Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stroudsburg Post Acute Nursing & Rehabilitationllc during CMS and state inspections, most recent first.
Inaccessible Over-the-Bed Lighting: Four residents were found with over-the-bed lights controlled by pull cords only two inches long, leaving the cords out of reach and preventing independent use. One resident with hearing and vision impairment said she could not access the light, another said she had never had a reachable cord, a third reported standing and stretching to turn the light on, and a fourth said her longer cord had broken weeks earlier and was not replaced. The NHA and DON confirmed the issue.
Meals Were Not Palatable or Appealing: Multiple cognitively intact residents and one resident with moderate cognitive impairment reported that meals were tasteless, overcooked, dry, cold, bland, or otherwise unappetizing, with pork often described as too tough to eat and vegetables as mushy or hard. Residents also said concerns raised in resident council and food committee meetings did not lead to changes. A test tray showed gritty, bland mashed potatoes and bland collard greens, and the NHA and DON could not explain the dissatisfaction.
Facility Assessment Did Not Reflect Locked Memory Care Unit or Resident Needs. The facility failed to update its Facility Assessment after opening a locked memory care unit on B-Wing for residents with dementia or wandering tendencies. The assessment did not identify the unit, the 34 residents living there, or the services, staffing, competencies, and resources needed to meet resident needs, including resident acuity, cognitive impairment, and behavioral or physical health needs. The NHA confirmed the assessment was incomplete.
A resident with dementia and impaired cognition was started on Seroquel for impulsivity after the resident signed a psychotropic consent form with the physician. The record did not show that the resident’s representative was informed of the antipsychotic, its risks and benefits, or alternative treatment options, and the DON confirmed no documentation was available showing informed consent from the representative before the medication began.
A resident with MS and intact cognition had an order for topical muscle rub cream, and surveyors observed three unlabeled cups of white cream on the bedside table with no one in the room. An RNS identified the substance as the resident's medication and confirmed the cups were not labeled, while the record showed no documented assessment that the resident was capable, safe, and clinically appropriate to self-administer and secure the medication; the DON and NHA could not provide evidence of such an assessment.
Failure to Timely Address Significant Weight Loss: The facility did not follow its weight protocol for a resident with DM and moderate cognitive impairment after a significant monthly weight loss was identified. The resident reported poor food quality and taste, said she could not eat the meals, and stated no one discussed the weight loss with her. The re-weigh was not completed on time, the first dietary note came more than a month later, and there was no evidence of a timely RD or IDT assessment of the cause of the weight loss or the resident’s nutritional status.
Failure to Provide Proper Prosthetic Care and Skin Monitoring: A resident with a right BKA, DM2, and Alzheimer's had a prosthesis applied improperly when the inner gel liner was omitted, and therapy noted blisters and redness on the residual limb and surrounding areas. The care plan and physician orders lacked individualized prosthetic wear, hygiene, and skin-monitoring interventions, and the facility did not document comprehensive wound assessments or evidence of a prosthetic care process.
Expired and Undated Medications in Medication Storage Room: An observation of the A Unit med room found an opened, undated multi-dose vial of Tuberculin in the med refrigerator and seven expired meds/supplements available for use, including Oyster Shell Calcium, Zinc, Vitamin B-6, and Melatonin. An RN Supervisor confirmed the findings.
Failure to Coordinate Hospice Services With Facility Care: A resident with dementia and ESRD was admitted to hospice, but the facility did not integrate hospice services into the resident’s comprehensive care plan. The hospice communication tool did not address multiple care areas, including pain-related behavioral symptoms, antipsychotic medication risks, COPD-related respiratory impairment, skin breakdown, neurological deficits, sleep issues, altered cognition, and ADL limitations, and the NHA and DON could not provide documentation showing coordinated hospice care.
Failure to Remove Resident From Bedpan Resulted in Stage III Pressure Injury: A resident with incomplete quadriplegia and neurogenic bowel was placed on a bedpan after an enema, but overnight staff did not verify he was removed as required by the care plan and physician orders. Documentation of removal and peri-care was entered hours later, and the resident later reported he had fallen asleep on the bedpan. Facility records and wound care notes showed he developed a new coccyx Stage III pressure injury after the overnight incident.
Lapse in Pest Control Led to Kitchen Insect Infestation: Small black flying insects were observed throughout the first-floor kitchen, including near a floor drain, on dry storage items, and on a stainless steel table. The dietary director confirmed the insects had been present for at least two weeks and said the facility was waiting for the pest management company to treat the area. The RC stated the last external pest control visit was months earlier and that a lapse in pest management services occurred after a maintenance director change.
Improperly Configured Specialty Mattresses: The facility failed to ensure two residents' specialty air mattresses were set according to manufacturer guidance and resident weight. One resident with skin breakdown and impaired mobility had an alternating pressure mattress left in static mode and set at a level intended for much heavier residents, while another resident with impaired skin integrity had a mattress set at a level intended for heavier residents. An RN confirmed the settings were not properly adjusted.
A resident was discharged after their responsible party had paid the facility in advance for the month of discharge, but the facility did not complete and clearly convey a final accounting of the resident’s personal funds within the required 30-day timeframe. An email from the NHA months after discharge stated the account was still pending due to awaited payments, and a later account statement showed a credit balance without confirming it as a final reconciliation. Billing records spanning several months did not document a final, reconciled statement, and the responsible party reported multiple unsuccessful attempts to obtain clear information needed to settle the resident’s estate. During surveyor interviews, the NHA could not provide evidence that a complete final accounting of all charges, credits, and remaining balance had ever been provided, resulting in a violation of resident rights and management regulations.
The facility failed to create and implement individualized discharge plans for two residents who expressed a desire to return to the community or home. For one cognitively intact resident with schizophrenia, the MDS Section Q showed no active discharge planning, and the care plan lacked goals, interventions, or documentation of barriers, despite the resident’s stated wish to live with a family member and the DON’s knowledge of family refusal and complex history. For another resident with dementia and moderate cognitive impairment, the MDS also showed no active discharge planning, and the care plan did not address discharge goals or options, even though the resident had a prior unsuccessful discharge, continued to express a desire to go home, and the SSD was aware of safety concerns and an uninhabitable home environment. The NHA and DON could not provide documentation of individualized discharge care plans for these residents.
