Inspection·December 5, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) for two of 30 residents sampled (Resident 4 and Resident 11).Findings include:The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the MDS dated [DATE], requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.A clinical records review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses including Hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (death of brain tissue caused by a lack of blood flow) affecting right dominant side. A quarterly MDS dated [DATE], revealed section GG-0115 (section related to functional abilities, the ability to perform tasks and activities necessary for daily living) indicated Resident 4 experienced no impairment in range of motion (ROM) (referring to the full movement of a joint or series of joints, measured in degrees) for upper and lower extremities. An observation of Resident 4 on December 4, 2025, at 8:50 AM revealed Resident 4's right upper extremity (including arm, wrist, and fingers) to be in a flexed (bent) position, close to Resident 4's upper body. Further observation of Resident 4 reveled the resident did not move her right upper extremity and used only her left upper extremity for all aspects of daily living, including moving her wheelchair.An interview with the Registered Nurse Assessment Coordinator (RNAC) on December 4, 2025, at 1:12 PM revealed the RNAC acknowledged the quarterly MDS did not accurately reflect the limited range of motion of the right upper extremity for Resident 4. A review of Resident 11's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified fracture (a break in the bone) of third lumbar vertebra (bone in the lower spine), subsequent encounter for fracture with routine healing.A review of the resident's progress notes indicate Resident 11 was admitted from the acute care facility, after a fall at home with L3 Burst Fracture (a severe spinal injury where the third lumbar vertebra shatters from extreme force) The admission MDS dated [DATE], revealed section J (section addressing fall history), question J1700 Fall History on Admission/ Entry or Reentry indicated Resident 11 did not have any fracture related to a fall in the six months prior to admission/ entry or reentry despite the resident having a fall at home resulting in a fracture. An interview with the RNAC on December 4, 2025, at 2:00 PM, revealed the RNAC acknowledged the admission MDS did not accurately reflect the fall with fracture prior to admission. 28 Pa. Code 211.5(f)(iii) Medical records28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 396130 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 396130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitestone Care Center 370 White Stone Corner Road 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)