealed that on January 15, 2024, nursing staff did not administer the Ativan . 5mg as scheduled for 10:30 PM. A review of the resident's Controlled Medication Utilization Record for dates December 23, 2023, through January 17, 2024, revealed that on January 15, 2024, the 10:30 PM dose of Ativan was not administered to the resident per the physician's order. During an interview January 18, 2024, at approximately 2:30 PM the Director of Nursing (DON) confirmed that nursing staff failed to follow acceptable standards of nursing practice during medication administration resulting in medication error, a double dose, and failed to administer the resident's Ativan as prescribed. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 review of clinical records and staff interview, it was determined that the facility failed to promptly act upon known risk factors for pressure sore development and implement individualized measures to deter skin breakdown and conduct a timely assessment of a resident's pressure sore and assure prompt physician prescribed treatment for one resident out of five sampled with pressure ulcers (Resident 64) Residents Affected - Few Findings include: Review of Resident 64's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of malignant neoplasm (cancerous tumor) of the bladder and lung, abnormal mobility, and abnormal gait (changes in walking pattern, and dysphagia (difficulty swallowing). A review of the resident's plan of care dated August 23, 2023, identified that he was at risk for skin breakdown and actual impaired skin integrity related to decreased mobility and a history of pressure ulcers upon admission. The facility's planned interventions for pressure ulcer prevention and management were to assess and document the status of the area, turn and reposition as indicated, and a bariatric bed with low air loss mattress. A readmission Braden Observation assessment (a tool to assess risk for pressure sores) completed by an RN dated November 22, 2023, at 4:00 PM, revealed that the resident scored 11 indicating that the resident was at high risk for pressure ulcers. Review of Resident 64's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed that the resident had moderate cognitive impairment and had functional limitation in range of motion impairment on both sides of his lower extremities (hip, knee, ankle, foot), extensive assistance of two plus persons physical assist for bed mobility, transfers, and toileting. A review of a SBAR (situation, background, assessment, recommendations) summary (can be used to communicate information between healthcare professionals) completed by Employee 9, a licensed practical nurse (LPN), dated January 8, 2024, at 10:26 PM, revealed that Resident 64 had a change in condition, evidence of a new skin wound or ulcer found. A review of a Pressure/Non-Pressure Skin Assessment investigation completed by Employee 8, a registered nurse (RN), dated January 9, 2024, at 3:35 PM (two shifts after the skin impairment was found), revealed that the wound was a stage 3 pressure ulcer [involves the full thickness of the skin and may extend into the subcutaneous tissue layer and there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface] to the right hip that measured 5.0 centimeters (cm) in length by 2.0 cm in width and 0.2 cm in depth with a small amount of serosanguineous drainage [is a type of wound drainage composed of red blood cells and serum, the clear fluid that surrounds them]. The wound bed had slough [is necrotic tissue that needs to be removed from the wound for healing to take place] and no odor present. The area was in-house acquired and was not present on admission. Resident had complaints of pain when touching the pressure area. Employee 8 noted that the resident only liked to lay on his right side due to significant contractures in all extremities. The facility's noted immediate interventions were to cleanse with NSS (normal saline solution), and apply Santyl and boarder foam dressing daily, and repositioned resident onto his left side to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 remove pressure off his right hip. Level of Harm - Minimal harm or potential for actual harm According to Employee 8's assessment of the resident's pressure sore, the RN noted that the resident only liked to lay on his right side due to significant contractures in all extremities. Prior to the identification of the resident's pressure sore on January 8, 2024, there was no documented evidence that the facility had shown sufficient efforts to address this known risk factor. The resident's clinical record failed to reveal documented evidence of more frequent attempts to turn and reposition the resident off the right side due to known significant lower extremity contractures and positioning that favored his right side, or alternate forms of positioning aides and devices to alleviate pressure on the resident's right side. Residents Affected - Few During an interview with the Director of Nursing (DON) on January 19, 2024, at 9:35 AM, confirmed that the facility could not provide documented evidence that Resident 64's new facility acquired state 3 pressure ulcer was timely assessed by a registered nurse and the attending physician was timely notified for treatment orders and effective pressure relieving preventative measures had been implemented prevent the pressure ulcer to his right hip. