Inspection visit
Health inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**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 information regarding the resident's wishes.
A review of Pennsylvania Statute Title 20: Chapter 54: Healthcare revealed that an advance health care
directive is a health care power of attorney, a living will, or a written combination of a health care power of
attorney and a living will.
A review of the clinical record revealed that Resident 74 was admitted to the facility on [DATE], with
diagnoses that included esophageal cancer (a tumor that occurs in esophagus - tube which connects from
throat to the stomach, resulting in difficulty in swallowing, chest pain, cough, sudden weight loss and
heartburn), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or
permanently due to different diseases or toxins in the body and may be reversible if the preexisting
disorders are treated), and protein calorie malnutrition ( the state of inadequate intake of food as a source
of protein, calories, and other essential nutrients occurring in the absence of significant inflammation, injury,
or another condition that elicits a systemic inflammatory response).
Review of Resident 74's admission Minimum Data Set (MDS- a federally mandated standardized
assessment process completed periodically to plan resident care) dated November 5, 2024, revealed the
resident was cognitively intact with a BIMS (brief interview mental screening tool used to screen and
identify cognitive impairment) score of 15 (12 to 15 indicates intact cognition).
Resident 74's clinical record revealed a Pennsylvania Physician Orders for Life-Sustaining Treatment
(POLST- The POLST is not intended to replace an advance health care directive document or other
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 23
Event ID:
395567
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
12/12/2024
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 0578
Level of Harm - Minimal harm
or potential for actual harm
medical orders. The POLST process and health care decision-making works best when the person has
appointed a health care agent to speak for them when they become unable to speak for themselves. A
health care agent can only be appointed through an advance health care directive or a health care power of
attorney), but no documented evidence of an Advance Directive or if the facility asked the resident if he
would like information to formulate an advance directive.
Residents Affected - Few
Further review of Resident 74's clinical record failed to reveal documented evidence that facility staff offered
the resident the opportunity to formulate an Advanced Directive. Additionally, there was no documented
evidence that the facility determined if the resident had or did not have an Advance Directive or Healthcare
Power of Attorney.
A review of the clinical record revealed Resident 18 was admitted to the facility on [DATE], with diagnoses
that included unspecified 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).
Review of Resident 18's admission Minimum Data Set (MDS- a federally mandated standardized
assessment process completed periodically to plan resident care) dated November 23, 2024, revealed the
resident was severely cognitively impaired.
Resident 18's clinical record revealed a Pennsylvania Physician Orders for Life-Sustaining Treatment
(POLST- The POLST is not intended to replace an advance health care directive document or other
medical orders, the POLST indicated the resident was a DNR (do not resituate) but there was no
documented evidence of an Advance Directive or evidence that the facility discussed advance directives
and offered the opportunity to formulate one with the residents representative.
Further review of Resident 18's clinical record failed to reveal documented evidence that facility staff offered
the resident the opportunity to formulate an Advanced Directive. Additionally, there was no documented
evidence that the facility determined if the resident had or did not have an Advance Directive or Healthcare
Power of Attorney.
An interview with the social services director (SSD) on December 11, 2024, at 10:30 AM, confirmed there
was no documented evidence to indicate the facility had determined if Residents 74 and 18 had or did not
have an advance directive upon admission to the facility. The SSD confirmed there was no documented
evidence that Resident 72 or Resident 18 were made aware of the right to formulate an advance directive
and that information to formulate an advance directive could be requested and provided by the facility.
28 Pa. Code 201.29 (a)(b) Resident rights
FORM CMS-2567 (02/99)
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Event ID:
Facility ID:
395567
If continuation sheet
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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
12/12/2024
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 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of clinical records and facility-initiated transfer notices and a staff interview, it was determined the
facility failed to provide written notices of facility-initiated hospital transfers to the resident and their
representative for one resident out of the 18 sampled (Resident 2).
Findings include:
A review of Resident 2's clinical record revealed the resident was initially admitted to the facility on [DATE]
with diagnoses that included chronic obstructive pulmonary disease.
A review of the clinical record revealed that Resident 2 was transferred to the hospital on November 20,
2024, and was readmitted to the facility on [DATE].