A resident with a PICC line for long-term IV vancomycin therapy and an active MSSA infection did not receive safe, person-centered PICC care as ordered. The care plan noted the PICC but lacked specific goals, interventions, and monitoring for PICC care and IV antibiotics. After a prior PICC malfunction and replacement, staff did not document arm circumference or external catheter length. On observation, the PICC dressing was peeling, saturated with yellow drainage, and dated well beyond the facility’s 7‑day change policy and the physician’s weekly order, despite the TAR showing a recent dressing change. IV tubing from an empty antibiotic bag was unlabeled, uncapped, and hanging freely, and no emergency PICC kit was present or ordered at the bedside. The RN Unit Manager and DON confirmed failures in dressing maintenance, tubing management, catheter monitoring, availability of emergency supplies, and accurate documentation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Surveyors found that food items, including nutritional shakes, salad dressing, BBQ sauce, and liquid eggs, were stored in the facility's walk-in refrigerator without proper labeling or adherence to manufacturer-recommended use periods. The Food Service Director confirmed that food and beverages should be labeled and dated, but the absence of this information prevented staff from determining product safety, resulting in a deficiency in food storage and labeling practices.
Several residents experienced extended delays in meal delivery at shared tables, with some waiting up to 20 minutes after others at their table had been served. Staff reported insufficient staffing and disorganized meal tray distribution, leading to undignified meal service. Facility leadership confirmed the lack of timely and coordinated meal delivery.
A resident with severe cognitive impairment and cardiac conditions did not have blood pressure or heart rate monitored prior to receiving Metoprolol, as required by physician orders. Additionally, the medication was inappropriately withheld on two occasions despite the resident's vital signs being above the hold parameters. These failures were confirmed by facility leadership.
Two residents admitted with complex care needs did not have baseline care plans developed within 48 hours that addressed all immediate health and safety concerns. One resident's plan omitted interventions for incontinence, skin integrity, and fall prevention, while another's plan failed to include fall risk interventions and therapy recommendations for safe handling, despite documented needs and staff awareness.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
A resident admitted with an indwelling Foley catheter did not have a physician order, documented medical justification, or an individualized care plan for catheter use and management. The catheter's presence, size, and care instructions were not recorded in the treatment administration record, and appropriate documentation was only initiated after surveyor inquiry.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
A resident with rheumatoid arthritis and mononeuropathy, assessed as cognitively intact and independent in smoking, was observed using a plastic cup as an ashtray and keeping a lighter in her room, contrary to facility policy requiring lighters to be secured at the nurse's station and use of approved ashtrays. Facility leadership could not provide documentation that these protocols were followed or that staff had identified burn holes in the resident's clothing prior to the survey.
The facility did not ensure that Department of Health survey results were posted and accessible on two nursing units. During interviews, several alert and oriented residents stated they were unaware of where the survey results were posted, and a facility tour confirmed the results were not visible. The DON and NHA acknowledged the survey results were not posted on the units.
A resident with severe cognitive impairment and multiple risk factors developed new unstageable pressure injuries due to the facility's failure to investigate the cause and consistently implement preventive interventions, such as regular skin checks and repositioning, as outlined in the care plan. Documentation did not confirm that required preventive measures were performed prior to the wounds' development, and no investigation was conducted after the injuries were identified.
A resident with severe cognitive impairment and chronic pain received a narcotic pain medication without documented attempts at non-pharmacological interventions, contrary to facility policy and physician orders. Additionally, the physician's order for the opioid lacked clear parameters to guide staff on when to administer it, and pain assessments were inconsistently documented.
The facility failed to properly label medications and biologicals, as observed with undated Lantus insulin pens and a normal saline solution bottle. Insulin pens lacked opening and expiration dates, and one was stored incorrectly. A resident's saline solution was undated and used beyond the recommended timeframe. These issues were confirmed by staff and the DON.
The facility's QAPI committee failed to correct deficiencies related to the storage and labeling of multi-use medications and the accountability of controlled substances. Despite a corrective plan, a revisit survey revealed ongoing issues, confirming the ineffectiveness of the quality assurance plan.
The facility failed to ensure accurate MDS assessments for three residents. One resident's assessment incorrectly documented the use of a trunk restraint, while another's inaccurately indicated anticoagulant medication administration. A third resident's assessment wrongly reported both antipsychotic and anticoagulant medication use. These discrepancies were confirmed by the RNAC.
A resident with Alzheimer's and glaucoma, who was not to self-administer medications, mistakenly used ear drops as eye drops after an LPN left medications unattended. The LPN confirmed that medications should not be left at the bedside, and the DON acknowledged the failure to maintain a hazard-free environment.
The facility failed to monitor the nutritional parameters of two residents who experienced significant weight fluctuations. One resident with dementia and severe protein calorie malnutrition lost 23.4 pounds without immediate reweighing or notifying the physician. Another resident with severe protein calorie malnutrition gained 13.2 pounds, also without reweighing or notification. The dietitian's requests for reweights were ignored, and further weight changes were not addressed, impeding accurate nutritional assessment.
A facility failed to follow its pain management policy by not attempting non-pharmacological interventions before administering Oxycodone to a resident with rheumatoid arthritis, COPD, and hypertension. Despite having a policy that requires such interventions, the resident's records showed multiple instances of medication administration without prior non-drug interventions. The DON confirmed this inconsistency, resulting in a deficiency.
A facility failed to create an individualized care plan for a resident with PTSD, neglecting to identify symptoms, triggers, and specific interventions to prevent re-traumatization. This oversight was confirmed by the Nursing Home Administrator, highlighting a lack of culturally competent, trauma-informed care.
The facility did not follow procedures for reconciling controlled drugs on a medication cart, as evidenced by missing nurse signatures on the Shift Change Checks sheet. Interviews with staff confirmed the expectation for nurses to count and sign off on controlled medications at each shift change, which was not done on multiple occasions.
A resident with severe cognitive impairment was administered morphine sulfate twice in November without documented clinical rationale, despite reporting a pain level of zero. This action violated the facility's pain management policy, which requires specific pain level parameters for administering pain medication.
Two residents in an LTC facility suffered neglect due to staff failures. One resident, with quadriplegia, was left on a bedpan for hours, resulting in a pressure wound, and did not receive proper wound care due to a lack of supplies. Another resident with dementia fell because staff did not follow the care plan, leading to a head injury. The DON confirmed the neglect in both cases.
A resident with incomplete quadriplegia and neurogenic bowel did not receive prescribed medications and wound treatment due to the facility's failure to implement pharmacy procedures. Medications were unavailable from the pharmacy, and despite the availability of some in the emergency supply, they were not administered. Additionally, the facility ran out of Mesalt for wound treatment over a holiday weekend, and staff did not consult the pharmacy or physician for alternatives.
A resident with quadriplegia and neurogenic bowel was left on a bedpan for an extended period, resulting in a pressure sore. The facility ran out of Mesalt for wound treatment, and LPNs failed to document the unavailability and attempts to contact the physician. Additionally, false documentation regarding the resident's care was identified.
