Health inspection·September 15, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on the minutes from Resident Council meetings and the facility's call bell audits and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by nine (9) of nine (10) residents attending a group meeting (Residents 2, 3, 9, 15, 18, 36, 42, 59, and 74). Residents Affected - Some Findings Include: During a group meeting conducted on September 13, 2023, at 10:00 a.m. with 10 alert and oriented residents, nine residents (Residents 2, 3, 9, 15, 18, 36, 42, 59, and 74) voiced concerns over long waits for staff to respond to their call bells when care and assistance is needed. The resident stated that there have been recent incidents when they have waited over an hour for nursing staff to respond to their call bells. The residents in attendance at this meeting reported voicing their concerns over the past few months during Resident Council meetings and through individual grievances. The residents stated that the issue with the long waits for staff to respond to their requests for assistance via the nurse call bell system has not yet been resolved. A review of the minutes from the Resident Council Meeting held in May 2023, and June 2023, revealed that the residents in attendance at these meetings voiced complaints regarding lengthy waits for staff assistance after activating the call bells. A review of the facility's call bell response report from August 7, 2023, through September 14, 2023, indicated that the facility's audit identified an average response time to answer a call bell was six minutes and forty-one seconds. However, during this period, the report indicated that there were 339 call bell activation-to-response instances that were over 25 minutes, 55 call bell activation-to-response instances over 45 five minutes, and 16 call bell activation-to-response waits that were over an hour. During an interview on September 15, 2023, at approximately 9:15 a.m., the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed during the Resident Council meetings as well as individually complaints residents continue to express complaints and file grievances regarding long waiting periods for staff assistance after activating call bells. The ADON and DON were unable to provide evidence that the resident's continued complaints and grievances regarding waiting periods for assistance after activating call bells had been resolved by the facility. Refer F585 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 2 of 24 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 09/15/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, a review of clinical records, and staff interview, it was determined that the facility failed to timely consult with the physician and failed to notify the resident's interested representative of a significant change in condition, an injury with potential for requiring physician intervention, for one out of nine residents sampled (Resident 24). Findings include: A review of Resident 24's clinical record revealed admission to the facility on January 15, 2020, with diagnoses that have included dementia, chronic kidney disease, peripheral vascular disease, and Alzheimer's disease. A quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated August 4, 2023, revealed that the resident was severely cognitively impaired with a BIMS score of 0 (Brief Interview for Mental Status section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired) and required extensive assist of two staff members for bed mobility, transfer, dressing, toileting, and extensive assist of 1 staff members for personal hygiene (combing hair, brushing teeth). Resident 24's clinical record indicated that she has a legal guardian as her responsible party, and emergency contact. A behavior note in the resident's clinical record dated October 18, 2023, at 7:10 AM, revealed that nurse aides aides reported that the resident was screaming, stating don't hit me while being changed. The resident was not being hit at that time, only receiving care and being changed. A quick note, dated October 20, 2023, at 6:47 AM, indicated that the resident was difficult to transfer this AM, very rigid and resistant. Required two staff assist with difficulty. A quick note, dated October 24, 2023, at 3:24 AM, indicated that the resident was awake at the start of night shift. She remained awake all night talking to herself loudly. Many attempts were made to quiet her, but resident just got louder, disturbing her roommate. A behavior note, dated October 24, 2023, at 6:45 AM, indicated that the resident continued with loud talking until 5:30 AM, and started screaming loud, clucking like a rooster when she was assisted up in wheelchair to go to the day room. She screamed loudly while going down the hallway. A behavior note, dated October 31, 2023, at 3:51 AM, indicated that the resident was crying and screaming all night. Pain medication was given. The resident was agitated while receiving care. A quick note, dated October 31, 2023, at 12:04 PM, indicated that the resident was screaming out in AM. The resident was noted gripping both her legs. Tendons/muscles behind both legs, appear tight. Physical Therapy made aware, therapy to evaluate. MD notified, in to see resident. New order obtained, venous doppler of left lower extremity (LLE) to rule out deep vein thrombosis - clot (DVT). Responsible party notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 3 of 24 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 09/15/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was no documented evidence that the physician had been informed of the resident's signs and symptoms of pain, increased crying, screaming, rigidity, agitation and difficulty transferring, which were noted from October 18, 2023, through October 31, 2023, until October 31, 2023, when the physician was in the facility. Observations on On November 