A review of the clinical record failed to reveal documented evidence the facility provided the resident and
the resident's responsible party (RP) with a written notice of the facility-initiated transfer and reason for the
transfer on November 20, 2024.
An interview with the Nursing Home Administrator on December 12, 2024, at 9:10am, confirmed the facility
had no documented evidence Resident 2's responsible parties were provided with a written notice of the
facility initiated transfer that was initiated on November 20, 2024.
28 Pa. Code 201.14(a) Responsibility of licensee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 3 of 23
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
12/12/2024
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 0625
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of clinical records and a staff interview, it was determined that the facility failed to provide written
notice of the facility's bed hold policy to a resident and the resident's representative upon the resident's
transfer to the hospital for one resident out of the 18 sampled (Resident 2).
Findings include:
A review of the clinical record revealed that Resident 2 required transfer to the hospital on November 20,
2024, and was readmitted to the facility on [DATE].
There was no documented evidence that the residents and/or their responsible parties or legal
representatives were provided written information about the facility's bed-hold policy (an agreement for the
facility to hold a bed for an agreed upon rate during a hospitalization) at the time of transfer.
During an interview on December 12, 2024, at approximately 9:10 am, the Nursing Home Administrator
(NHA) was unable to provide evidence that the facility made Resident 2 and their representative, aware of a
facility's bed-hold and reserve bed payment policy upon transfer to the hospital.
28 Pa Code 201.18 (e)(1) Management
28 Pa Code 201.29 (a) Resident rights
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 4 of 23
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
12/12/2024
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of clinical records 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).
Residents Affected - Few
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 restraints or require restraints and confirmed the quarterly
MDS November 2, 2024, Section P0100 Restraints was coded in error to indicate the resident had a
restraint in place.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 5 of 23
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
12/12/2024
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
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.
Residents Affected - Few
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 suppository; 10 mg; insert 1 suppository rectally as needed for constipation if no BM on the
fourth day and no result from MOM.
-Enema (Mineral Oil), insert 1 application rectally as needed for constipation if no BM on the fifth day and
no result from the suppository notify md if no bowel movement.
Review of Resident 59's bowel tracking for November 2024, revealed that Resident 59 did not have a bowel
movement on November 19, 20, 21, 22, and 23, 2024.
Review of Resident's Medication Administration Record (MAR) for November 2024, revealed no
documented evidence that nursing administered the prescribed bowel protocol during the time period
without a bowel movement to promote bowel activity.
There was no documented evidence the staff had notified the physician the resident went five consecutive
days, November 19, 20, 21, 22, and 23, 2024, without a bowel movement.
During an interview with the Director of Nursing (DON) on December 12, 2024, at 9:20 AM, the DON was
unable to provide evidence the physician ordered bowel protocol was followed for Resident 59 during the
period without bowel activity stated above, nor evidence of timely physician notification.
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa. Code 211.5(f) Medical records
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 6 of 23
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
12/12/2024
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**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 can be written in the initial
evaluation for resident participation in the restorative program. It was indicated the restorative program is a
nursing program and is at the discretion of the nursing restorative coordinator. Further a care plan will be
developed for a restorative program.
Clinical record review revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses which
included diabetes and muscle weakness.
A quarterly MDS (Minimum Data Set - a federally mandated standardized assessment conducted at
specific intervals to plan resident care) dated November 20, 2024, revealed the resident to be cognitively
intact with a BIMS score of 15 (BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen
and identify the cognitive condition of residents upon admission into a long-term care facility. A score of
13-15 indicates cognitively intact) and required staff assistance for activities of daily living.
A review of a physical therapy Discharge summary dated [DATE], revealed a recommendation of
discharged from therapy services and start restorative nursing program (RNP) for range of motion of
bilateral lower extremities.
A review a care plan for ADL functional status/rehabilitation dated May 22, 2024, restorative nursing
interventions to include active range of motion to left lower extremities for 30 repetitions and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 7 of 23
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
12/12/2024
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 0688
passive range of motion to right lower extremity for 30 repetitions.
