Health inspection·September 13, 2024

F 0641 An interview Employee 3 RNAC (registered nurse assessment coordinator) on September 11, 2024, at 1:24 PM confirmed the resident MDS' were not accurate. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(e)(1) Management Residents Affected - Few 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 2 of 16 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 09/13/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of clinical records, select facility policy, and resident and staff interviews it was determined the facility failed to maintain an environment free of potential accident hazards during medication administration for one resident of 21 sampled (Resident 39). Findings include: A review of facility policy titled Medication Administration, last reviewed by the facility on November 17, 2023, indicated that for each medication, the medication administration record and the label on the medication container will be checked for the correct name of the resident and medication, time to be administered, strength, and route of administration. If any discrepancies, check with the physician's order and the pharmacy before giving the medication. The policy also indicated that residents may self-administer their own medications unless their attending physician deemed them not capable of doing so. Review of clinical records for Resident 39 revealed admission to the facility on December 17, 2023, with diagnosis to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure). A quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated August 21, 2024, indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function. A score of 13-15 represents intact cognitive responses). Review of a physician's order dated January 4, 2024, revealed the resident was not to take her own medications or administer eye drops without proper assessment. Do not leave medications at bedside. Review of facility documentation titled Medication Error Report dated July 16, 2024, at 1:24 PM revealed that Resident 39 was administered the wrong medication via the wrong route (the way by which the medication in taken into the body- i.e. oral, intravenously, eye, ear, etc.). The report indicated the resident asked for more applesauce and Employee 1 (licensed practical nurse) placed the resident's medications on the bedside table and stated she would be right back. Resident 39 placed ear drops into her eyes while the nurse was out of the room. The report indicated there was no physician's order for the ear drop medication. Interview with Resident 39 on September 10, 2024, at 12:05 PM confirmed she self-administered drops into her eyes on July 16, 2024. She stated the nurse put down two bottles of drops and left the room for a while. I grabbed the bottle and put it in my eyes. Why she brought the ear drops in to clean my ears is beyond me. Interview with Employee 1 on September 10, 2024, at 1:50 PM revealed that upon entering the resident's room, she placed the eye drop bottles on the residents bedside table tray. While giving Resident 39 her oral medication, the resident requested more applesauce to take with her pills. Employee 1 left the room to get more applesauce from her medication cart and left the eyedrops bottles on the bedside table tray. She reported she told the resident I'll be right back. While at her medication cart a facility employee, with a bleeding hand, approached Employee 1 and asked for assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 3 of 16 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 09/13/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employee 1 obtained gauze for the employee and returned to Resident 39's room. Upon re-entering Resident 39's room, the resident told Employee 1 she self-administered the drops into her eyes and then realized they were ear drops. Employee 1 confirmed that resident medications were not to be left at the bedside. She also confirmed that Resident 39 did not have a current order for ear drops and there was no documentation for Resident 39 to self-administer her own medications. During an interview with the Director of Nursing (DON) on September 11, 2024, at approximately 9:45 AM, she confirmed that nursing staff are to check the medication label for the correct name of medications before entering the residents room. She confirmed that medications should not be left at the bedside. The facility failed to ensure the residents environment was free of accident hazards. 28 Pa Code 211.12 (c)(d)(5) Nursing services 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 4 of 16 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 09/13/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policy and clinical records, and staff interview it was determined the facility failed to monitor the nutritional parameters of a resident with an identified significant weight loss and weight gain for 2 of 21 residents sampled (Resident 25 and Resident 64). Residents Affected - Few Findings include: Review of a facility policy titled Weight Monitoring last reviewed by the facility on November 7, 2023, revealed the unit manager or designee will notify the clinical dietary department of any 5 pound fluctuation in weight within 24 hours. Further the physician and responsible party will be notified. If a fluctuation of 5 pounds or greater is noted, the resident must again be weighed immediately to verify accuracy. A review of Resident 25's clinical record revealed admission to the facility on November 12, 2015, with diagnoses to include dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and severe protein calorie malnutrition (lack of sufficient nutrients in the body). A review of the resident's weights noted the following: June 13, 2024 - 110.8 lbs. July 3. 