1, 2023, at approximately 10:20 AM, Resident 24 was heard screaming and yelling out and observed Resident 24 seated in a wheelchair, in a large community room, with other residents present. Staff approached the resident in an attempt to calm her, with some degree of success. Closer observation of Resident 24 found her flushed, screaming, with facial grimacing. A behavior note, dated November 1, 2023, at 6:53 AM, indicated that the resident continued with loud talking through the night. When she was assisted up in wheelchair to go to the day room she screamed loudly during changes and while going down the hallway. A consult note, dated November 1, 2023, at 12:47 PM, indicated that the resident was seen at nursing request for complaints of LLE pain. Venous doppler results received by this provider today with negative findings. The consult noted that the resident does appear to have LLE pain on exam although difficult to assess. Overall, vitals are stable, and patient is not in any acute distress at time of exam. There are no other concerns from nursing. Impression, acute, uncontrolled pain in left leg. New order Voltaren gel three times a day (TID), Tylenol as needed, comprehensive metabolic panel (CMP - lab work) to rule out electrolyte disturbances, nursing to monitor for worsening signs/symptoms. Follow up in 1 week. A quick note, dated November 1, 2023, at 6:00 PM, indicated while applying the Voltaren gel to the left leg, resident yelled in pain and began to sob. Observation of the resident's left leg was swollen, red, seeping fluid, and painful. Order obtained, X-ray ordered. A quick note, dated November 1, 2023, at 10:10 PM, indicated x-ray results were received revealing that the resident had sustained an acute displaced spiral fracture at the shaft of the tibia, and a fracture at the proximal fibula (bones in the lower leg). MD aware, orders obtained to transfer to hospital emergency room. Interview with the Director of Nursing (DON) on November 1, 2023, at approximately 12:40 PM, confirmed she was unable to provide documented evidence of timely notification of the physician of the residents change in condition, initiating on October 18, 2023. 28 Pa Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 4 of 24 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 09/15/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment Findings include: An observation September 13, 2023 at 1:20 PM the floor of the A unit room [ROOM NUMBER] storage room was dirty and sticky. [NAME] stains were observed on multiple ceiling tiles and surrounding the air vent in the ceiling and the ceiling tile was sagging. An accummulation of dead insects were observed in ceiling light covers on the first floor hallway between the nurses station and the resident dining room. Spider/cob webs were observed on the door to the resident dining room and around the perimeter of the doorway. Several heating and cooling units in the room had a buildup of dust and lint in the vents. There were multiple spider/cob webs observed on the window sills of the windows around the room. During an interview September 15, 2023 at 1 P.M., the Nursing Home Administator confirmed that the facility's environment should be maintained in a clean and homelike manner. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 5 of 24 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 09/15/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on a review of grievances lodged with the facility and facility call bell audits and staff and resident interviews it was determined that the facility failed to demonstrate prompt efforts to resolve repeated resident complaints regarding untimely staff response to residents' requests for assistance, and to sustain corrective actions identified in the grievance resolutions to prevent similar complaints including those voiced by four residents (Resident 53, 1, 13, and 63). Findings included: A review of grievances filed with the facility revealed a grievance filed by Resident 53 on June 5, 2023, indicating that the resident waited an hour and fifteen minutes for assistance after activating the call bell. The grievance form indicated that the issue was resolved. However, Resident 53 filed another grievance on September 6, 2023, indicating that the resident is having on-going issues with long waiting periods for staff assistance when utilizing the call bell, including waiting over an hour for assistance to use the bed pan. The grievance form did not indicate whether this current complaint was resolved as of the time of review during the survey ending September 15, 2023. A grievance was filed with the facility by Resident 13 on July 7, 2023, relaying that residents are waiting for their assigned nurse aides to return from break before they can get assistance when other nurse aides are available to provide resident care. The grievance form indicated that the issue was resolved. A grievance was filed with the facility by Resident 1 on July 24, 2023, indicating that a nursing aide walked out of his room without ensuring his call bell was within reach. The resident indicated that there was no way to get assistance to turn down his air conditioner. The grievance form did not indicate whether the issue was yet resolved as of the time of the survey ending September 15, 2023. Resident 1 filed another grievance on August 21, 2023, reporting that the resident had waited an hour and thirty minutes for staff assistance after activating the call bell. The grievance form indicated that this current complaint was resolved. Resident 63 filed a grievance with the facility on August 14, 2023, indicating that staff did not assist the resident out of bed until noon. the The grievance form indicated that the issue was resolved. During a group meeting conducted on September 13, 2023, at 10:00 a.m. with 10 alert and oriented residents, nine residents (Residents 2, 3, 9, 15, 18, 