Level of Harm - Minimal harm
or potential for actual harm
A review of nursing staff documentation dated November 1, 2024, through November 30, 2024, revealed
that staff completed RNP exercises for Resident 6 daily for between 2 minutes and 30 minutes daily.
Residents Affected - Some
There were no nursing evaluations of the RNP program to include resident progress, the continuation of the
services or the need to revise the program from the inception of the program May 22, 2024, through the
end of the survey December 12, 2024.
During an interview on December 11, 2024, at approximately 11:00 AM, the Assistant Director of Nursing
confirmed residents RNP programs should be evaluated monthly and documented in the medical record.
She stated that she had not reviewed any of the programs since taking over the program in May 2024.
During an interview December 12, 2024 at 10:00 AM, the Nursing Home Administrator confirmed it is the
facility's responsibility and policy to ensure residents receive appropriate services and assistance to
maintain or improve mobility with the maximum practicable independence.
28 Pa. Code: 211.12(d)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 8 of 23
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
12/12/2024
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**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 possible.
Additionally, the policy indicted that a Continence Evaluation will be conducted to determine if a 72-hour
Bowel and Bladder Tracking is indicated. If tracking is indicated, the licensed Nurse will instruct the nursing
assistants (NA) to fill out the form. When a new pattern has been identified, a new Continence Evaluation
will be completed and the licensed nurse will develop a toileting plan, determining the approaches needed
to achieve the goal(s), establish the type of staff intervention needed to meet each resident's goal(s), select
equipment and aids needed to be successful and note the interventions, and review the plan as needed to
identify any necessary modifications.
A review of Resident 27's clinical record revealed that the resident was most recently readmitted to the
facility on [DATE], with diagnoses that included sepsis (an infection of the blood stream resulting in a cluster
of symptoms such as drop in a blood pressure, increase in heart rate and fever), COPD (chronic obstructive
pulmonary disease an ongoing lung condition caused by damage to the lungs and the damage results in
swelling and irritation), and morbid obesity (is a complex chronic condition that can lead to several serious
health issues).
A review of the resident's Admission/readmission Observation completed by Employee 1 RN (registered
nurse) dated September 27, 2024, at 4:49 PM, revealed the resident always was incontinent of urine and
always incontinent of bowel and required adult incontinence briefs to manage incontinence.
Additionally, at the time of the readmission observation assessment, Employee 1 initiated a Continence and
Retraining/Scheduled Toileting and Decision/Determination Observation form that indicated bladder and
bowel were to be assessed due to readmission. Resident 27's had a history of UTI's (urinary tract
infections), functionally was unable to walk to the bathroom which required the use of a wheelchair for
locomotion, and usually aware of her toileting needs.
However, Resident 27's Continence and Retraining/Scheduled Toileting and Decision/Determination
Observation form failed to reveal that staff completed a 72-hour bladder and bowel tracking form to assess
the resident's continence to potentially implement a scheduled toileting program, as practicable, or develop
individualized incontinence management schedule.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 9 of 23
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
12/12/2024
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
A review of Resident 27's comprehensive person-centered plan of care revealed the facility failed to
indicate the resident's bladder and bowel continence status or her individualized toileting/incontinence
management program to ensure the resident's highest practicable level of independence and dignity.
During an interview with the Assistant Director of Nursing (ADON) on December 12, 2024, at 9:17 AM,
revealed that the facility could not provide documented evidence that Resident 27's bladder and bowel
continence/incontinence was assessed, and that a 72-hour bladder and bowel tracker was completed as
per facility policy.
A review of the clinical record revealed that Resident 74 was admitted to the facility on [DATE], with
diagnoses that included esophageal cancer (a tumor that occurs in the tube which connects from throat to
the stomach resulting in difficulty in swallowing, chest pain, cough, sudden weight loss and heartburn),
metabolic encephalopathy (is a condition in which brain function is disturbed either temporarily or
permanently due to different diseases or toxins in the body), and protein calorie malnutrition (is the state of
inadequate intake of food),
A review of the resident's Admission/readmission Observation completed by the ADON dated October 31,
2024, at 5:05 PM, revealed that the resident was able to stand and pivot from wheelchair with assistance,
was alert and oriented and understands clear-comprehension, and always continent of urine with use of
urinal. The resident's bowel continence section was not completed.
