Health inspection·July 25, 2023

F 0600 Level of Harm - Actual harm Residents Affected - Few the floor on the side of the bed. The note indicated that the resident fell off the mechanical lift while being transferred from an electric wheelchair to a bed. The resident reported falling off the lift and denied a head injury; however, facility staff stated that blood was present on the floor. A nursing progress note dated March 1, 2023, at 12:25 p.m. indicated that Resident 30 was to be transported to the the emergency room for evaluation and possible treatment after sustaining an injury. The hospital history and physical dated March 2, 2023, at 9:47 a.m., noted that Resident 30 sustained a hematoma (collection of blood outside of the blood vessels) on the back of the head, a 4 cm laceration on the scalp requiring sutures, a right femur (thigh bone) closed fracture requiring surgery, and ecchymosis (bruising) on the right leg. The hospital documentation indicated that while receiving treatment in the hospital, the resident became tachycardic (accelerated heart rate), was administered a blood transfusion, and was then admitted to the intensive care unit. The hospital operative report, dated March 2, 2023, at 9:17 a.m., noted that Resident 30's femur was surgically repaired, and a drain was inserted in the resident's right calf to reduce extreme swelling and serous blisters (blisters filled with clear liquid). Nursing notes March 9, 2023, at 12:26 p.m. indicated that the resident returned to the skilled nursing facility. admission nursing skin observation dated March 9, 2023, indicted that Resident 30 was assessed with the following injuries: Jawline bruising measuring 9.0 cm x 3.0 cm Laceration on the back of the scalp measuring 4.0 cm x 3.0 cm Right hip sutures measuring 3.0 cm x 2.0 cm Left antecubital (area of the arm opposite the elbow) bruising measuring 2.0 cm x 1.0 cm Right antecubital (area of the arm opposite the elbow) bruising measuring 7.0 cm x 4.0 cm Left lower leg bruise measuring 15.0 cm x 13.0 cm A second left lower leg bruise measuring 13.0 cm x 13.0 cm Nursing progress notes and the resident's March 2023 Medication and Treatment Records for March 2023 revealed that Resident 30 reported experiencing intermittent pain ranging from mild to severe from March 9, 2023, through March 19, 2023. A review of the facility's investigation report revealed that Resident 30 fell and sustained injuries when Employee 1, nurse aide, failed to follow the resident's plan of care and attempted to transfer the resident with the mechanical lift without the assistance of a second staff member present. The facility's investigation also determined that Employee 1 provided false statements during their investigation regarding the number of staff that were utilized to transfer Resident 30 at the time of the incident. A witness statement provided by Employee 2, nurse aide, dated March 2, 2023, indicated that {Resident 30} was laying on the ground by (the) bed, with the Hoyer pad still attached to the machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 2 of 6 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 395491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stroudsburg Post Acute Nursing & Rehabilitationllc 4227 Manor Drive Stroudsburg, PA 18360 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 0600 Level of Harm - Actual harm {Employee 1} was the only staff person in the room. Employee 2 also indicated that Employee 1 attempted to have Employee 2 provide a false statement about the incident. In the same statement, Employee 2 reported that {Employee 1} kept coming up to me and saying, stick to what I told you that you were in the room, and you don't know anything else. Residents Affected - Few An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 25, 2023, at approximately 2:30 p.m., confirmed that Employee 1 transferred Resident 30 without the assistance of a second person as the resident required resulting in serious physical injury to the resident. Clinical record review revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses to include incomplete quadriplegia (severe or complete loss of motor function in all four limbs) and neurogenic bowel (loss of bowel control due to brain or spinal cord damage). A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 20, 2023, indicated that Resident 42 was dependent on facility staff and required the assistance of two staff members for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) and toilet use (how resident uses the toilet room, commode, bedpan, or urinal and transfers on or