36, 42, 59, and 74) voiced concerns over long waits for staff to respond to their call bells when care and assistance is needed. The resident stated that there have been recent incidents when they have waited over an hour for nursing staff to respond to their call bells. The residents in attendance at this meeting reported voicing their concerns over the past few months during Resident Council meetings and through individual grievances. The residents stated that the issue with the long waits for staff to respond to their requests for assistance via the nurse call bell system has not yet been resolved. A review of the facility's call bell response report from August 7, 2023, through September 14, 2023, indicated that the facility's audit identified an average response time to answer a call bell was six minutes and forty-one seconds. However, during this period, the report indicated that there were 339 call bell activation-to-response instances that were over 25 minutes, 55 call bell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 6 of 24 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 09/15/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activation-to-response instances over 45 five minutes, and 16 call bell activation-to-response waits that were over an hour. During an interview on September 15, 2023, at approximately 9:15 a.m., the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that residents continued to lodge grievances regarding long waiting periods for staff assistance after activating call bells. The ADON and DON were unable to provide evidence of sustained resolution to the residents' continued complaints and grievances regarding long waiting periods for staff assistance after activating call bells. Refer F 565 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: 395491 If continuation sheet Page 7 of 24 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 09/15/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's abuse prohibition policy, select investigative reports, and clinical records, and resident and staff interviews, it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one residents out of the 25 sampled (Resident 1) resulting in multiple pressure injuries. Findings include: A review of the facility policy titled Resident Abuse & Neglect Prevention Program dated as last revised by the facility in November 2022, revealed that management and staff are jointly and individually responsible to ensure each resident shall be free from abuse, neglect and misappropriation of property. Further policy review revealed that the facilities define neglect as the deprivation by a caretaker of goods or services (failure to provide goods and services) necessary to maintain physical or mental health and avoid physical harm, mental anguish, or mental illness. Clinical record review revealed that Resident 1 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 August 18, 2023, indicated that Resident 1 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 1's plan of care in place for activities of daily living (ADLs) dated April 13, 2023 and updated May 22 , 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 1'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 . The care plan was updated July 25, 2023, following an incident during which staff left the resident on the bed pan for an extended period of time, resulting in multiple pressure areas with the planned approach for staff to limit the time this resident can stay on the bed pan. Staff were also to document the removal of his bedpan to prevent prolonged application. During an interview on September 12, 2023, at 10:30 a.m., Resident 1 stated that the planned bowel regimen 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 September 9, 2023, after being administered the second enema by an Agency LPN during the 3 PM to 11 PM, the resident stated that I was placed on the bedpan. At 2 A.M. ( September 10, 2023) my bottom was sore because I was left on the bed pan. An 11 P.M. to 7 A.M. nurse came in and took me off the bed pan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 8 of 24 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 09/15/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few The resident's clinical record failed to reveal evidence that staff turned and repositioned the resident every two hours on September 9, 2023 10:00 p.m. through September 10, 2023 2:00 a.m., as indicated in the resident's plan of care. The facility's investigation dated September 10, 2023, included a witness statement from Employee 7, (agency LPN 3 PM to 11 PM shift), indicating that at 10 P.M the first enema was given to the resident then at 10:30 P.M. the second enema was given to the resident. She stated that at 11 P.M. the oncoming LPN was told that the enemas were given to the resident 30 minutes apart and that at the end of her 3 PM to 11 PM shift Resident 1 was still on the bedpan. A review of a witness statement dated September 10, 2023 revealed Employee 9 (LPN 11 PM to 7 AM shift) stated that {Employee 8} (nurse aide) told me that Resident 1 was on the bed pan. However, I remember administering the resident's medications at 12 AM and he never told me he was on the bedpan. I don't recall the 3 PM to 11 PM LPN (Employee 7) telling me that he was still on the bed pan at the end of her shift. A review of a witness statement dated September 10, 2023 revealed Employee 8 (nurse aide) stated that at 2 A.M., (on September 10, 2023) {Resident 1} rang his call bell and told me he was still on the bed pan. I asked him what time he was put on the pan. He stated that it was about 9:55 P.M. (on September 9, 2023). Nothing was relayed to me that he was on the bed pan. {Resident 1} was removed from the bed pan at 2:05 A.M. and it was reported to the LPN and the RN supervisor. A nursing progress note dated September 11, 2023, at 10:25 a.m. indicated that Resident 