Inaccessible Over-the-Bed Lighting
Penalty
Summary
The facility failed to ensure that four residents had reasonable and safe access to operate their over-the-bed lighting. During observations, Residents 63, 134, 90, and 10 were each found with over-the-bed light fixtures that had pull cords measuring only two inches in length, and the cords were not within reach of the residents. This prevented the residents from independently turning the lights on and off. The facility policy on environment stated that the physical environment should support resident comfort, safety, privacy, dignity, and emotional well-being, and that routine environmental rounds would monitor lighting and other conditions, with identified concerns addressed promptly. Resident 63 stated she was hard of hearing and requested written communication, and after written information was provided, she indicated she also had impaired vision and could not reach the light cord independently. Resident 134 stated she had been admitted three weeks earlier and said there had never been a cord she could reach to turn on the light. Resident 10 stated she could not reach the light and frequently stood up and stretched to try to turn it on, and said she wanted to be able to read at night without having to get out of bed or stand and reach. Resident 90 stated she had previously had a longer cord to activate her light, but it broke several weeks earlier and had not been replaced; she said she used the light frequently and wanted independent access again. The NHA and DON confirmed the facility failed to ensure accessible over-the-bed lighting for these residents.
Meals Were Not Palatable or Appealing
Penalty
Summary
The facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature for multiple residents. Resident 4, who was cognitively intact with a BIMS score of 15 and had diagnoses including depression and hyperlipidemia, stated that most meals were tasteless, meats were overcooked and hard to eat, pork was inedible, and scrambled eggs had no taste. Resident 6, also cognitively intact with a BIMS score of 15 and diagnosed with incomplete quadriplegia and neurogenic bowel, reported that vegetables were consistently mushy, kielbasa tasted like a hot dog, hot ham and cheese sandwiches were often cold, meat was dry and overcooked, food lacked seasoning, and pork was too hard to eat. Resident 37, who was cognitively intact with a BIMS score of 15 and had diagnoses including hypertension and diabetes, stated that the food had no taste or nutritional value, was often overcooked, and consisted of many of the same white foods. Resident 55, who had moderately impaired cognition with a BIMS score of 12 and diagnoses including hypertension and rheumatoid arthritis, reported that meals were overcooked and tasteless, potatoes were like powdered leftovers, gravy was not fully mixed, vegetables were hard, soup was mostly flavored water with hard vegetables, and pork was too tough to eat. She also stated she often relied on food brought by her daughter and frozen meals kept in her bedside refrigerator because she had not eaten a full meal in a long time. During a resident council interview, five alert and oriented residents, including Residents 48, 68, 73, 131, and 132, stated they were dissatisfied with the quality, taste, seasoning, and appearance of the meals. They described dry, tough, unappetizing meat, bland food, poor presentation, and lack of response when residents raised concerns at resident council and food committee meetings. A test tray for the A-1 Hall nursing unit showed off-white mashed potatoes that were gritty and bland, collard greens that were soft and bland, and chicken with no issues noted. When the information was reviewed with the NHA and DON, they were unable to explain why residents were frustrated and dissatisfied with the food served at the facility.
Facility Assessment Did Not Reflect Locked Memory Care Unit or Resident Needs
Penalty
Summary
The facility failed to conduct and update a facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the current floor plan showed the B-Wing residential section outlined in red, and the Nursing Home Administrator stated this indicated a locked unit. The facility had created and opened a locked memory care unit for residents with dementia or wandering tendencies on November 4, 2025. Observation of the B-Wing from May 19, 2026, through May 21, 2026, showed the unit doors were locked, required a security code for entry and exit, and sounded an audible alarm when opened after the code was entered. The facility’s matrix identified 34 residents residing on the B-Wing. Review of the Facility Assessment, last reviewed on March 3, 2026, showed it did not identify the locked memory care unit or the specific services, staffing, and resources needed to meet the individual and collective needs of the residents on that unit. The assessment also did not include comprehensive data about the current resident population, including disease types, conditions, physical and behavioral health needs, cognitive impairments, and overall acuity. It further failed to identify how increased resident acuity affected staffing needs, workload, supervision, and the time required to provide basic care, and it did not evaluate the overall number of staff or the competencies and skill sets needed to ensure qualified staff were available to meet resident needs. During interview, the NHA confirmed the Facility Assessment did not contain all required information related to the facility’s current resident population, services, and staffing resources.
Failure to Inform Resident Representative of Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure that a resident’s representative was informed of treatment options and the risks and benefits of psychotropic medication before antipsychotic therapy was started. Resident 65 had diagnoses including dementia and age-related debility, with an admission MDS showing moderately impaired cognition and a later quarterly MDS showing severe cognitive impairment. A physician ordered Seroquel 25 mg at bedtime for impulsivity, and a nurse documented that the resident was educated on psychotropic medication therapy and potential side effects and that consent was obtained from the resident. The clinical record included a Consent for Psychoactive Medication Therapy form signed by the resident and the physician, with language indicating agreement to additional psychotropic medication changes as determined by the psychiatrist or primary physician. However, there was no indication that the resident’s representative was made aware of the consent for the antipsychotic medication. At the time of survey review, the resident was listed as their own representative, but after surveyor inquiry the facility updated the record to show a designated POA served as the resident’s representative. The DON confirmed there was no documentation available at the time of survey showing informed consent was obtained from the representative before psychotropic medication began, or that risks, benefits, or alternative treatment options were explained.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that self-administration of medication was clinically appropriate for one resident with multiple sclerosis and cognitive intactness documented on the quarterly MDS with a BIMS score of 15. The resident had a physician's order for muscle rub cream 10-15% (menthol-methyl salicylate) to be applied to the back twice daily for back pain, and during an observation three clear plastic medication cups containing an unknown white cream substance were found on the resident's bedside table while no one was in the room. During an interview, the RNS identified the white cream as the resident's muscle rub cream and confirmed the cups were not marked or labeled to identify their contents. The clinical record contained no evidence that the facility had assessed the resident to determine whether he was capable, safe, and clinically appropriate to self-administer and properly secure the medication in his room. The DON and NHA later stated they were unable to provide documented evidence that such an assessment had been completed before surveyor inquiry.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to implement its weight management policy and failed to timely assess and re-evaluate significant weight loss for one resident with diabetes and moderate cognitive impairment. The facility’s Weight Protocol required monthly weights by the 7th, dietitian review of any 5-pound weight change, re-weighs by the 15th, and an interdisciplinary weight meeting after the 15th. The resident’s weight decreased from 190 pounds to 175.8 pounds in one month, a loss of 14.2 pounds or 7.4 percent, but the next documented weight was not obtained until later in the month, and the re-weigh was not completed in accordance with policy. The resident told surveyors that the food was horrible, that she was dissatisfied with the taste and quality of meals, and that she had lost a significant amount of weight because she was unable to eat the food provided. She stated she wanted to lose weight but did not want to lose weight because she could not eat the meals, and reported that no one had discussed the weight loss with her. Family members sometimes brought meals. The first dietary note addressing the weight loss was not entered until more than a month after the significant loss was identified, and there was no evidence that the registered dietitian or interdisciplinary team completed a timely assessment or re-evaluation of the cause of the weight loss, the resident’s nutritional status, her concerns about food intake, or whether nutritional goals were being met.