off toilet) and was cognitively intact with Brief Interview for Mental Status (BIMS - a tool to assess cognitive function) score was 15. Resident 42's plan of care in place for activities of daily living (ADLs) dated April 13, 2023, revealed a self-care performance deficit due to quadriplegia, limited physical mobility, and limited range of motion with planned interventions that Resident 42 would continue with the bowel program nightly and continue to use a bedpan. Resident 42's plan of care, dated April 13, 2023, also indicated that the resident was at risk of developing impaired skin integrity due to decreased mobility with planned interventions for staff to turn and reposition the resident every 2 hours while in bed. During an interview on July 25, 2023, at 10:30 a.m., Resident 42 stated that the planned bowel program begins at 10:00 p.m. Staff administer the resident's first enema at 10:00 p.m. and a second enema at 11:00 p.m. After receiving the enema, the resident sits on the bed pan until he has a bowel movement and staff provide care. The resident further explained that on May 21, 2023, after being administered the second enema, no staff came to remove the bed pan. I don't have much sensation below my waist, so I remember being uncomfortable, but I didn't feel the bed pan. I fell asleep, and it wasn't until the morning that staff noticed that I was still on the pan. Staff did not turn me throughout the night. The resident's clinical record failed to reveal evidence that staff turned and repositioned every two hours on May 21, 2023 11:00 p.m. through May 22nd, 2023 8:00 a.m., as indicated in the resident's plan of care. The facility investigation dated May 22, 2023, included a witness statement from Employee 6, nurse aide, indicating the Employee 6 rolled Resident 42 in the morning of May 22, 2023, the bedpan was stuck to the resident's buttocks, and feces were observed everywhere. Employee 6 indicated that the resident's skin had huge indentations from the bed pan and the resident was covered with blood, feces, and urine. A nursing progress note dated May 22, 2024, at 9:00 a.m. indicated that Resident 42 was found on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 3 of 6 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 395491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stroudsburg Post Acute Nursing & Rehabilitationllc 4227 Manor Drive Stroudsburg, PA 18360 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 0600 the bedpan while in bed. The resident's skin was observed to have bilateral buttocks wounds, bilateral posterior thighs wounds, and a sacrum wound. Level of Harm - Actual harm A skin observation tool dated May 22, 2023, indicated that the resident had the following skin injuries: Residents Affected - Few Sacrum pressure injury measuring 1.3 cm x 11.0 cm x 0.1 cm (Stage II Pressure Injury- Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. This includes intact or ruptured blisters. Stage 2 pressure ulcers are shallow with a reddish base) Left buttock pressure injury measuring 9.3 cm x 1.2 cm x 0.2 cm (Stage II Pressure Injury) Right buttock pressure injury measuring 9.3 cm x 1.0 cm x 0.2 cm (Stage II Pressure Injury) Left gluteal fold pressure injury measuring 3.0 cm x 0.6 cm x 0.2 cm (Stage II Pressure Injury) Right gluteal fold pressure injury measuring 3.0 cm x 0.8 cm x 0.2 cm (Stage II Pressure Injury) Left rear thigh pressure injury measuring 8.5 cm x 0.8 cm x 0.2 cm (Stage II Pressure Injury) Right rear thigh pressure injury measuring 19 cm x 0.7 cm x 0.2 cm (Stage II Pressure Injury) A witness statement provided by Employee 3, licensed practical nurse, dated May 22, 2023, at 12:50 p.m. indicated that she went to Resident 42's room around midnight (May 21, 2023 into May 22, 2023). Employee 3 stated that the resident did not report being on a bedpan. Employee 3 stated that everyone knows the 11 PM to 7 AM shift takes the resident off the bedpan. Employee 3 stated that Employee 4, nurse aide, should have taken him off the bedpan. A witness statement provided by Employee 4, nurse aide, dated May 22, 2023 p.m. revealed that she denied placing a bedpan under the resident. Employee 4 stated, No one informed me that a bedpan was placed under him. I did my last rounds around 4:00 a.m. (May 22, 2023) Employee 4 indicated that the resident was last turned and checked at 4:00 a.m. (May 22, 2023) An employee witness statement dated May 22, 2023, by Employee 5, licensed practical nurse, indicated that Resident 42 was administered a first enema at 11:00 p.m. (on May 21, 2023) and a second enema at 12:00 a.m. (on May 22, 2023) Also, Employee 5 stated that a verbal report was provided to Employee 3 with the time Resident 42 was administered the last enema and instructions that the resident was still on the bedpan and needed to be cleaned up. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 25, 2023, at approximately 2:30 p.m., that staff neglected to provide Resident 42 the care planned for the resident's bowel program and turning and repositioning to prevent multiple skin injuries. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 4 of 6 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 395491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stroudsburg Post Acute Nursing & Rehabilitationllc 4227 Manor Drive Stroudsburg, PA 18360 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interviews, it was determined that the facility failed to implement pharmacy procedures to ensure timely acquiring and administering a medication prescribed for one resident out of seven sampled (Resident 42). Findings include: A clinical record review revealed Resident 42 was admitted to the facility on [DATE], with diagnoses to include incomplete quadriplegia (severe or complete loss of motor function in all four limbs) and atopic neurodermatitis (skin condition that starts with an itchy patch of skin. Scratching makes it itch more, itching can be so intense it disrupts sleep and quality of life) and is cognitively intact. During an interview with Resident 42 on July 25, 2023, at approximately 11:30 a.m. he stated that he had not received a medication prescribed by his Dermatologist because the facility didn't have it. Review of resident's clinical record revealed that he was readmitted to the facility on [DATE], after being hospitalized . The resident had a current physician order, initially dated May 14, 2023, for Nicotinamide oral tablet 750-27-2-0.5 mg (Niacinamide w/ zinc-copper-methylfolate-Se-Cr) daily as recommended by dermatologist (Niacinamide or nicotinamide is a form of vitamin B3 found in food and used as a dietary supplement and medication). Further review of the resident's physician orders revealed that the medication was on order. Review of Resident 42's medication administration record (MAR) dated May 2023, indicated staff documented that the medication was administered to the resident daily from May 15, 2023, through May 28, 2023. On May 29, 2023, the MAR indicated to see progress notes, but there was no corresponding progress note. On May 30, 2023, and May 31, 2023, the MAR staff also documented that the medication was administered as ordered. Review of Resident 42's MAR dated June 2023, indicated on June 1, 2023, to see progress note. This progress note dated June 1, 2023, at 7:45 a.m. indicated that the medication was not administered but on order, follow up with pharmacy to be completed today. Further review of June 2023 MAR indicated that staff documented that the medication was administered to the resident on June 2, 2023 and June 3, 2023. A progress note dated June 4, 2023, at 8:07 a.m. indicated that the medication was not administered and call pharmacy to inquire on expected delivery date. According , 2023, through June 26, 2023. A nursing progress note dated June 27, 2023, at 9:05 a.m. indicated that the medication was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 5 of 6 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 395491 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stroudsburg Post Acute Nursing & Rehabilitationllc 4227 Manor Drive Stroudsburg, PA 18360 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 0755 administered as ordered and that it was ok to hold till arrival from pharm. [pharmacy]. Level of Harm - Minimal harm or potential for actual harm Review of pharmacy invoice for Resident 42, revealed that the pharmacy did not provide the resident's physician ordered Nicotinamide supplement until June 29, 2023, despite nursing staff documentation that the medication was administered to the resident daily during the months of May 2023 and June 2023. Residents Affected - Some Interview with the Director of Nursing (DON) on July 25, 2023, at approximately 3:00 p.m. failed to provide documented evidence that the physician ordered medication was timely delivered to the facility and available for administration to the resident when needed. Further interview with the DON confirmed that the facility's licensed nurses failed to accurately document the administration of the medication on the resident's MAR for the months of May and June 2023. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 6 of 6