1 was found on the bedpan while in bed. The resident's skin was observed to have bilateral buttocks wounds, bilateral posterior thighs wounds. A skin observation tool dated September 11, 2023, indicated that the resident had the following skin injuries: Left buttock pressure injury measuring 0.4 cm x 1.5 cm x 0.1 cm (Stage II Pressure Injury) Right gluteal fold pressure injury measuring 0.5 cm x 1.5 cm x 0.1 cm (Stage II Pressure Injury) Left posterior thigh pressure injury measuring 0.5 cm x 1 cm x 0.1 cm (Stage II Pressure Injury) Right posterior thigh pressure injury measuring 3 cm x 5 cm x 0.1 cm (Stage II Pressure Injury) The Physician was notified and a treatment was ordered, The resident is his own responsible party. Employee 7 (agency LPN) was terminated from employment at the facility. An observation of the resident's pressure areas on September 15, 2023 at 9 A.M. revealed all above noted pressure areas healing. An interview with the Director of Nursing (DON) on September 15, 2023, at approximately 12 p.m., that staff neglected to provide Resident 1 the care planned for the resident's bowel program, timely removal from the bed pan and turning and repositioning to prevent multiple skin injuries. 28 Pa. Code 201.29 (a)(c) Resident Rights (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 9 of 24 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 09/15/2023 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 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 10 of 24 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 09/15/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's abuse prohibition policy and procedures, Standard Operating Procedure for Background Checks, Screenings, and Processes, and employee personnel files and staff interview, it was determined that the facility failed to implement their established procedures for screening three of four employees for employment (Employees 1, 2, and 3) Residents Affected - Some Findings include: A review of the facility's Resident Abuse and Neglect policy last reviewed by the facility October 20, 2022, revealed procedures for screening potential employees that included to screen all potential employees for a history of abuse, neglect, mistreatment or misappropriation of property as defined by applicable requirements. All reasonable efforts will be made by the facility to obtain information from previous and/or current employers in an attempt to screen for history of abuse, neglect or mistreatment of residents. A review of the facility's Standard Operating Procedure for Background Checks, Screenings, and Processes provided during the survey ending September 15, 2023, revealed procedures for employment verification to include reasonable efforts will be made to obtain employment verification for a new hire. The facility will attempt to obtain the date of hire, date of separation, reason for separation, and misconduct history from candidate's lasts employer. Review of employee personnel files revealed that Employee 1 (nurse aide) was hired July September 8, 2023, and had a prior employer noted on the employee's application. There was no documented evidence that reference checks from previous employers were obtained prior to the staff's start of employment. Review of employee personnel files revealed that Employee 2 (maintenance) was hired September 8, 2023, with a prior employer noted on the application. There was no documented evidence that reference checks from previous employers were obtained prior to the staff's start of employment. Review of employee personnel files revealed that Employee 3 (dietary) was hired September 8, 2023, with a prior employer noted on the application. There was no documented evidence that reference checks from previous employers were obtained prior to the staff's start of employment. Interview with the Director of Human Resources on September 15, 2023, at 11:00 AM verified that the facility was unable to provide documented evidence that any reasonable efforts were made to contact a previous employer according to the facility's screening procedures outlined in the Resident Abuse policy and Standard Operating Procedure for Employees 1, 2, and 3. 28 Pa Code 201.19 (1) Personnel records 28 Pa. Code 201.29 (c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 11 of 24 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 09/15/2023 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 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 a review of clinical records and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed nurses administered medications as prescribed to one resident of the 19 sampled residents (Resident 20). Residents Affected - Few Findings included: A clinical record review revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (an irregular and often very rapid heart rhythm) and hypertensive heart and chronic kidney disease (blood pressure that is higher than normal and related heart and kidney organ damage). A physician order, initially dated September 15, 2022, indicated that Resident 20 was to receive Carvedilol Tablet 3.125 mg one tablet by mouth in the morning for hypertension (HTN) and instructions to hold the medication if the resident's systolic blood pressure (the first number indicates how much pressure your blood is exerting against your artery walls when the heart contracts) is less than 110 mmHg or if the resident's heart rate is less than 60 beats per minute. According to the resident's Medication Administration Record for September 2023, nursing staff administered Carvedilol Tablet 3.125 mg to the resident on September 11, 2023, at 9:00 a.m. but the resident's systolic blood pressure was 106 mmHg, and below the physician prescribed parameter of 110 mmHg. Nursing staff again administered Carvedilol Tablet 3.125 mg to the resident on September 8, 2023, at 9:00 a.m. and the resident's systolic blood pressure was 100 mmHg The resident's June [DATE] indicated that nursing administered Carvedilol Tablet 3.125 mg to Resident 120 on June 28, 2023, at 9:00 a.m. but the resident's heart rate was 56 beats per minute, and below the physician prescribed paramaters of 60 beats per minute. During an interview on September 15, 2023, at approximately 9:00 a.m., the Assistant Director of Nursing and Director of Nursing confirmed that Resident 20's Medication Administration Records indicated that the resident was administered medication outside of the physician's parameters for administration. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 12 of 24 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 09/15/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 and clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized approaches to restore normal bladder function to the extent possible for two out of 25 sampled residents (Resident 31 and 75). Findings include: A review of facility policy titled Bowel, Bladder, and Toileting Program, last reviewed by the facility in October 2022, indicated that the purpose of the policy is to ensure that each resident who is incontinent of urine or bowel is identified, evaluated, and provided appropriate treatment and/or services to achieve or maintain as much normal urinary and bowel function as possible. The policy also indicated that nursing staff will assess the resident's continence status at the time of admission, re-admission, quarterly, and with significant changes in status. A comprehensive urinary and bowel continence assessment will be completed. A clinical record review revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (brain damage that results from a lack of blood), osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down), and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A comprehensive quarterly continence evaluation of Resident 31 the facility conducted February 2023 and May 2023 but no evidence that the facility conducted a comprehensive quarterly continence evaluation in August 2023. A review of a Quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care), dated March 6, 2023, indicated that the resident was frequently incontinent when evaluated for urinary continence over the seven-day look-back period. A review of a Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident remained frequently incontinent when evaluated for urinary continence over the seven-day look-back period. A review of a Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was now always incontinent when evaluated for urinary continence over the seven-day look-back period. There was no evidence that the facility had acted upon the resident's decline in urinary incontinence identified on the quarterly MDS assessment dated [DATE], and reviewed and revised the resident's care plan for urinary incontinence to include individualized planned measures to restore the resident's urinary continence to the extent practicable. During an interview on September 15, 2023, at approximately 9:15 a.m., the Assistant Director of Nursing and Director of Nursing confirmed that the facility did not act on Resident 31's decline in urinary continence noted on the August 2023 quarterly MDS assessment. The DON also verified that nursing failed to conduct a comprehensive quarterly continence evaluation in August 2023 according to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 13 of 24 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 09/15/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm facility policy and updates or new interventions were care planned and implemented to restore urinary continence to the extent possible. A review of the clinical record of Resident 75 revealed admission to the facility on March 31, 2023, with diagnoses to include dementia and anxiety. Residents Affected - Few A Quarterly MDS assessment dated [DATE] revealed the resident was severely, cognitively impaired, required assistance of staff for activities of daily living including ambulation, transfers and toileting and occasionally incontinent of bladder. The resident's care plan dated April 3, 2023, revealed an ADL self care deficit related to confusion, dementia and fatigue with planned interventions for the resident to ambulate with assistance of one staff with gait belt, the resident was continent of bowel and bladder and to transfer/ambulate with assist of one with hand held assist and gait belt to the toilet. The MDS assessment noted that the resident was occasionally incontinent of urine, which was not addressed on the resident's care plan A quarterly MDS assessment dated [DATE], revealed the resident was severely, cognitively impaired, required assistance for activities of daily living including transfers, ambulation and toileting and now continent of bladder. However, a review of the bladder tracking associated with the MDS assessment indicated that this resident had 17 urinary incontinent episodes in the 7 day look back period, indicating that this resident was frequently incontinent. A review of an associated Bladder assessment dated [DATE] revealed that the resident was continent of bowel and bladder based on interviews with the staff due to the resident's severe cognitive impairment. A facility fall investigation report dated September 7, 2023 at 12:35 revealed that Resident 75 was found on the floor of her room. The resident was noted be incontinent at the time of the fall and was last toileted at 8 A.M. The planned intervention at the time of the fall to prevent recurrence was the implementation of a scheduled toileting bowel and bladder program to toilet the every 2 hours. A review of a facility fall investigation report dated September 8, 2023, at 11:03 P.M. revealed that Resident 75 was found sitting on the floor of her room, incontinent of bladder at the time of the fall. There was no documentation of the last time