Failure to Provide Proper Prosthetic Care and Skin Monitoring
Penalty
Summary
The facility failed to ensure a resident with a right below-the-knee prosthesis received appropriate care and assistance to maintain physical well-being. The resident had diagnoses including right below-the-knee amputation, Type 2 diabetes with a left foot ulcer, and Alzheimer's disease, and was moderately cognitively impaired with a BIMS score of 12. The facility policy required routine assessment of the prosthetic device and the resident's skin integrity, assistance with application and removal as needed, and documentation of assessments and abnormalities, but the resident's care plan and physician orders did not include individualized interventions for safe prosthetic use, wear schedule, hygiene, or skin monitoring. On April 14, 2026, after returning from therapy, the resident removed the prosthetic device and blisters were observed on the right residual limb. The nurse practitioner and wound nurse were notified and orders were received for skin prep and an ABD dressing daily. A physical therapy note from the same day documented that the resident arrived to therapy with the prosthetic leg donned, but it had not been applied properly and the inner gel liner had not been placed before the prosthesis. The therapist observed blisters to the right lateral knee and anterior medial thigh, along with redness to the patella. Facility documentation later described treatable wounds of the left heel and right prosthesis site, but no specific wound location on the residual limb, measurements, characteristics, staging, or detailed assessment findings were documented. There were also no documented wound assessments addressing the blisters and redness noted by therapy, including location, description, drainage, or treatment effectiveness. During interview, the NHA, DON, and Director of Therapy were unable to provide documented evidence of a prosthetic care assessment process, wearing schedule, residual limb skin monitoring protocol, staff education, resident education, or comprehensive wound assessments related to the resident's prosthetic use.
Expired and Undated Medications Found in Medication Storage Room
Penalty
Summary
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, the first floor A Unit medication storage room. A review of the facility’s Medication Storage Policy stated that all medications, including prescription medications, controlled substances, and OTC medications, must be stored in designated secure areas under proper storage conditions according to manufacturer recommendations and facility procedures. During observation of the first floor A Unit medication storage room, a multi-dose vial of Tuberculin was found in the medication refrigerator opened, available for use, and not dated when opened. Review of the manufacturer dosage and administration information showed that multidose vials opened and in use for more than 30 days should be discarded. The same observation also identified seven expired medications and supplements available for use, including two bottles of Oyster Shell Calcium 500 mg with an expiration date of July 2025, one bottle of Zinc 50 mg with an expiration date of January 2026, two bottles of Vitamin B-6 100 mg with an expiration date of January 2026, and two bottles of Melatonin 1 mg with an expiration date of February 2026. An RN Supervisor confirmed the opened, undated Tuberculin vial and the expired medications and supplements in the medication storage room.
Failure to Coordinate Hospice Services With Facility Care
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of Resident 119 on a daily basis. Resident 119 was admitted to the facility with diagnoses including dementia and end-stage renal disease and was admitted to hospice services on April 22, 2026, related to dementia and suspected osteomyelitis. A clinical record review showed the resident’s plan of care was not integrated with hospice services or with measures to ensure nursing facility staffing coordinated and monitored resident care in conjunction with the hospice provider. The comprehensive plan of care did not integrate hospice care and interventions for multiple identified needs, including potential pain-related behavioral health symptoms related to end-stage renal disease, risk for adverse effects related to antipsychotic medication use, risk for respiratory impairment related to COPD, actual skin breakdown related to impaired mobility, moisture, and refusals for care, neurological deficiencies related to metabolic encephalopathy, sleep cycle issues related to medications and sleeplessness, altered cognition and impairment related to dementia, and activities of daily life deficiencies related to dementia and physical limitations. During observation, the hospice communication tool at the nursing station did not contain or account for these care areas or corresponding interventions hospice staff perform. The NHA and DON were unable to provide documented evidence that hospice care services were integrated into a comprehensive care plan for Resident 119.
Failure to Remove Resident From Bedpan Resulted in Stage III Pressure Injury
Penalty
Summary
The facility failed to protect Resident 3 from neglect when staff did not provide the care and services needed to avoid physical harm and maintain physical health. Resident 3 was admitted with incomplete quadriplegia and neurogenic bowel, was cognitively intact, and was dependent on staff for bed mobility. His care plan directed staff to promptly remove him from the bedpan after an enema, discourage him from remaining on the bedpan longer than 30 minutes, and ensure overnight staff checked at the beginning of the shift that he had been removed from the bedpan. Physician orders also required verification that overnight care was completed, including removal from the bedpan, peri-care, and linen changes. On the night of the incident, an LPN administered a Fleet bisacodyl enema, and documentation later stated that the resident was off the bedpan and peri-care had been provided by overnight nurse aides. However, this documentation was completed more than seven hours after the resident had been placed on the bedpan, and the facility investigation found no documented evidence that staff completed the required intervention to verify he had been removed during the overnight shift. Witness statements showed one NA helped place the resident on the bedpan at about 10:50 PM, and the resident later reported he fell asleep and believed staff failed to reposition and remove him from the bedpan overnight. Facility documentation and external wound care records showed the resident developed a new coccyx wound after being left on the bedpan overnight. A full body skin assessment identified a new blister on the coccyx, and the wound care note described a Stage III pressure injury measuring 5.1 cm by 11.4 cm by 0.3 cm with moderate serosanguineous drainage and necrotic tissue. During interview, the resident stated he was upset because he developed a new wound after being left on the bedpan all night, and facility representatives acknowledged the pressure injury occurred after staff failed to remove him from the bedpan overnight.
Lapse in Pest Control Led to Kitchen Insect Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the first-floor kitchen free of insects and pests. A review of the facility policy titled Rodents and Pests showed that an exterminator was under contract and available upon request. However, during an observation in the kitchen, small black flying insects were seen in multiple areas, including near and on a floor drain by the entrance from the hallway, on brown cardboard boxes and a clear plastic flour container in the dry storage area, and on a stainless steel table opposite the kitchen entrance. Multiple small black flying insects were also observed throughout the kitchen during the walkthrough. The dietary director confirmed the presence of the insects in the kitchen and stated the facility was waiting on the pest management company to treat the area. She was unsure when the flies first appeared but said they had been present for at least two weeks. The regional consultant stated the last external pest control company visit was in September 2025 and explained there had been a lapse in pest management services after the maintenance director was replaced. The deficiency was cited because the facility allowed a lapse in pest prevention services, resulting in an infestation of small flying black insects in the first-floor kitchen.