A review of Resident 74's admission Minimum Data Set assessment (MDS - a federally mandated
standardized assessment process conducted periodically to plan resident care) dated November 5, 2024,
revealed that the resident was cognitively intact with a BIMS (brief interview mental screening tool used to
screen and identify cognitive impairment) score of 15 (12 to 15 indicates cognitive intact), required
substantial/extensive assistance from staff for transfers, and toileting, and toileting hygiene.
Additionally, the admission MDS was coded to indicate that a trial urinary and trial bowel toileting program
was not attempted and was occasionally incontinent of urine, frequently incontinent of bowel, and was not
on a bladder or bowel toileting program.
Resident 74's clinical record failed to reveal any documented evidence that continence/incontinence status
was assessed to develop and implement an individualized toileting or incontinence management program
to ensure the resident's highest practicable level of independence and dignity.
An interview with the Assistant Director of Nursing (ADON), on December 12, 2024, at 9:30 AM, revealed
the facility could not provide documented evidence that upon admission Resident 74's bladder and bowel
continence/incontinence was assessed, and that a 72-hour bladder and bowel tracker was completed as
per facility policy, and plan of care was fully developed to reflect the resident's toileting needs.
At the time of the interview with the ADON, it was confirmed that upon admission the facility failed to
assess Resident 27 and Resident 74's bladder and bowel continence/incontinence and failed to complete a
72-hour bladder and bowel tracker as per facility policy, and that the facility failed to fully develop a plan of
care to reflect the resident's toileting needs to ensure the resident's highest practicable level of
independence and dignity.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 10 of 23
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
12/12/2024
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 0690
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 211.10(a)(d) Resident care policies
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 11 of 23
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
12/12/2024
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 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of clinical records 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).
Residents Affected - Few
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 facility failed to develop and implement an individualized person-centered plan to address, this
resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional
well-being and safety.
Interview with the Director of Social Services on December 11, 2024, at approximately 11:00 a.m.,
confirmed she was unaware of the resident's PTSD diagnosis and there had not been a care plan in place
to address the resident's diagnoses of PTSD.
Interview with the Nursing Home Administrator on December 11, 2024, at 1:00 p.m., confirmed the facility
was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance
with professional standards of practice and accounting for resident's experiences and preferences to
eliminate or mitigate triggers that may cause re-traumatization of the resident.
28 Pa Code 211.12 (d)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 12 of 23
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
12/12/2024
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 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of clinical records 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).
Residents Affected - Some
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 person-centered plan for the resident's dementia care,
while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety
and using individualized, non-pharmacological approaches to care, including purposeful and meaningful
activities that address the resident's customary routines, interests, preferences, and choices to enhance the
resident's well-being.
The facility failed to develop and implement an individualized person-centered plan to address, modify and
manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include
individualized interventions based on an assessment of the resident's preferences, social/past life history,
customary routines, and interests in an effort to manage, modify or decrease the resident's
dementia-related behavioral symptoms.
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 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 the resident's care plan initiated July 18, 2022 for cognitive deficit indicated the resident had 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).
A review of the resident's current care plan, initially dated April 15, 2024, in effect at the time of the survey
ending December 12, 2024, revealed no documented evidence the facility had developed an individualized
person-centered plan for the resident's dementia care, while maximizing the resident's dignity, autonomy,
privacy, socialization, independence, choice, and safety and using
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 13 of 23
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
12/12/2024
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 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that
address the resident's customary routines, interests, preferences, and choices to enhance the resident's
well-being.
The facility failed to develop and implement an individualized person-centered plan to address, modify and
manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include
individualized interventions based on an assessment of the resident's preferences, social/past life history,
customary routines, and interests in an effort to manage, modify or decrease the resident's
dementia-related behavioral symptoms.
Interview with Nursing Home Administrator on December 12, 2024, at approximately 10:00 AM, confirmed
the facility was unable to provide evidence of the development and implementation of an individualized
person-centered plan to address the resident's dementia care.