2024 - 87.4 lbs. indicating a 23.4 lb. weight loss or 21.1% loss of body weight. The facility failed to reweigh the resident immediately after the resident had a 23.4 pound weight loss. There was no documented evidence the facility had notified the physician and resident representative of the significant weight loss. Review of a dietary note dated July 9, 2024, at 11:11 AM revealed the dietitian noted the resident's significant weight loss and questioned the accuracy of the weight. The dietitian further indicated she requested nursing to do a reweights on the resident three times, but the facility staff failed to do so. There was no new weight available to review. Further review of the resident's weights noted the following: July 11, 2024 - 109.2 lbs. August 8, 2024 - 102.8 lbs. indicating a 6.4 lb. weight loss or 5.9% loss of body weight. The facility failed to reweigh the resident immediately after the resident had a 6.4 pound weight loss. There was no documented evidence the facility had notified the physician and resident representative of the significant weight loss. A review of Resident 64's clinical record revealed admission to the facility on May 1, 2023, with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 5 of 16 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 09/13/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm diagnoses to include a nontraumatic intracranial hemorrhage (ruptured blood vessel causing bleeding inside the brain), dysphagia (difficulty swallowing foods or liquids), and severe protein calorie malnutrition (lack of sufficient nutrients in the body). A review of the resident's weights noted the following: Residents Affected - Few June 26, 2024 - 142.4 lbs. July 11, 2024 - 155.6 lbs. indicating a 13.2 lb. weight gain or 9.27% gain of body weight. The facility failed to reweigh the resident immediately after the resident had a 13.2 pound weight gain. There was no documented evidence the facility had notified the physician and resident representative of the significant weight gain. Review of a dietary note dated July 29, 2024, at 3:26 PM revealed the dietitian noted the resident's significant weight gain. The dietitian indicated she requested nursing to do a reweights on the resident to confirm the current weight change and there was no new weight available to review. A recommendation was made to discontinue Ensure (nutritional supplement) at meals. Further review of the resident's weights noted the following: August 14, 2024 - 156.7 lbs. August 21, 2024 - 184.0 lbs. indicating a 27.3 lb. weight gain or 17.42% gain of body weight. The facility failed to reweigh the resident immediately after the resident had a 27.3 pound weight gain. There was no documented evidence the facility had timely notified the physician and resident representative of the significant weight gain. Interview with the Registered Dietitian on September 12, 2024, at 11:30 AM confirmed the facility failed to timely notify the physician of the resident's significant weight changes and that staff failed to obtain and record Resident 25 and 64's reweights to provide the necessary information to accurately assess the resident's nutritional status and needs and evaluate the adequacy of the resident's nutritional intake and plan nutritional support as necessary. 28 Pa Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 6 of 16 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 09/13/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 select facility policy and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one out of 21 residents reviewed (Residents 24 ) Residents Affected - Few Findings include: Review of a facility policy entitled Pain Management Nursing last revised July 2023, indicated that non drug interventions should be tried prior to medication administration and as appropriate in conjunction with medication usage to provide pain relief. Interventions can include positioning, PT/OT (physical therapy/occupational therapy) modalities, relaxation techniques, and diversional activities. A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (chronic inflammatory disease that affects the joints. This results in painful joints, swelling and stiffness in the joints), chronic obstructive pulmonary disease (type of obstructive lung disease characterized by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum production. COPD typically worsens over time), and hypertension (high blood pressure). A review of current physician's orders for Resident 24 revealed an order August 22, 2024, for Oxycodone HCL 5mg every 6 hours as needed (PRN) for moderate to severe pain (pain scale 6-10). A review of Resident 24's Medication Administration Record (MAR) dated September 2024, revealed that Oxycodone 5mg was administered on the following dates and times: September 1, 2024, at 7:50 p.m. September 2, 2024, at 8:45 p.m. September 3, 2024, at 3:14 a.m. September 4, 2024, at 10:13 p.m. September 6, 2024, at 12:09 a.m. September 6, 2024, at 6:31 p.m. September 7, 2024, at 9:26 a.m. September 9, 2024, at 9:55 a.m. September 10, 2024, at 12:18 a.m. September 10, 2024, at 8:08 p.m. September 11, 2024, at 10:07 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 7 of 16 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 09/13/2024 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was no evidence the facility attempted non-pharmacological interventions prior to the administration of this narcotic pain medication. During an interview with the facility's Director of Nursing (DON) on September 13, 2024, at 1:15 p.m. confirmed that the facility failed to consistently attempt non-pharmacological interventions to alleviate the resident's pain. 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 8 of 16 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 09/13/2024 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 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 that 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 71). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 71 was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD). The resident's current care plan, in effect at the time of review on September 13, 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 Nursing Home Administrator on September 13, 2024, at 10:00 AM confirmed the facility was unable to demonstrate that 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: 395491 If continuation sheet Page 9 of 16 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 09/13/2024 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of select facility policy and controlled drug shift count records, observations, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on one of four medication carts (A2 Cart E even). Finding include: A review of the Shift Change Checks sheet for September 2024, for the medication cart on A2 Cart E even September 12, 2024, at approximately 9:00 a.m., revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following dates to verify completion of the task to count the controlled drugs in the respective medication cart on: September 1, 2024, off-going 11p.m. to 7a.m. shift September 2, 2024, off-going 7a.m. to 3p.m. shift September 9, 2024, on-coming 7a.m. to 3p.m. shift September 10, 2024, on-coming and off-going for the 3p.m. to 11p.m. shift September 12, 2024, on-coming 7a.m. to 3p.m. shift. Interview with Employee 4 (LPN), on September 12, 2024, at approximately 9:00 a.m., confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift to confirm inventory of narcotics. Interview with Employee 5 (RN Unit Manager), on September 12, 2024, at approximately 9:15 a.m. further confirmed that nursing staff must count controlled medications at the end of each shift and both the on-coming and off-going nurses must sign that the narcotic inventory is correct. Interview with the Director of Nursing (DON) on September 13, 2024, at approximately 1:10 p.m., confirmed that it is her expectation that nursing staff signs the Control Substance logs, Inter Shift Drug Record, at change of shift to demonstrate that they completed the count of the controlled drugs to identify potential discrepancies. 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 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 10 of 16 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 09/13/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, select facility policy, and staff interview, it was determined the facility failed to adequately indicate the need for an opioid pain medication for one resident out of 13 residents reviewed (Resident 9). Residents Affected - Few Findings include: A review of facility policy titled, Pain Management, last revised July 2023, revealed it is facility policy to evaluate and manage pain for all residents. The policy indicates pain management orders should always have parameters using the numerical scale to be given for a pain of Mild 1-3, Moderate 4-6, or Severe 7-10. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that include unspecified psychosis (a condition that indicates the presence of psychosis but with inadequate information to make the diagnosis of a specific psychotic disorder) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 6, 2024, revealed that Resident 9 BIMS (Brief Interview for Mental Status-a tool to assess cognitive function) is coded as 99 (a score of 99 indicates that the resident was unable to provide or did not provide answers to complete this section). The assessment indicated Resident 9's cognitive skills for daily decision-making are severely impaired. Further review of the clinical record revealed a physician order for Resident 9 to receive morphine sulfate (concentrate) oral solution 20 mg/ml with direction to give 0.25 ml by mouth every three hours as needed for pain initiated on December 22, 2022. An additional physician's order indicating to administer as needed a dose of morphine. 0.25 ml every three hours as needed. Thursdays prior to bath initiated on December 22, 2022. A medication administration record dated November 2024 revealed Resident 9 was administered morphine sulfate (concentrate) oral solution 20 mg/ml on the following dates: November 7, 2024, at 5:57 PM for a pain level of 0 out of 10 November 21, 2024, at 4:11 PM for a pain level of 0 out of 10 During an interview on November 27, 2024, at approximately 1:00 PM, the Director of Nursing (DON) was unable to provide documented evidence for the clinical rationale for Resident 9 to receive Morphine Sulfate (concentrate) oral solution 20 mg/ml on November 7, 2024, or November 21, 2024. The DON confirmed that Resident 9 was administered morphine sulfate (concentrate) oral solution 20 mg/ml twice in November with a pain level of zero out of 10. The DON confirmed that it is the facility's responsibility to adequately indicate the need for an opioid pain medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 11 of 16 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 09/13/2024 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 0757 28 Pa. Code 211.5 (f)(xi) Medical records. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 12 of 16 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 09/13/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, it was determined the facility failed to ensure adherence to medication expiration/use by dates on one of six medication carts (A2/Cart E even) and failed to ensure biologicals were properly dated when opened and available for use for one of 21 residents reviewed. (Resident 14). Findings include: A review of manufacturer instructions for storage of Lantus Solostar Insulin Pen revealed that the pen should be stored in the refrigerator until ready to use. Once the insulin pen is taken out of refrigerator for use, it may be used for up to 28 days. Observation of the medication cart on A2 identified as Cart E even, on September 12, 2024, at 9:08 a.m., in the presence of Employee 4, a Licensed Practical Nurse (LPN) revealed two opened Lantus insulin pen(medication to treat diabetes) in individual pharmacy labeled bags. Further review of the insulin pens revealed that neither pen was dated when opened or had an expiration/use by date indicated on the packaging. Additional observation of the undated insulin pens revealed that each individual plastic bag was labeled for Resident 72. A Lantus insulin pen identified for another resident was found in one of Resident 72's pharmacy labeled