Improperly Configured Specialty Mattresses
Penalty
Summary
The facility failed to consistently implement pressure injury prevention interventions by not ensuring specialty air mattresses were properly configured and operated according to manufacturer guidance and resident-specific weight parameters for two residents. Facility policy required evidence-based preventive skin care, pressure redistribution devices based on interdisciplinary assessment, and daily checks of air mattress settings. The manufacturer guidance stated the mattress should be inflated on static mode for setup and then changed to alternating mode for operation, with settings adjusted according to resident weight. One resident had diagnoses including COPD and chronic kidney disease and had actual skin breakdown related to impaired mobility. The care plan included use of an alternating pressure mattress and physician-ordered treatments, and a physician also ordered daily checks of the mattress function and settings. The resident weighed 138.2 pounds, but an observation showed the mattress soft-firm setting positioned between levels 6 and 7 while the mattress remained on static mode. Manufacturer guidance indicated that a setting between levels 6 and 7 was intended for residents weighing approximately 245 to 350 pounds, and that alternating pressure mode should be activated during operation. Another resident had diagnoses including COPD and had actual or potential impaired skin integrity related to decreased mobility, fragile skin, and incontinence. A physician ordered a low air loss concave mattress, and the care plan included use of a low air loss mattress and ordered treatments. The resident weighed 114.8 pounds, but an observation showed the resident lying on an alternating pressure mattress with the soft-firm setting at level 5. Manufacturer guidance indicated level 5 was intended for residents weighing approximately 200 to 300 pounds. An RN confirmed that both residents' mattresses were not properly adjusted according to weight and manufacturer guidance, and confirmed one resident's mattress remained in static mode rather than alternating pressure mode.
Failure to Provide Timely Final Accounting of Discharged Resident’s Personal Funds
Penalty
Summary
The deficiency involves the facility’s failure to complete and convey a final accounting of a discharged resident’s personal funds within 30 days of discharge, as required by regulation. The resident, identified as CR1, was admitted on an unspecified date and discharged on September 12, 2025. Financial documentation showed that the responsible party had paid the facility in advance for the month of September 2025. An email dated November 12, 2025, from the Nursing Home Administrator to the responsible party indicated that the resident’s account had not yet been reconciled because the facility was awaiting payments from other sources and that the account remained pending. The facility’s records included an account statement dated December 31, 2025, reflecting a credit balance, but the facility could not demonstrate that this statement represented a final accounting of all charges, credits, and the remaining balance. Review of billing documentation from April 2025 through February 2026 did not show evidence that a final, reconciled accounting of the resident’s personal funds was provided or clearly explained to the responsible party within 30 days of discharge. During an interview, the responsible party reported contacting the facility multiple times to inquire about the status of the account and stated that she did not receive clear information regarding the final status of the account after discharge, noting that the last communication received was the December 31, 2025 statement. She indicated that this information was needed to complete financial matters related to the resident’s estate. In a separate interview, the Nursing Home Administrator was unable to provide documentation that a final accounting of the resident’s personal funds, including all charges, credits, and remaining balance, had been completed and conveyed within the required timeframe. The surveyors determined that, as of March 2026, the facility had not provided evidence that the final accounting and status of the resident’s personal funds had been completed and communicated within 30 days of discharge, in violation of 28 Pa. Code 201.18(b)(2)(e)(1) and 201.29(a).
Failure to Develop Individualized Discharge Plans Reflecting Resident Goals
Penalty
Summary
The facility failed to develop and implement individualized discharge planning that addressed residents' discharge goals and incorporated those goals into their comprehensive care plans for two residents. One resident with schizophrenia, who was cognitively intact with a BIMS score of 15, had an MDS Section Q assessment indicating that the overall discharge plan was unknown and that no active discharge planning process was occurring for a potential return to the community. The resident’s comprehensive care plan, initiated months earlier and recently reviewed, contained no interventions, goals, or planning related to discharge preferences, discharge planning activities, or barriers to discharge, despite documentation that the resident expressed a desire to return to the community and live with his sister. The DON reported that the sister did not want the resident to live with her and that the resident’s complex history made community discharge difficult, but these considerations and barriers were not documented in the care plan. Another resident with dementia and moderate cognitive impairment, reflected by a BIMS score of 12, also had an MDS Section Q assessment documenting that the overall discharge plan was unknown and that no active discharge planning process was occurring for a return to the community. This resident’s comprehensive care plan, initiated after readmission following an unsuccessful discharge, did not include discharge planning goals, interventions, or evaluation of discharge options, even though the record showed the resident continued to express a desire to return home. The Social Services Director stated that the resident occasionally expressed a desire to go home but that discharge was considered unsafe due to the resident’s inability to care for herself and the home being described as uninhabitable; however, no discharge care plan addressing the resident’s stated preference, barriers to discharge, or alternative options had been developed. The NHA and DON were unable to provide documentation showing individualized discharge care plans for either resident.