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select incident reports, and staff interview it was determined that the facility failed to provide a resident with the necessary amount of staff assistance with activities of daily living, bed mobility, to safely provide resident care based on the resident's current functional abilities and prevent a fall during the provision of resident care, resulting in a fractured nose, for one resident out of 18 sampled (Resident 46). Findings included: A review of Resident 46's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a history of a malignant neoplasm of the brain [is a cancerous brain tumor], chronic pain syndrome, and anxiety. Resident 46's initial fall risk plan identified that the resident was at risk for falls characterized by a history of falls, injury and /or multiple risk factors related to decreased mobility with a noted goal to minimize risks for falls and minimize injuries related to falls. Planned fall prevention interventions were to apply a perimeter mattress and check placement each shift, bed in the lowest position, and to implement preventative fall interventions/devices. The resident was noted to have an ADL/self-care deficit related to pain/decreased mobility with a planned intervention that included transfer with assistance of two with mechanical lift. An MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 29, 2023, revealed that the resident was cognitively intact and required extensive assistance with support of two plus-persons physical assistance for bed mobility and toilet use and extensive assistance of one-person physical assist. A physical therapy (PT) screen dated August 9, 2023, revealed that the resident had a decline in bed mobility and a physical therapy (PT) evaluation and treatment to improve bed mobility and overall function was planned. Resident 46's Physical Therapy Discharge Summary completed by Employee 5, a physical Therapist (PT) for dates of service from August 9, 2023, through September 14, 2023, revealed that the resident's discharge status for bed mobility was maximum assistance, total dependence with attempts to initiate and noted that the resident had increased pain, which limited progress. An incident report for a witnessed fall completed by Employee 6, a registered nurse (RN), dated September 16, 2023, at 4:54 PM, revealed that she was called to Resident 46's room after the resident reportedly fell off the bed while being changed by Employee 7, a nurse aide. Upon arrival to the room, the resident was lying on his back {on the floor}, on the left side of the bed with a bloody nose and a small abrasion was noted on the bridge of the resident's nose. Staff assisted the resident up via Hoyer lift back to bed and assessed to have been alert and oriented times four and vital signs were within normal limits (WNL). Initial neurological check was completed and WNL. Resident 46 reported that when Employee 7 was turning him on to his left side to change his soiled brief that he {Resident 46} lost his grip while holding on to a chair {and fell out of bed}. A review of a fall witness statement completed by Employee 7, a nurse aide, dated September 16, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few 2023, no time indicated, revealed that Resident 46 informed his aide before dinner that he needed to be changed before his relatives arrived. Employee 7 noted I proceeded to clean him {Resident 46}, while I was wiping his bottom, the resident slipped off the bed and landed on his face and right shoulder. I immediately called for help at 4:54 PM, and nursing responded immediately and proceeded to evaluate him and during the evaluation the resident stated that his right arm gave way. Further review of the fall incident report revealed that the physician was notified of Resident 46's witnessed fall and new orders were given to transfer the resident to the emergency room for further evaluation and treatment. A review of a nursing progress note completed by Employee 6, RN, dated September 16, 2023, at 9:36 PM, revealed that the resident was being discharged from the ER with a diagnosis of a non-displaced nasal (nose) fracture with a consult to ENT (ear, nose, and throat specialist) required for repair and to hold Eliquis (blood thinner) through Monday. A review of the facility's Post Fall Huddle Form completed by Employee 8, a RN, dated September 17, 2023, revealed that the root cause of Resident 46's fall from bed was that the air mattress was compressed. The immediate keep safe intervention was an assist of two staff for ADL care. A review of the resident's task summary report dated September 2023, revealed that on September 16, 2023, the date of the incident, the resident's air mattress was last check for proper function at 7:44 AM. There was no documented evidence that the air mattress was checked after 7:44 AM, on September 16, 2023. At the time of survey ending January 19, 2024, the facility was unable to state why Resident 46's safety and fall prevention plan was not revised to reflect physical therapy's discharge status/recommendations for services ending September 14, 2023. indicating that the resident required maximum assistance with bed mobility. The facility failed to provide the necessary staff assistance with bed mobility based on the resident's current functional abilities for bed mobility and the noted declines in the resident's functional status identified prior to the resident's fall to ensure safety during the provision of care. An interview with the Director of Nursing (DON) on January 18, 2024, at approximately 2:35 PM, confirmed that the resident was not provided ADL care based on the resident's current mobility requirements after declines in the resident's functional abilities related to increased pain levels to ensure safety to prevent the fall resulting in non-displaced nasal fractures. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, the DON/designee reviewed all residents ADL care plans to ensure there was bed mobility assistance level. To prevent this from recurring, the DON/designee educated all licensed nursing staff to ensure that on admission or change in condition, that the care plan is updated to reflect bed mobility assistance level and that the letter K is present by tasks to ensure NA can view. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm To monitor and maintain on-going compliance, the DON/designee reviewed five resident care plans weekly times four weeks and then monthly times two to ensure bed mobility assistance level was completed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. Residents Affected - Few The facility's corrective action plan was completed September 25, 2023, and confirmed during the survey of January 19, 2024. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to clinically justify increasing the dose of an antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 15). Findings include: A review of the Resident 15's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The resident had a current physician order dated July 18, 2023, for Seroquel (antipsychotic medication) 25 milligrams (mg) one tablet twice daily related to persistent mood disorder, unspecified psychosis not due to a substance or known physiological condition, hallucinations unspecified, major depressive disorder, recurrent, unspecified, with administration times at 9:00 AM and 5:00 PM. A review of Documentation Survey Report v2 noting the interventions to monitor the resident's behavioral symptoms from January 2023 through May 2023, revealed that staff had not observed any behaviors displayed by the resident. A review of Behavioral Tracking for use of an antipsychotic medication from January 2023 until May 2023 there were no behaviors documented to justify the continued use of Seroquel medication. A pharmacy consultation dated January 2023, revealed that the pharmacist recommended to the physician to attempt a gradual dose reduction (GDR) of the physician prescribed medication Seroquel. The record noted that the physician accepted the recommendation and decreased the dose of Seroquel to 12.5 mg by mouth daily. A review of the clinical record of physician orders revealed that the resident's dose of Seroquel was decreased to 12.5 mg by mouth daily on January 6, 2023. A review of the clinical record revealed that the resident's dose of Seroquel was discontinued on March 14, 2023. Following the discontinuation of the antipsychotic drug Seroquel on March 14, 2023, there was no documented evidence that the resident was displaying behavioral symptoms. Nursing progress notes dated March 27, 2023, that the resident's urine analysis and culture and sensitivty was positive for positive for ([E. coli] a group of bacteria that can cause various illnesses in people). The physician was made aware, and opted not to treat, but to make a urology appointment, which was scheduled for June 21, 2023. Nursing progress notes dated March 28, 29, 31, 2023, revealed that the resident had been repeatedly calling outside providers. The resident was making numerous phone calls to outside facilities including urology related to an upcoming appointment and television companies with questions related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 programs. Level of Harm - Minimal harm or potential for actual harm A physician order dated April 1, 2023, was noted to restart Seroquel 25 mg by mouth daily. Residents Affected - Few Physician/PA/NP Progress Note dated April 12, 2023, at 11:02 PM, revealed that the resident had increased anxiety with obsessive compulsive disorder ([OCD]a pattern of unwanted thoughts and fears known as obsessions) behavior and was calling various companies trying to order services. Seroquel was restarted but consider psych evaluation and trial of Depakote (an anti-seizure medication used for mood disorders). This consideration of Depakote was not attempted, according to the resident's clinical record. Further review of progress notes dated April 13, 2023, at 6:50 PM, the physician contacted nursing staff to inform nursing that the resident called his office with complaints of urinary frequency 12 times the night prior and that her appointment was not until June or July. The physician ordered Amoxicillin (antibiotic medication) 875 milligrams (mg) by mouth twice daily for seven days, based on the results of the resident's prior urine culture (from March 26, 2023). A psychiatric consultation report dated May 17, 2023, revealed that the resident was seen on that day for a psychiatric evaluation, to follow up on behavior management mood. The consult report noted that resident had no delusions. Discussed current mood and behaviors with staff, with no reports of fixated behaviors of continuously calling multiple doctors' offices regarding her medications and appointments. Assessment and plan note no indication of anxiety or depression. Staff reports concerns of fixated thoughts and repetitively calling multiple doctors offices despite being redirected. Seroquel restarted on April 1, 2023, consider increasing to 50 mg by mouth daily for major depressive disorder (MDD) (a mood disorder that causes feeling of sadness and lack of interest) with psych features. A physician order was noted May 19, 2023, to increase of Seroquel to 50 mg by mouth daily. However, there was no documentation of the clinical justification for the increase in dosage of the antipsychotic medication Seroquel for Resident 15. Interview with the nursing home administrator (NHA) and director of nursing (DON) on January 19, 2024, at approximately 11: 00 AM confirmed that the resident's clinical records lacked documentation of clinical justification for increasing the resident's dose of Seroquel and the necessity of the increase in the treatment of the resident's symptoms. 28 Pa. Code 211.2 (d)(3) Medical Director 28 Pa. Code 211.9(a)(1)(k) Pharmacy Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395567 If continuation sheet Page 17 of 17