28 Pa Code 211.12 (d)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 14 of 23
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
12/12/2024
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 - Some
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 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 at bedtime for depression, Trazadone 200 mg (an antidepressant
medication) by mouth at bedtime for depression, and Sertraline 50 mg (an antidepressant medication) by
mouth at bedtime for depression.
A review of a pharmacy consultation report dated October 14, 2024 completed by the consultant facility
pharmacist recommended a gradual dose reduction (GDR) of the residents Mirtazapine 7.5 mg
antidepressant medication.
The GDR request was declined by the RN nurse practitioner on October 17, 2024. The documented
reasoning was resident recently hospitalized secondary to behavior against staff. A GDR is contraindicated.
A review of a pharmacy consultation report dated November 15, 2024 completed by the consultant facility
pharmacist recommended a gradual dose reduction (GDR) of the residents Trazadone antidepressant
medication.
The GDR request was declined by the physician assistant on November 19, 2024. The documented
reasoning stated Residents psych medications are managed by the consultant psychiatrist. Please defer to
this physician for medication management.
Further review of the pharmacy consultant report failed to include a resident specific rationale to justify the
continued use of the multiple antidepressants in use for this resident.
In addition, there was no documented evidence at the time of the survey to justify the concurrent use of
multiple antidepressant medications for this resident.
An interview with the Director of Nursing (DON), on December 11, 2024, at approximately 1:00 PM,
confirmed the facility failed to ensure that Resident 19's attending physician provided clinical
justification/rationale for the continued administration of antidepressant medication and the concurrent
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 15 of 23
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
12/12/2024
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
use of multiple antidepressant medications.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 211.9 (k) Pharmacy services.
28 Pa. Code 211.12 (c) Nursing services.
Residents Affected - Some
28 Pa. Code 211.2 (d)(3) Medical Director
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 16 of 23
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
12/12/2024
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**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 include the dementia care plan for Resident 19, from the initial electronic
medical record system to the system currently in use at the facility at the time of the survey ending
December 12, 2024.
During an interview conducted on December 11, 2024, 11:00 AM, the Director of Nursing (DON) confirmed
that Resident 19's current care plan was incomplete. She stated that the facility changed electronic records
systems on April 8, 2024, and all the resident medical information was not transferred from the prior
electronic clinical records to the current system. The DON stated she did not know how many of the current
residents at the time of the survey had complete medical records.
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 17 of 23
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
12/12/2024
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 0865
Have a plan that describes the process for conducting QAPI and QAA activities.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Some
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 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 indicated 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 include the dementia care plan for Resident 19, from the initial electronic
medical record system to the system currently in use at the facility at the time of the survey ending
December 12, 2024.
During an interview conducted on December 11, 2024, 11:00 AM, the Director of Nursing (DON) confirmed
that Resident 19's current care plan was incomplete. She stated that the facility changed electronic records
systems on April 8, 2024 and all the resident medical information was not transferred from the prior
electronic clinical records to the current system. The DON stated she did not know how many of the current
residents at the time of the survey had complete medical records.
During an interview December 12, 2024, the DON and NHA confirmed the ongoing issue regarding the
transfer of medical records into the current electronic medical record was not part of the ongoing quality
assurance program at the facility.
The facility's quality assurance monitoring plans designed to ensure solutions were sustained, failed to
identify the continuing deficient practice with these quality requirements and prevent deficient practice.
Refer F744, F842
28 Pa. Code 211.12(c) Nursing services
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 18 of 23
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
12/12/2024
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 0865
28 Pa. Code 201.18(e)(1) Management
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 19 of 23
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
12/12/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**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).
Residents Affected - Some
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 treat residents infected with and sensitized to scabies and to prevent the spread
of scabies to other residents and staff.
Affected residents should remain in contact precautions until 24 hours after treatment. Exposed staff
members should report any rashes developing on their bodies to the Infection Preventionist or DON
(Director of Nursing). A resident sharing a room with someone infected with scabies will be monitored for
scabies. If symptoms are not present, daily assessments will occur until the case is resolved.