Failure to Maintain Safe PICC Line Care and IV Antibiotic Management
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, person-centered PICC line care and IV antibiotic administration for a resident receiving long-term IV therapy. The resident was admitted with a left leg fracture and active MSSA infection and had a PICC line inserted in the hospital for long-term IV antibiotics. The comprehensive care plan identified the presence of a PICC line for antibiotic therapy but did not include measurable goals, specific interventions, or monitoring related to PICC line care and IV antibiotic administration. Physician orders directed weekly PICC dressing changes on Tuesdays and as needed, and ordered IV vancomycin 1000 mg twice daily through a specified end date. Clinical documentation showed that on one occasion the PICC line was not patent, would not allow infusion of vancomycin, and had been pulled out 5 cm from the insertion site, resulting in the resident being sent to the emergency room, where the PICC was replaced. After replacement, there was no documented evidence that staff monitored arm circumference or measured and documented the external catheter length, despite the known prior complications with the PICC line. This lack of monitoring occurred even though the hospital documentation specified the new catheter length and external measurement at the skin. During an observation, the resident’s PICC dressing was found peeling at the bottom, with yellow drainage throughout most of the surface, and was dated from a prior month, indicating it had not been changed in accordance with the facility’s seven-day dressing change policy or the physician’s weekly order. The resident reported it had been a long time since the dressing was changed, and the RN Unit Manager confirmed the dressing should have been changed. At the same time, an empty antibiotic bag was observed on the IV pole connected to unlabeled IV tubing that lacked a sterile end cap and was hanging freely. No emergency PICC kit or supplies were present in the room, and there were no physician orders or documentation requiring or monitoring an emergency kit at the bedside. The Treatment Administration Record showed a dressing change documented as completed the day before, which was inconsistent with the observed condition and date on the dressing. The DON confirmed the failures related to PICC dressing maintenance, tubing management, catheter monitoring, absence of emergency supplies, and inaccurate documentation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Label and Store Food Items According to Safety Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food storage and labeling practices in the food and nutrition services department. During an initial tour, a tray of seven thawed 4-ounce nutritional shakes was found in the walk-in refrigerator with a defrost date of June 5, 2025, despite the manufacturer's label specifying the product must be used within 14 days of thawing. As of the observation date, the shakes had been thawed for over six weeks, exceeding the recommended use period. Additional observations included a one-gallon container of salad dressing and a one-gallon container of BBQ sauce, both opened but lacking dates of opening, making it impossible to determine their viability. A 32-ounce carton of liquid eggs was also found opened and undated, despite manufacturer instructions requiring use within three days after opening. During interviews, the Food Service Director confirmed that all food and beverages are expected to be labeled, dated, stored, and thawed according to food safety standards. The absence of opening and thawing dates on multiple food items prevented staff from determining whether products were still safe to use, representing a failure to follow federal food safety standards and manufacturer guidelines. No information about specific residents or their conditions was provided in the report.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
The facility failed to provide meal service in a manner that maintained residents' dignity by allowing extended delays in meal delivery at shared tables. Observations revealed that at Dining Table #5, one resident received her meal and began eating while the other three residents at the same table waited between 15 to 20 minutes before being served. Similarly, at Dining Table #4, one resident was served first, while the other two residents at the table waited 10 to 13 minutes before receiving their meals. These delays occurred while staff continued to serve other residents in the dining room. Staff interviews indicated that there were not enough staff members assigned to the dining room to ensure timely meal delivery and assistance. Additionally, meal trays were not organized by table but were randomly placed on the meal cart, further delaying service to some residents at shared tables. The Nursing Home Administrator and DON confirmed that the lunch meal service was not conducted in a timely or coordinated manner, resulting in a failure to ensure that residents were provided meals in a dignified manner.
Failure to Follow Physician Orders for Medication Administration Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses evaluated and provided nursing care according to physician orders for a resident with hypertension and atrial fibrillation. The resident, who was severely cognitively impaired, had a physician's order for Metoprolol to be administered twice daily with specific parameters to hold the medication if the systolic blood pressure was less than 100 mm Hg or the heart rate was less than 60 beats per minute. However, a review of the Medication Administration Records (MAR) for May and June revealed no evidence that the resident's blood pressure or heart rate was monitored prior to administering the antihypertensive medication as required by the order. Additionally, in July, the MAR showed that Metoprolol was held on two occasions due to 'parameters,' even though the resident's blood pressure and heart rate were above the hold thresholds specified in the physician's order. These findings were confirmed by facility leadership, who acknowledged that the physician's orders were not followed as written. The deficiency was identified through clinical record review, facility policy review, and staff interviews.
Failure to Develop and Implement Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, as required. For one resident with end-stage renal disease and diabetes mellitus, the baseline care plan addressed dialysis needs but did not include interventions for incontinence, skin integrity concerns, mobility limitations, or fall prevention, despite documentation of these issues in the clinical record. Staff interviews confirmed that the baseline care plan lacked the minimum healthcare information necessary to address the resident's immediate health and safety needs upon admission. For another resident with paraplegia, assessments identified a high risk for falls and a need for two staff to assist with bed mobility and hygiene. However, the baseline care plan did not document interventions to mitigate fall risk or include therapy recommendations for safe resident handling. Interviews with therapy and nursing leadership confirmed that the care plan was not updated to reflect these critical needs, and no evidence was provided to show that the required information was incorporated into the resident's baseline plan of care.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Document and Plan Care for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that appropriate physician's orders, documented medical justification, and an individualized plan of care were in place for the use and management of an indwelling urinary catheter for a resident admitted with a Foley catheter. Upon review, there was no documentation in the resident's care plan reflecting the presence of the catheter or the need for catheter-related care, despite the resident being admitted with the device. Additionally, the treatment administration record did not include entries documenting the catheter's presence, size, balloon volume, or instructions for nursing care, and there were no physician orders or medical justification for the catheter's use at the time of the surveyor's observation. Observation of the resident confirmed the presence of the Foley catheter, and interviews with the resident and facility staff verified that the catheter had been in place since admission. The Director of Nursing and Registered Nurse Assessment Coordinator acknowledged the absence of a physician order and a care plan for the catheter. Documentation and appropriate care planning were not initiated until several days after admission and only after the issue was identified by surveyors.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified concerns.
Failure to Implement Smoking Safety Procedures and Use of Approved Ashtrays
Penalty
Summary
The facility failed to implement its established procedures for smoking safety and the safety of smoking areas, as evidenced by the case of one resident who smokes. According to the facility's Smoking/Vaping Policy, residents who smoke are to have an initial smoking assessment upon admission, with safety considerations such as the need for assistance, supervision, and the use of special equipment. Matches and lighters are required to be kept at the nurse's station, and only approved, noncombustible ash containers are to be used in designated smoking areas. However, observations revealed that the resident was using a plastic cup as an ashtray while smoking in the designated area, and had a blue lighter stored in her cigarette pack in her room, contrary to facility policy. The resident reported difficulty using the facility-provided ash receptacles and therefore used a plastic cup instead. Further review of the resident's clinical record showed she had a history of rheumatoid arthritis and mononeuropathy, was assessed as cognitively intact, and was considered safe to smoke independently. Despite this, the resident's shirt was observed to have multiple small holes, which she identified as old burn marks. Facility leadership, including the DON and NHA, were unable to provide documentation that the required protocols for securing lighters and matches were followed, nor could they confirm that the plastic cup used as an ashtray was an approved receptacle. Additionally, there was no evidence that staff had previously identified or addressed the burn holes in the resident's clothing until prompted by surveyors.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors on both Nursing Units 1 and 2. During a group interview, four alert and oriented residents reported they did not know where the survey results were posted. Subsequent observation and a facility tour confirmed that the survey results could not be located on either unit. In an interview, the DON and NHA acknowledged that the Department of Health survey results were not posted on Nursing Units 1 or 2, resulting in a lack of accessibility for residents and visitors.
Failure to Investigate and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to investigate the cause of newly developed pressure injuries and did not consistently implement preventive interventions for one resident. The resident, who was severely cognitively impaired and at high risk for pressure ulcer development due to multiple comorbidities including diabetes, incontinence, neuropathy, and peripheral vascular disease, had a care plan in place with interventions such as regular skin checks, repositioning, and use of pressure-relieving devices. Despite these interventions being documented in the care plan, there was no evidence that they were consistently carried out prior to the identification of new pressure injuries. A review of the resident's records showed that two unstageable pressure injuries developed on the left and right ischium, with wound assessments documenting progression in size and severity over several weeks. Physician orders for wound care were implemented after the wounds were identified, and the family requested offloading every two hours. However, there was no documentation to confirm that offloading or other preventive measures were consistently performed before the wounds appeared. Additionally, there was a lack of documentation of skin assessments between the last recorded shower and the discovery of the wounds. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that no investigation was conducted to determine the cause of the pressure injuries, nor was there a review to ensure that preventive interventions had been implemented as required. The facility's failure to investigate the cause and ensure consistent implementation of preventive measures led to the deficiency cited under the relevant nursing services regulation.