this resident was toileted. The resident had a fall the prior date, September 7, 2023, with contributing factors related to incontinence and toileting needs and an every two hour toileting program was planned, but there was no evidence it had been implemented as the time of the resident's last toileting was not noted on the fall investigation report. An interview conducted September 14, 2023 at 12 P.M., revealed that the Infection Preventionist stated that she completed Resident 75's current bowel and bladder assessment. She confirmed that the resident's bladder assessment and continence status was not consistent with the documented episodes of urinary incontinence. She confirmed that a 2 day bladder diary and an evaluation of the data to determine a plan was not completed for this resident to identify any potential voiding patterns or toileting habits. The facility failed to consistently and accurately assess Resident 75's bladder continence status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 14 of 24 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 09/15/2023 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 0690 and develop and implement individualized measures to restore normal function to the extent practicable. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 15 of 24 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 09/15/2023 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 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 that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 25 residents (Resident 75). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses to include 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). An admission MDS Assessment (Minimum Data Set, an assessment completed periodically to plan resident care) dated April 6, 2023, revealed that Resident 75 was severly cognitively impaired. A review of Resident 75's nursing progress notes from her admission until discharge on [DATE], revealed that the resident exhibited behaviors of restlessness, trying to get out of bed without staff assistance, unsafe self-transferring from the bed and wheelchair, anxiousness, fidgety behavior, was frequently awake all night, confused, yelling cursing and wandering. Further it was noted the resident had three falls in the facility from April 2023 until July 2023 related to these restless behaviors. A review of a facility investigation report and nursing documentation dated July 30, 2023 revealed, Nursing heard Resident 41, a cognitively aware resident, shouting. The RN ran to his room and discovered him arguing with Resident 75, a severly cognitively impaired resident. Resident 41 stated that Resident 75 punched him in the mouth and he then hit Resident 75 in the back in retaliation. Both residents were transferred to the hospital for evaluation. A review of a witness statement dated July 30, 2023, (no time identified) from Employee 5 (nurse aide) revealed that the employee stated on July 30, 2023 (no time indicated), I heard {Resident 41} yelling help. I went into his room to see what he needed. {Resident 75} was in his room going through his closet. {Resident 41} told me that Resident 75 hit him in the mouth. I didn't see it happen, but Resident 75 likes to go into {Resident 41's } his room often. I redirected him out of his room. {Resident 41} also said that {Resident 75} hit me so I hit her back. Resident 41 stated that Resident 75 was continuously going into his closet and he told her to leave the room multiple times. Resident 75's care plan to address cognitive loss related to dementia failed to address the specific dementia-related behaviors exhibited by the resident to include intrusive behaviors towards other residents. There was no documented evidence that the facility had developed individualized person-centered interventions to address Resident 75's behaviors utilizing individualized, non-pharmacological approaches to care, such as purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 16 of 24 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 09/15/2023 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the resident's current plan of care no documented evidence that the facility had developed individualized person-centered dementia care plan to address the resident's needs for dementia care to improve the resident's quality of life. An interview with DON (Director of Nursing) on September 14, 2023, at approximately 1:00 PM confirmed the facility failed to develop and implement an individualized person-centered plan to address the residents' dementia-related behavioral symptoms. 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 17 of 24 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 09/15/2023 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 review of controlled drug records and resident clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records and accurate administering of medications prescribed for one resident of 25 reviewed (Resident 68). Finding include: A review of Resident 68's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included cerebral infarction (stroke) and dementia. The resident was receiving hospice services. A review of a significant change MDS Assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 25, 2023, revealed Resident 68 was moderately, cognitively impaired with a BIMS score of 8 (BIMS-brief interview for mental status), required assistance for activities of daily living and was on hospice services. A physician order dated September 3, 2023, was noted for Fentanyl Patch (an opioid pain medication) 12 mcg/hr 72 hour patch, apply 1 patch transdermally every 72 hours for pain, then remove. A review of the resident's September 2023 Medication Administration Record (MAR) indicated a Fentanyl patch 12 mcg/hr was applied to Resident 68 on September 4, 2023 and removed on September 7, 2023, as per the physician ordered