Clinical record review revealed that Resident 56 was admitted to the facility on [DATE], with diagnoses to
include heart failure, hypertension (high blood pressure), and anxiety.
A quarterly MDS assessment (Minimum Data Set - a federally mandated standardized assessment
conducted at specific intervals to plan resident care) dated September 2, 2024, revealed the resident to be
moderately cognitively impaired with a BIMS (Brief Interview for Mental Status, a short cognitive screening
tool used to assess a person's cognitive functioning) score of 12 (a score of 8 to 12 suggests moderate
cognitive impairment) and required staff assistance for activities of daily living.
A review of a care plan initiated October 29, 2024 for skin integrity revealed the resident had a rash related
to scabies with interventions to include, conduct a systematic skin inspection per facility policy, dermatology
consult as needed, discourage resident from scratching area to reduce tissue damage, encourage resident
to request medication before symptoms become unbearable, record the location, size (length, width, and
depth), color, distribution, contour, consistency of rash(s) per facility policy, and monitor, document, and
report to the provider any changes in color, temperature, sensation, pain or presence of drainage and/ or
odor.
A review of nursing notes dated September 19, 2024, at 7:50 P.M. revealed the resident's daughter
reported Resident 56 had a small rash on her upper right arm, and a small red area was noted. The
Resident was noted to be scratching at the area. The rash was cleansed with soap and water. A note was
left for the physician to examine the resident.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 20 of 23
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
12/12/2024
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 0880
There was no documented nursing skin assessment completed at that time.
Level of Harm - Minimal harm
or potential for actual harm
A review of nursing progress note dated September 20, 2024, at 4:56 P.M. revealed the nurse practitioner
was in to see the resident and address the family concerns of the itchy rash. A new order was noted for
Hydrocortisone cream 1% (steroid cream) to the rash twice a day until resolved and then reassess.
Residents Affected - Some
A review of a nursing progress note dated September 27, 2024, at 12:51 P.M. revealed the physician was in
to see and examine the resident. The resident complained to the physician about an itchy rash to her right
arm. New orders were noted to start a Medrol dose pack (oral steroids) and Clobetasol 0.05% cream (a
medication used to treat skin conditions) twice a day for 5 days.
A review of a skin assessment dated [DATE] revealed, an existing skin issue noted, scab on lower mid
back, with no redness. There was no documentation of a rash on the assessment form at that time.
A review of a nursing progress note dated October 6, 2024, at 8:51 A.M. revealed the physician was in to
see the resident and a new order was noted to start Claritin (oral allergy medication)10 mg by mouth, daily
for itch and Betamethasone (topical steroid cream)0.05 topical ointment apply topically to affected areas
twice daily.
A review of a skin assessment dated [DATE], revealed, an existing skin issue noted. Scratches on lower mid
back/ sacrum with no redness or drainage. There was no documentation of a rash on the assessment form
at that time.
A review of a nursing progress note dated October 16, 2024, at 2:17 P.M. indicated the nurse practitioner
saw the resident and discontinued the Claritin and wrote a new order to start Allegra (an oral allergy
medication) 180 mg PO (by mouth) daily.
A review of a skin assessment dated [DATE] revealed, an existing skin issue noted, dermatitis throughout
the resident's body with mid back and sacrum scratches.
A review of a skin assessment dated [DATE] revealed, an existing skin issue noted, scratches on the lower
mid back and sacrum. No redness or drainage. Small red itchy bumps noted over te resident's entire body.
A review of a psychiatry note dated October 28, 2024, 8:24 A.M. by the contracted nurse practitioner stated
the resident was seen for a follow up psychiatry visit. The resident stated that her mood is frustrated. The
resident spoke in depth regarding her rash and management by her attending physician and lack of sleep.
The resident reported anxiety related to her current situation.
A nursing note dated October 28, 2024, at 11:48 A.M. revealed, a call was placed to dermatology and an
appointment was scheduled for October 29, 2024 at 9:00 A.M.