Failure to Implement Non-Pharmacological Interventions and Lacking Clear PRN Opioid Parameters
Penalty
Summary
The facility failed to implement non-pharmacological interventions prior to administering a narcotic pain medication and did not ensure that physician orders for the narcotic included clear parameters for use. According to the facility's pain management policy, non-drug interventions such as repositioning, therapy modalities, and relaxation techniques were required before administering PRN pain medications, and pain assessments were to be documented using a numerical scale or the PAINAD tool. For one resident with severe cognitive impairment, diabetes, neuropathy, and peripheral vascular disease, the clinical record showed that Tylenol was administered on several occasions with documentation of attempted non-pharmacological interventions, but without recording pain scale ratings or clinical rationale for medication selection. On a specific occasion, the resident received Oxycodone for a pain rating of 9 out of 10, but there was no documentation that non-pharmacological interventions were attempted prior to administration, as required by both facility policy and physician orders. Additionally, the physician's order for Oxycodone lacked defined parameters, such as pain scale thresholds, to guide staff in determining when to administer the opioid. The Nursing Home Administrator confirmed these findings during an interview, acknowledging the absence of required documentation and specific criteria in the physician's order.
Medication and Biological Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to medication expiration and use-by dates on one of its medication carts and did not properly date biologicals when opened for use. During an observation of a medication cart, two opened Lantus insulin pens were found without dates indicating when they were opened or their expiration/use by dates. Additionally, one of the insulin pens was incorrectly stored in another resident's pharmacy-labeled packaging. This was confirmed by an LPN present during the observation and later by the Director of Nursing (DON), who acknowledged that the insulin pens should have been dated when opened to ensure they did not exceed their expiration dates. Furthermore, the facility did not ensure that biologicals, such as normal saline solution, were labeled with the date they were opened and the timeframe for discarding after opening. In Resident 14's room, an opened and undated bottle of normal saline solution was observed on two separate occasions, with the volume decreasing over time, indicating continued use. The RN Unit Manager confirmed that the saline solution should have been dated when opened and discarded after 24 hours. The DON also confirmed the facility's failure to label biologicals according to professional standards.
Failure in Medication Management and Controlled Substance Accountability
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address quality deficiencies related to the storage and use by dates of multi-use medications and the accountability of controlled substances. During a survey conducted on September 13, 2024, deficiencies were identified in the procedures for storing and labeling multi-dose medications and maintaining accurate records for controlled substances. The facility developed a plan of correction, which included specific procedures such as replacing insulin pens for a resident, auditing medication carts, and educating nursing staff on handling controlled substances. However, during a revisit survey on November 27, 2024, it was found that the facility's QAPI committee did not successfully implement the corrective plan. The ongoing deficient practices were observed in the same areas of concern, indicating that the quality assurance plan was ineffective. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility's plan failed to prevent the recurrence of these deficiencies, specifically in the labeling and storage of multi-use medications and the accountability of controlled substances.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For Resident 59, the quarterly MDS assessment inaccurately documented the use of a trunk restraint, which was not supported by any physician's orders or the resident's clinical record. The Director of Nursing confirmed that the resident had never been subjected to any physical restraint while residing in the facility. Resident 66's quarterly MDS assessment incorrectly indicated the administration of anticoagulant medication during the 7-day look-back period, despite the clinical record showing no prescription for such therapy in August 2024. Similarly, Resident 24's MDS assessment inaccurately reported the administration of both antipsychotic and anticoagulant medications. The clinical record confirmed the resident received antipsychotic medication daily during the look-back period but did not receive any anticoagulant therapy. These inaccuracies were confirmed by the RNAC during an interview.
Medication Administration Error Due to Inadequate Supervision
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards during medication administration for a resident diagnosed with Alzheimer's disease and glaucoma. The resident, who was cognitively intact with a BIMS score of 15, was not to self-administer medications according to a physician's order. However, during a medication administration, a licensed practical nurse (LPN) left the resident's medications, including eye drops, on the bedside table while attending to another task. During the nurse's absence, the resident mistakenly self-administered ear drops into her eyes, which were not prescribed for her. The incident was documented in a Medication Error Report, and interviews with the resident and the LPN confirmed the sequence of events. The LPN acknowledged that medications should not be left at the bedside and that the resident did not have an order for ear drops or self-administration of medications. The Director of Nursing confirmed that the facility's policy required staff to check medication labels before entering a resident's room and that medications should not be left unattended. This oversight resulted in a failure to ensure the resident's environment was free of accident hazards.
Failure to Monitor Nutritional Parameters and Notify Physician
Penalty
Summary
The facility failed to monitor the nutritional parameters of two residents, Resident 25 and Resident 64, who experienced significant weight fluctuations. Resident 25, diagnosed with dementia and severe protein calorie malnutrition, experienced a 23.4-pound weight loss, which was not immediately reweighed as per facility policy. Additionally, there was no documented evidence that the physician and resident representative were notified of this significant weight loss. The dietitian noted the weight loss and questioned its accuracy, requesting reweights multiple times, but the facility staff did not comply. Subsequent weight measurements showed further weight loss, yet the facility again failed to reweigh the resident or notify the physician and resident representative. Similarly, Resident 64, with diagnoses including a nontraumatic intracranial hemorrhage, dysphagia, and severe protein calorie malnutrition, experienced a 13.2-pound weight gain, which was not immediately reweighed. The facility did not document notifying the physician and resident representative of this significant weight gain. The dietitian noted the weight gain and requested reweights to confirm the change, but no new weight was recorded. Further weight measurements indicated an additional 27.3-pound gain, yet the facility again failed to reweigh the resident or notify the physician and resident representative in a timely manner. The Registered Dietitian confirmed these failures, highlighting the lack of timely notification and reweighting, which impeded accurate assessment of the residents' nutritional status and needs.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to adhere to its pain management policy by not attempting non-pharmacological interventions before administering pain medication to a resident. The policy, last revised in July 2023, mandates that non-drug interventions such as positioning, physical therapy, occupational therapy, relaxation techniques, and diversional activities should be tried prior to medication administration. However, a review of the clinical records for a resident with rheumatoid arthritis, chronic obstructive pulmonary disease, and hypertension revealed that Oxycodone was administered multiple times in September 2024 without evidence of prior non-pharmacological interventions. The resident had a physician's order for Oxycodone HCL 5mg every 6 hours as needed for moderate to severe pain. Despite this, the Medication Administration Record showed several instances of Oxycodone administration without documented attempts of non-drug interventions. The Director of Nursing confirmed during an interview that the facility did not consistently attempt these interventions, leading to a deficiency under 28 Pa. Code 211.12 (d)(3)(5) Nursing Services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Upon review, it was found that the care plan did not identify the resident's PTSD symptoms or triggers, nor did it include specific interventions to minimize these triggers and prevent re-traumatization. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the facility's inability to provide culturally competent, trauma-informed care in accordance with professional standards of practice. The lack of a tailored care plan compromised the resident's emotional well-being and safety.