schedule. The September 2023 MAR indicated that a Fentanyl Patch 12 mcg was applied to Resident 68 on September 7, 2023. However, there was no documented evidence that Resident 68's Fentanyl patch was removed on September 10, 2023. A review of a facility investigation and nursing documentation dated September 10, 2023, at 7 A.M. revealed that upon change of shift narcotic count September 10, 2023, 11 PM to 7 AM and 7 AM to 3 PM (shift change), the oncoming nurse inquired as to the placement of Resident 68's Fentanyl patch. The nurses were unable to verify the placement of the patch as a double nurse verification was not completed on prior shift. The resident was observed without a shirt on the prior 11 PM to 7 AM shift. The Physician and the responsible party were notified. The resident's daughter stated that she bathed her father on September 8, 2023 and did not see any kind of patch on the resident's chest. A review of a witness statement dated September 10, 2023 at 8:54 PM Employee 6 (LPN) stated that upon change of shift, a fentanyl patch not observed on the resident. The RN Supervisor contacted the resident's daughter. The residents daughter stated that she visited Resident 68 on September 8, 2023, she sponge bathed her father and did not observe a patch of any kind to the resident's chest or upper body. A review of the resident's Controlled Drug Records revealed that on September 4, 2023, 6, Fentanyl 12 mcg/hr patches were dispensed from the Pharmacy for Resident 68's use. The form noted nursing staff signed out patches from the resident's supply for administration to the resident on September 4, 2023 at 5 PM, September 7, 2023, at 9 P.M. and September 10, 2023 at 10 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 18 of 24 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 09/15/2023 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 Interview with the Director of Nursing on September 14, 2023, at approximately 1:00 PM revealed that a physical accounting of Fentanyl patches on a resident's body is completed by two licensed nurses at the beginning of every shift. The DON confirmed that the facility failed was unable to account for the fentanyl patch reportedly applied to the resident on September 7, 2023, to maintain accurate controlled drug usage. A review of shift change checks-medication and treatment carts revealed no nursing staff signatures on the first floor A-1 medication cart for the following dates and shifts to confirm completion of the controlled drug counts between the outgoing and oncoming shift nurses: September 1, 2023, 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM shifts September 2, 2023, 11 PM to 7 AM shift September 3, 2023, 7 AM to 3 PM, 3 PM to 11 PM shifts September 4, 2023, 3 PM to 11 PM shift September 5, 2023, 3 PM to 11 PM shift September 6, 2023, 11 PM to 7 AM, 7 AM to 3 PM and 3 PM to 11 PM shifts September 7, 2023, 7 AM to 3 PM shift September 8, 2023, 3 PM to 11 PM shift September 10, 2023 at 7 AM to 3 PM shift During an interview on September 14, 2023, at 1 PM the DON confirmed that narcotic/controlled drugs are to be counted by the off-going and the on-coming licensed nurse on each medication cart at change of shift. Any discrepancies in the narcotic count are immediately reported to the Nursing Supervisor. She further confirmed that on the above noted dates and shifts, the required narcotic medication counts were not completed. 28 Pa Code 211.12 (c)(d)(1)(3) Nursing services. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 19 of 24 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 09/15/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of select facility policy, meal delivery times, snack listing and the minutes from Residents' Council meetings and resident interviews, it was determined that the facility failed to routinely offer evening snacks including to nine of ten residents interviewed (Residents 2, 3, 9, 15, 18, 36, 42, 59, and 74) and failed to offer a nourishing snack to all residents when the dinner meal is greater than 14 hours before breakfast is served. Findings include: Review of the facility policy entitled HS Snacks last reviewed by the facility on October 20, 2022, indicated that a HS snack will be provided by the dietary department for all residents not on a therapeutic calorie restriction diet. Snacks will be delivered by dietary to all the nursing units, and will be offered by the nursing staff. During a group meeting with residents conducted on September 13, 2023, at 10:00 a.m. with 10 alert and oriented residents, nine residents (Residents 2, 3, 9, 15, 18, 36, 42, 59, and 74) voiced concerns regarding the lack of snacks. The residents stated that they have concerns regarding not being offered snacks on the weekend and that the variety of snacks offered is limited. A review of the minutes from the Resident Council meeting held in June 2023, the resident in attendance voiced concerns regarding not being offered or receiving snacks in the evening, and at the August 2023, Resident Council meeting the residents voiced complaints regarding the limited variety of snacks available to them in the facility. Review of meal tray delivery times revealed: 1st cart to unit A2 dinner meal is 4:50 p.m. and breakfast meal is 7:16 a.m. (14 hours and 26 minutes) 1st cart to unit A1 dinner meal is 5:00 p.m. and breakfast meal is 7:20 a.m. (14 hours and 20 minutes) 2nd cart to unit A2 dinner meal is 5:04 p.m. and breakfast meal is 7:25 a.m. (14 hours and 21 minutes) 2nd cart to unit A1 dinner meal is 5:10 p.m. and breakfast meal is 7:32 a.m. (14 hours and 22 minutes) 3rd cart to unit A2 dinner meal is 5:17 p.m. and breakfast meal is 8:10 a.m. (14 hours and 53 minutes) 3rd cart to unit A1 dinner meal is 5:22 p.m. and breakfast meal is 8:20 a.m. (14 hours and 58 minutes) The dinner meal is greater than 14 hours before breakfast is served, therefore a nourishing snack