insulin pen plastic storage bag. Employee 4 confirmed the insulin pens were not dated when opened or had an expiration/use by date identified. Employee 4 further confirmed the insulin pens were not stored accordingly as evidenced by another resident's insulin pen being stored in Resident 72's pharmacy labeled packaging. During an interview with the DON (Director of Nursing) on September 13, 2024, at approximately 1:30 PM it was confirmed the insulin pens should have been dated when opened and put into use, to ensure the medication did not exceed the expiration/use by date. Clinical record review revealed Resident 14 was admitted to the facility May 27, 2016, with diagnoses which included Multiple Sclerosis, peripheral vascular disease, and heart disease and had an unstageable pressure ulcer on his right gluteus. A review of current physician orders revealed an order dated September 6, 2024, to cleanse the wound with NSS (normal saline solution), pat dry, apply Santyl ointment (ointment used to remove damaged tissue) to wound base, cover with ABD (absorbent dressing) pad daily. Observation of Resident 14's room on September 10, 2024, at 10:00 a.m. revealed an opened, undated 500 mL bottle of normal saline solution containing approximately 200 mL on the resident's nightstand. Repeat observation on September 12, 2024, at 9:35 a.m. revealed that same opened, undated 500 mL bottle of normal saline solution containing approximately 100 mL, on the resident's nightstand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 13 of 16 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 09/13/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observations were confirmed by Employee 5 (RN Unit Manager) on September 12, 2024, at 9:40 a.m. Employee 5 further confirmed the normal saline solution should have been dated when opened and discarded after 24 hours. During an interview with the Director of Nursing (DON) on September 13, 2024, at 1:30 p.m., confirmed the facility failed to ensure that biologicals such as saline solution was labeled in accordance with professional standards indicating when opened and available for use and timeframe to be discarded after opening and available for use. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 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 14 of 16 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 09/13/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on a review of the facility's plan of correction from the survey ending September 13, 2024, the results of the current revisit survey on November 27, 2024, observation, and staff interviews it was determined the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and identify ongoing deficient practices related to storage and use by dates of multi-use medications and controlled substance accountability. Findings include: As a result of the deficiencies cited under the requirements related to the acceptable storage and use by dates of multi-use medications, and pharmacy procedures to promote accurate controlled medication records during the survey of September 13, 2024, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure solutions were sustained. The corrective plan was to be completed and functional by October 31, 2024. However, during the survey ending November 27, 2024, continuing deficient facility practice was identified with these same requirements. According to the facility's plan of correction for the deficiency cited on September 13, 2024, relating to implementation and adherence to procedures to ensure acceptable storage and use by dates for multi-dose medications, procedures implemented to ensure deficient practice was corrected included (1) pharmacy replacing insulin pens for Resident 14 and assured that each pen is in its own resident specific labeled bag and properly dated when opened/expires, (2) all remaining carts audited for correct storage and labeling of medications, (3) random audits of medication carts to monitor labeling and storage will be done weekly x 4 weeks and then monthly to monitor compliance, and (4) audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation. The results of the revisit survey conducted on November 27, 2024, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure multi-use medications were audited for correct storage and labeling. According to the facility's plan of correction for the deficiency cited on September 13, 2024, relating to accountability of controlled medication records, procedures implemented to ensure deficient practice was corrected included (1) medication count for the controlled substances in the A2 Even cart verified as correct. Narcotic sheet for A2 Even cart audited and nurses contacted/re-educated on handling of controlled substance, (2) all licensed nursing staff educated on handling of controlled substances policy and procedure, (3) random audits of narcotic count shift to shift sign off sheets will be done weekly x 4 weeks and then monthly to monitor compliance, (4) audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation. The results of the revisit survey conducted on November 27, 2024, cited under, revealed the facility's QAPI committee failed to successfully implement their plan to ensure that controlled medications were accounted for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395491 If continuation sheet Page 15 of 16 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 09/13/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator and Director of Nursing on November 27, 2024, at approximately 2:15 PM confirmed the facility's quality assurance plan was ineffective in identifying and investigating these continued areas of deficient practice and its corrective plan failed to prevent recurrence of similar quality deficiencies in the areas of labeling and storage of multi-use medications and controlled substance accountability. Residents Affected - Some Refer F755, F761 28 Pa. Code 201.14(a) Responsibility of Licensee. 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: 395491 If continuation sheet Page 16 of 16