Stroudsburg Post Acute Nursing & Rehabilitationllc

Inspectors wroteBased on review of select facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents had reasonable and safe access to operate their over-the-bed lighting for four residents out of 29 residents reviewed (Residents 63, 134, 10, and 90).

Inspectors wroteBased on resident and staff interviews and meal test tray results, it was determined the facility failed to serve meals that are palatable and attractive for four out of 29 residents reviewed (Residents 4, 6, 37 and 55), including experiences reported by five residents during a resident group interview (Residents 48, 68, 73, 131, and 132).

Inspectors wroteBased on observation, review of the Facility Assessment (a comprehensive evaluation conducted by the facility to determine the resources necessary to care for its resident population), and staff interviews, it was determined the facility failed to conduct and update a facility-wide assessment, using evidence-based methods to identify the specific resources necessary to care for its resident population.

Inspectors wroteBased on clinical record review, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's representative was informed of treatment options, as well as the risks and benefits for psychotropic medications for one of 29 residents reviewed (Resident 65).

Inspectors wroteBased on observation, a review of clinical records, and select facility policy and staff interviews, it was determined the facility failed to ensure the self-administration of medications was clinically appropriate for one of 29 residents reviewed (Resident 131).

Inspectors wroteBased on clinical record review, facility policy review, resident interview, and staff interview, it was determined that the facility failed to implement its weight management policy and failed to timely assess and re-evaluate significant weight loss for one of 29 sampled residents reviewed (Resident 81).

Inspectors wroteBased on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident with a prosthetic device received the necessary care and services to attain or maintain the highest practicable physical well-being, consistent with professional standards of practice, for 1 of 29 residents reviewed (Resident 10).

Inspectors wroteBased on observation, a review of select facility policy, and staff interview, it was determined the facility failed to ensure that medications and pharmaceutical products were stored in accordance with expiration date guidelines in one of three medication storage areas (first floor A Unit medication storage room).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure the coordination of hospice services with facility services to meet the resident's needs on a daily basis for one out of 29 residents reviewed (Resident 119).

Inspectors wroteBased on a review of the facility's Abuse Prohibition and Neglect Prevention policy, clinical records, physician orders, care plans, medication administration records, facility investigative documentation, and resident and staff interviews, it was determined the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one of nine residents reviewed (Resident 3), resulting in a Stage III pressure injury constituting actual harm due to neglect.

Inspectors wroteBased on observations, a review of facility policy, and interviews with staff, it was determined the facility failed to maintain an effective pest control program to ensure the facility was free of insects and pests for one floor out of two floors observed (First Floor).

Inspectors wroteBased on a review of clinical records, air mattress manufacturer guidance, select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement pressure injury prevention interventions by failing to ensure specialty air mattresses were properly configured and operated according to manufacturer guidance and resident-specific weight parameters for two of nine residents reviewed (Residents 2 and 4).

Inspectors wroteBased on review of clinical records, resident financial account documentation, billing records, and staff interview, it was determined the facility failed to provide a final accounting of personal funds for one discharged resident (Resident CR1) within 30 days of discharge, in accordance with regulatory requirements, for one of seven residents reviewed for resident funds.

Inspectors wroteBased on a review of clinical records, facility policy, resident interviews, and staff interviews, it was determined the facility failed to develop and implement an individualized discharge planning process that addressed residents' discharge goals and incorporated those goals into the resident's comprehensive care plan for two of seven residents reviewed (Residents 3 and 4).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to provide person-centered care as prescribed to meet the resident's current clinical needs and failed to follow physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line for one of 7 sampled residents (Resident 2).

Inspectors wroteBased on a review of clinical records, select facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to implement necessary safety interventions for one of 21 residents reviewed (Resident 90), who had been identified as at risk for falls which resulted in actual harm, bilateral periprosthetic knee fractures.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.

Inspectors wroteBased on review of select facility policy, observations and staff interview, it was determined the facility failed to provide meal service in a manner that maintained the resident's dignity by allowing extended delays in meal delivery at shared tables for seven residents out of 21 sampled (Residents 33, 15, 67, 35, 2, 23, and 37)

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to develop and implement a baseline care plan within 48 hours for two of 17 residents reviewed that were admitted during the prior 30 days (Residents 88 and 90).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for one resident out of 21 residents reviewed (Resident 20).

Inspectors wroteBased on observation, a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to implement interventions to prevent the development of a pressure injury for one resident out of 21 sampled (Resident 1).

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interviews, it was determined the facility failed to ensure that appropriate physician's orders, a documented medical justification, and an individualized plan of care were in place for the use and management of an indwelling urinary catheter for one of 21 residents reviewed. (Resident 87).

Inspectors wroteBased on a review of the facility's plan of correction from the survey ending July 25, 2025, the documented outcomes of the facility's Quality Assurance and Performance Improvement (QAPI) committee, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure its quality assurance program effectively identified and addressed recurring deficient practices related to the development and implementation of resident baseline care plans (Residents 1 and 10) and nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders (Residents 1, 9 and 16).

Inspectors wroteBased on observation, a review of clinical records and select facility policy, and resident and staff interviews, it was determined the facility failed to implement procedures for smoking safety and safety of smoking areas, as evidenced by one out of the two residents sampled who smoke (Resident 39). A review of the facility policy titled Smoking/Vaping Policy, last reviewed by the facility on May 30, 2025, revealed it is the policy of the facility to maintain an environment that promotes the safety and well-being of our residents, employees, and visitors through established processes that support this goal. The policy indicates for residents an initial resident smoking assessment will be completed upon admission for all residents who smoke or vape. [...]

Inspectors wroteBased on observation and resident and staff interviews, it was determined that the facility failed to ensure the most recent Department of Health survey results were readily accessible to residents and visitors for two out of the two nursing units (Nursing Units 1 and 2) and experiences reported by 4 out of 4 residents interviewed during a group interview (Residents 42, 47, 51, and 67). During a resident council interview on July 23, 2025, at 10:00 AM, four alert and oriented residents in attendance (Residents 42, 47, 51 and 67) indicated they did not know where the facility posted the Department of Health survey results. During an observation and facility tour on July 23, 2025, at 11:00 AM on Nursing Units 1 and 2, the Department of Health survey results were not able to be located. [...]

Inspectors wroteBased on clinical record review, review of select facility policies, and staff interviews, it was determined that the facility failed to investigate the potential cause of new pressure injuries and failed to consistently implement preventive interventions to avoid the development of pressure injuries for one of five sampled residents (Resident 2).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined the facility failed to implement non-pharmacological interventions prior to the administration of a narcotic pain medication and failed to ensure that physician orders for the administration of the narcotic pain medication contained clear parameters for use, for one of five sampled residents (Resident 2).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 21 sampled (Residents 59, 66, and 24).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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 )

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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 planned for two residents (Resident 1 and Resident 2) out of six sampled residents.

Inspectors wroteBased on a review of clinical records and staff interviews it was determined that the facility failed to implement pharmacy procedures to assure timely acquiring and administration of medications to one of six sampled residents (Resident 1).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of six sampled residents (Resident 1).

Inspectors wroteBased 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). 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased on review of clinical records and select facility policy and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to timely obtain physician orders to assure timely medication administration to one resident out of 10 reviewed (Resident 43).