must be provided. A nourishing snack means items from the basic food groups (carbohydrate, protein (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 20 of 24 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 09/15/2023 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 0809 and fat), either singly or in combination with each other. Level of Harm - Minimal harm or potential for actual harm Unit A1 currently has 43 residents with 11 residents receiving a therapeutic (diabetic) snack Unit A2 currently has 35 residents with 9 residents receiving a therapeutic (diabetic) snack Residents Affected - Some Review of the HS snacks sent to each unit revealed the following snacks delivered: 4 - 1/2 P&J sandwiches 15 cheddar whales or snack of the month 12 - 2 pack of cookies or donut 4 -bananas 10 - daily desserts 2 - 4 oz apple sauce cups 3 - packs hot cereal 2 - cold cereal 30 packs graham crackers There was no evidence that each resident on the nursing unit was offered a nourishing snack because the meal times were greater than 14 hours. Interview with the dietitian on September 15, 2023 at 10:20 a.m. was unable to state why every resident was not offered a nourishing snack due to the interval of more than 14 hours between dinner and breakfast. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 21 of 24 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 09/15/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview it was determined that the facility failed to maintain acceptable practices for the storage of food to prevent the potential for microbial growth in food and contamination, which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Observation of the Unit A1 resident food pantry on September 13, 2023, at 10:45 a.m. revealed the following sanitation issues with the potential to introduce contaminants into food and increase the potential for food-borne illness. In the A1 resident food pantry there were milk creates filled with 4 one gallon jugs of drinking water, three of which were stored directly on the floor, which was confirmed by Employee 4 . (A1 unit clerk) at the time of the observation. Interview with the Dietary manager on September 13, 2023 at 12:15 p.m. confirmed that the drinking water should not be stored directly on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 22 of 24 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 09/15/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, it was determined that the facility failed to provide a safe and sanitary environment for residents, staff and the public. Residents Affected - Some Findings include: Observation on September 12, 2023, and September 13, 2023, the B side of the building revealed multiple water collection receptacles located throughout the area. Above the cans were collection devices placed above the ceiling tiles with plastic hoses attached. The devices collected the water leaking through the roof into the device and into the can. Multiple cans contained paper and plastic garbage in the cans, left by staff and visitors. During an interview September 13, 2023, at approximately 10 A.M., the Director of Maintenance stated that he first discovered the leaking roof in June 2022. He stated that he did a building assessment and found multiple patches of deteriorating roof over the B wing of the facility. He stated that there was a small amount of roof damage on the A wing side, but this was not considered an immediate issue. The Director of Maintenance stated that multiple roofing companies were then contacted for estimates. A company was contacted and completed an assessment on the status of the roof. The proposal was given to the facility's ownership at the end of the summer 2022, but the work has yet to be approved for payment and initiated. During an interview with the Nursing Home administrator (NHA) September 13, 2023 at approximately 10:15 A.M., he stated that there has been no response from the facility's ownership as to when the roof will be repaired. 28 Pa. Code 201.18 (b)(1)(e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 23 of 24 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 09/15/2023 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 0926 Have policies on smoking. 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 facility's smoking policy and staff interview, it was determined that the facility failed to implement established procedures for care planning to ensure safe smoking by one resident out of two residents sampled (Resident 6). Residents Affected - Few Findings include: Review of the facility policy Smoking/Vaping last reviewed October 20, 2022, indicated that nursing staff will ensure that the written care plan clearly addresses the residents smoking status. If a resident smokes, the care plan must clearly address their capacity to smoke independently, any equipment required (such as adaptive equipment, smoking apron) and any restrictions as to time, possession and storage of smoking materials. During entrance conference on September 12, 2023, at 9:30 a.m. the Director of Nursing provided a list of facility residents that currently smoke, which included one resident, Resident 6. Review of Resident 6's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included Alzheimer's disease, and nicotine dependence. Review of Resident 6's plan of care, conducted during the survey ending September 15, 2023, revealed no indication that the resident's smoking was fully addressed to include any equipment required for safe smoking, any restrictions as to time for smoking and the resident's possession and storage of smoking materials. Interview with the Director of Nursing on September 14, 2023 at 9:15 a.m. she confirmed Resident 6 did not have a smoking care plan that included all information according to the facility policy. 28 Pa. Code 209.3 (a)(c) Smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 24 of 24