Failure to Reconcile Controlled Drugs on Medication Cart
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on one of its medication carts, specifically the A2 Cart E even. A review of the Shift Change Checks sheet for September 2024 revealed that the required signatures from both the on-coming and off-going nurses were missing on several occasions. These dates included September 1, 2, 9, 10, and 12, 2024, indicating that the task of counting controlled drugs was not verified as completed during these shift changes. Interviews with staff members, including an LPN, an RN Unit Manager, and the Director of Nursing, confirmed the expectation that nursing staff must count controlled medications at the end of each shift and sign the logs to confirm the inventory is correct. The absence of these signatures suggests a failure to adhere to the facility's procedures for controlled drug reconciliation, as outlined in the facility's policy and state regulations.
Inadequate Justification for Opioid Administration
Penalty
Summary
The facility failed to adequately justify the administration of an opioid pain medication, morphine sulfate, to a resident with severe cognitive impairment. The resident, who was admitted with diagnoses of unspecified psychosis and major depressive disorder, was prescribed morphine sulfate to be administered as needed for pain. However, the medication was given on two occasions in November 2024, despite the resident reporting a pain level of zero out of ten. This action was not in accordance with the facility's pain management policy, which requires pain management orders to have parameters using a numerical scale for pain levels. During an interview, the Director of Nursing confirmed the lack of documented clinical rationale for administering the opioid medication to the resident on the specified dates. The facility's policy, last revised in July 2023, mandates that pain management should be evaluated and managed for all residents, with specific guidelines for administering pain medication based on reported pain levels. The failure to adhere to these guidelines resulted in the administration of unnecessary medication, highlighting a deficiency in the facility's adherence to its own pain management policies.
Neglect in Resident Care Leads to Physical Harm
Penalty
Summary
The facility failed to provide necessary care and services to prevent physical harm and maintain the health of two residents, leading to neglect. Resident 1, who was admitted with incomplete quadriplegia and neurogenic bowel, was dependent on staff for bed mobility and toilet use. Despite a care plan requiring staff to remove the resident from the bedpan at the beginning of the 11:00 PM to 7:00 AM shift and to reposition the resident every two hours, the resident was left on a bedpan from 9:27 PM on February 3, 2024, until 4:30 AM the next day. This resulted in a stage 2 pressure wound on the resident's buttocks. The investigation revealed that Employee 1, an LPN, falsely documented the removal of the bedpan and failed to notify the oncoming shift. Employee 2, a nurse aide, neglected to perform the scheduled turning and repositioning, which would have identified the resident's prolonged time on the bedpan. Additionally, the facility neglected to provide Resident 1 with the necessary wound treatment due to a lack of Mesalt, a dressing used for the resident's wound care. Despite a physician's order for daily treatment, the facility ran out of Mesalt over a holiday weekend, and staff failed to consult with the physician for alternative treatment. Employee 4, an LPN, used the last of the Mesalt on May 26, 2024, and did not attempt to obtain more from the pharmacy, resulting in incomplete wound care for the resident. Resident 2, who was admitted with dementia and required moderate assistance for activities of daily living, fell while being walked back from the dining room. The staff member, Employee 7, neglected to follow the resident's care plan, which required the use of a gait belt and a wheelchair to follow the resident. The employee was too far from the resident to provide proper assistance, leading to the resident's fall and resulting in a large hematoma and swelling. The Director of Nursing confirmed that the staff neglected to provide the necessary care and services for both residents.
Failure to Administer Medications and Wound Treatment Timely
Penalty
Summary
The facility failed to implement pharmacy procedures to ensure the timely acquisition and administration of medications for a resident with incomplete quadriplegia and neurogenic bowel. The resident was admitted with specific physician orders for medications including Bactrim, Prednisone, Plavix, Vancomycin, and Carvedilol. However, the resident did not receive these medications on specified dates because they were not available from the pharmacy. The Director of Nursing (DON) confirmed that the facility's procedure when medications are unavailable is to check the emergency supply and consult the physician for further instructions. Despite the availability of some medications in the emergency supply, there was no documented evidence that the physician was consulted. Additionally, the facility ran out of Mesalt, a dressing used for the resident's wound treatment, over a holiday weekend. The resident did not receive the prescribed wound treatment due to the unavailability of Mesalt. Interviews with staff revealed that the Central Supply employee was informed of the shortage but could not order more until after the holiday. The LPN did not contact the pharmacy for an alternative supply, assuming it was closed. The DON acknowledged that the staff should have used the emergency supply to prevent missed doses and confirmed the lack of documentation regarding physician consultation for the unavailability of medications and treatments.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with incomplete quadriplegia and neurogenic bowel. The resident reported being left on a bedpan for an extended period, resulting in a pressure sore. Additionally, the facility ran out of Mesalt, a dressing used for the resident's wound treatment, and the prescribed treatment was not administered as ordered. Employee 4, an LPN, did not document the unavailability of Mesalt or her attempts to contact the physician regarding this issue. Furthermore, she failed to record a dressing change performed later in the day due to the dressing becoming soiled. Another LPN, Employee 6, signed the treatment administration record indicating the treatment was performed as prescribed, despite the lack of Mesalt. There was no documentation of any consultation with the physician for an interim treatment plan. Additionally, an investigation revealed that Employee 1 falsely documented the removal of the resident from the bedpan, which was confirmed by the Nursing Home Administrator. These documentation failures were in violation of professional standards and state regulations.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 151 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stroudsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whitestone Care Center | 3.5 mi | ★★★★★ | 11 | 0 |
| Sapphire Care And Rehab Center | 6.6 mi | ★★★★★ | 13 | 0 |
| Slate Belt Health & Rehabilitation Center | 7.4 mi | ★★★★★ | 6 | 0 |
| Brookmont Healthcare And Rehabilitation Center | 7.6 mi | ★★★★★ | 10 | 0 |
| Clover Rest Home | 10.2 mi | ★★★★★ | 0 | 0 |
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