A nursing note dated October 29, 2024, at 10:34 A.M. revealed the resident returned from the dermatology
appointment with diagnosis of scabies. A new order was noted to discontinue the Betamethasone (steroid
cream) cream and to start Permethrin (anti-scabies treatment) cream apply topically from head to toe when
sent from pharmacy, wash off in shower 12 hours post application, maintain contact precautions. Further
recommendations included, clothing and bedding should be washed in hot water and any roommate should
be treated for possible scabies.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 21 of 23
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
12/12/2024
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnosis to
include after care for a fracture (broken bone) and non-Hodgkin lymphoma (cancer). Resident CR1 and
Resident 56 were roommates since Resident CR1's admission to the facility.
There was no evidence that after the October 29, 2024, dermatology consultation that Resident CR1 or her
responsible party were notified of the diagnosis of scabies and offered treatment as recommended by the
dermatology office.
A review of nursing documentation dated November 4, 2024 at 11:28 A.M. revealed nursing assessed the
resident's skin fully. The resident had small areas where a rash remained. Multiple self-inflicted scratch
marks were noted to bottom and top of the arms where there was no rash. The resident still complained of
itching.
A nurses note dated November 4, 2024 at 4:03 P.M. revealed the physician was called regarding the
resident's itching and a new order was noted for Benadryl (an allergy medication) 25mg by mouth every 6
hours as needed for 1 week.
A nurses note dated November 4, 2024, at 9:28 P.M. revealed the resident was upset rolling up and down
halls and day room cursing at staff about medicines, other residents, her medical records, and food. The
resident was unwilling/unable to articulate what was bothering her. Staff asked the resident to please refrain
from bad language in public areas. The resident was offered Benadryl for itching, snacks, and drinks.
Further the resident indicated she wants a lawyer to make her itching stop.
A review of a skin assessment dated [DATE], revealed, an existing skin issue noted, scratches on lower mid
back, pimple-like area to right scapula, a rash to right mid back and flank area, and a rash to the right
breast and under the right breast. There were no measurements for the noted areas or any additional
description of the areas.
A nurses note dated November 5, 2024, at 1:28 P.M. indicated dermatology was called regarding the
resident's continued complaints of itching, informed of new areas of concern. A new order was noted to
start Betamethasone (steroid cream) ointment twice a day.
A nursing progress note dated November 5, 2024, at 10:35 P.M. revealed the second dose of permethrin
cream was applied and was scheduled to be washed off in the morning.
A nurses note dated November 12, 2024, at 1:43 P.M. revealed, the resident was assessed with nursing
and physician assistant. A new order noted for Caladryl (anti itch lotion) three times a day and make a
follow up appointment with dermatology.
A nurses note dated November 13, 2024, at 2:26 P.M. revealed the resident returned from the dermatology
appointment with new orders for Ivermectin (an oral anti scabies medication) 3 mg, take 4 tablets by mouth
on day 1 and repeat 14 days later.
A review of a dermatology consultation report dated November 13, 2024, revealed the resident was seen
for a follow up visit for scabies. The areas affected were noted as the arms, abdomen, back, buttocks,
breast, chest, and legs. The areas were noted as worsened. The physician's findings included small
papules and burrows with scales, excoriations, and crust located on the arms, breasts, abdomen, back and
buttocks. Another two applications of the Permethrin cream was ordered at that time.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 22 of 23
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
12/12/2024
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
There was no evidence at the time of the survey that comprehensive and accurate skin assessments were
completed for Resident 56 with symptoms displayed since September 19, 2024 to the survey ending
December 12, 2024.
An interview with the ADON on November 11, 2024, at approximately 1:00 PM verified the facility failed to
implement proper infection control practices, including the facility's established policy and procedures for
skin assessments to prevent and mitigate further spread of scabies.
28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services
28 Pa. Code 201.18 (b)(1)(e)(1) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395567
If continuation sheet
Page 23 of 23
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F758 - Medication Errors
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.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 12, 2024 survey of DUNMORE HEALTH CARE CENTER?
This was a inspection survey of DUNMORE HEALTH CARE CENTER on December 12, 2024. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DUNMORE HEALTH CARE CENTER on December 12, 2024?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.