Inspection·November 17, 2023

F 0584 Resident 101, at head of bed, 67.1 degrees (Room across hall from previous two rooms) Level of Harm - Minimal harm or potential for actual harm Review of temperature logs taken by Employee 1 for October and November 2023, revealed that the temperatures of the rooms were 70 degrees or above. The audit form did not include specific rooms and only one temperature was taken on each hallway. Residents Affected - Some Review of outdoor temperatures for Watsontown, PA on November 15, 2023, revealed that at 8:15 AM the temperature was 28.4 degrees Fahrenheit and at 9:05 AM, the temperature was 30.2 degrees Fahrenheit. Observation and interview with Resident 86 on November 15, 2023, at 11:42 AM revealed that her bed never gets made. The bed was not made at the time. The floor in front of Resident 86's chair had dirt spots that the surveyor was able to clean with a wet paper towel. Resident 86 indicated that her room was swept today, and a dustpan was used. A pretzel and other crumbs were found at the floor edges. Resident 86 had a pillow on her bed with a pillowcase that was partially removed and the plastic covering of the pillow was cracked throughout. Observation of the nightstand revealed that a nebulizer (machine to administer breathing treatments into the lungs) was present with the mouthpiece uncovered. Resident 86 indicated that she has not used the nebulizer in a while, and it didn't need to be there. Observation of Resident 86's bathroom which was shared with three other residents has a urinary collection bag for a catheter (a drainage bag that collects urine for when a person has a tube inserted in the bladder to drain urine) and a urinal hanging on a towel rack. Resident 86 said she no longer has a catheter. Observation on November 16, 2023, at 9:00 AM with Employee 13, licensed practical nurse, revealed the privacy curtain around Resident 18's bed did not close at the foot of her bed. Resident 18 resided in a four-bed room. The privacy curtain was hanging off the tracks at the foot of the bed. Observation on November 16, 2023, at 12:09 PM with Employee 13 revealed that the privacy curtain was off the tracks and did not close near Resident 35's right lower side of the bed and the foot of the bed. Resident 35 was in a semi-private room. Follow up observation of Resident 86's bed on November 16, 2023, at 1:26 PM revealed her bed was not made. The above information was reviewed in an interview with the Nursing Home Administrator and Director of Nursing on November 16, 2023, at 2:30 PM. Observation of Resident 72's room on November 14, 2023, at 11:10 AM revealed the lower portion of the door to his room and all marred. Observation of Resident 112's room on November 14, 2023, at 11:18 AM revealed that the door to her room is all marred. The left wall (as you look at her bed) had spillage on it and was all marred. To the right of the bulletin board on the same wall there was an area noted where the paint had been pulled off. The cove base between the nightstand and the bed was coming off. Observation of Resident 85's room on November 14, 2023, at 11:22 AM revealed her wheelchair was dirty and the wheelchair cushion was dirty with spillage. When looking at the window in the room, there was an area of the wall on the right side near the windowsill that was missing paint and down to the drywall. The wall to the left of the bathroom door was marred with an area that was patched but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 2 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not painted. In the bathroom, the wall to the left of the sink was patched but not painted. The wall under the mirror was starting to peel. The outer edges of the night light were dirty, and the floor around the toilet base was dirty. Observation of Resident 47's room on November 15, 2023, at 11:55 AM revealed the wall to the right side of the bed was marred. Observation of the lower-level east hallway revealed the cove base was missing to the left side of the clean utility room and both sides of the hallway below the handrail were marred with black marks and paint chipped in areas. Observation of the lower-level east hallway 44-49 revealed that the wall on both sides of the hallway below the handrail have chipped paint and were marred with black marks. Observation of the lower-level east hallway 44-49 revealed the dining room door to be marred with black marks and some of the wood finish was missing. The cove base in the dining room was chipped and cracked and the left wall as you enter the dining room had an area that was patched but not painted. The above information was reviewed in an interview with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:10 PM. Observation of the Lower Level hallway on November 14, 2023, at 10:56 AM and November 15, 2023, at 8:40 AM revealed an entrance to the main resident hallway that had an accumulation of dead leaves on the floor. There were two test strips for measuring blood glucose discarded on the floor. Observation on November 14, 2023, at 11:02 AM of the Lower Level dining room/lounge located at the end of the hall had an accumulation of debris in corners of the room. There was a brown, small sized table that had food debris on it. Observation on November 14, 2023, at 1:47 PM revealed the Lower Level tub room had the following findings: two posters on the wall titled, Saf-Lift / Saf-[NAME], were discolored yellow, had various tears, and were curled. There was a large brown stain on a ceiling tile. A Conair hairdryer unit was loose and started to detach from the wall. There was a golf-ball sized hole in the wall of a previously patched area outside of the tub room in the main hallway area just before the double doors that led to the other resident rooms. Observation on November 15, 2023, at 8:40 AM and again at 12:38 PM of the main entrance to the facility revealed a portable table with a container of hand sanitizer, the table was covered in dust. There was a sign on the wall that indicated the facility was smoke-free that had an accumulation of dust, cobwebs, and dead bugs on the top of it. There was an accumulation of debris on the floor. A wall mounted hand sanitizer dispenser had an accumulation of dead bugs on the drip tray. Observation of the Lower Level on November 15, 2023, at 9:44 AM revealed a resident lift in the hallway. There was a gray and black canvas bag attached to the lift that had a large brown stain on the outside of it. The interior of the bag held a charging plug with a significant build-up of hair. There were several pieces of paper trash discarded in the bottom of the canvas bag. There was a brown stain on the ceiling tile above where the lifts were being kept. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 3 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Observation of Resident 25's room on November 14, 203, at 1:23 PM and November 15, 2023, at 9:28 AM revealed crumbs, debris, and a tissue under the resident's bed. The above information for the Lower Level and Resident 25's room was reviewed with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 2:30 PM. Residents Affected - Some 483.10(i)(1)-(7) Safe/clean/comfortable/Homelike Environment Previously cited 4/12/23 and 12/9/22 28 Pa. Code 201.18(b)(3)(e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 4 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement its abuse prohibition policy pertaining to screening for five of five newly hired employees reviewed (Employees 1, 6, 7, 8, and 9). Residents Affected - Some Findings include: A review of the facility policy entitled Employment Screenings for Potential Hires: Pennsylvania, last reviewed July 21, 2023, revealed for applicants who have not resided in Pennsylvania for the two years prior to the application or who currently live in another state, the facilty will obtain a report from the FBI using the FBI fingerprint card criminal history check process. This will be completed within 90 days of hire. A review of Employee 1's, maintenance director, personnel record revealed that the facility hired him on July 25, 2023. There was no documented evidence in Employee 1's personnel record that the facility obtained an attestation of Pennsylvania residency or completed an FBI check. A review of Employee 6's, activities, personnel record revealed that the facility hired her on July 18, 2023. There was no documented evidence in Employee 6's personnel record that the facility obtained an attestation of Pennsylvania residency or completed an FBI check. A review of Employee 7's, receptionist, personnel record revealed that the facility hired her on July 18, 2023. There was no documented evidence in Employee 7's personnel record that the facility obtained an attestation of Pennsylvania residency or completed an FBI check. A review of Employee 8's, dietary aide, personnel record revealed that the facility hired her on August 22, 2023. There was no documented evidence in Employee 8's personnel record that the facility obtained an attestation of Pennsylvania residency or completed an FBI check. A review of Employee 9's, nurse aide, personnel record revealed that the facility hired her on October 3, 2023. There was no documented evidence in Employee 9's personnel record that the facility obtained an attestation of Pennsylvania residency or completed an FBI check. An interview with the Nursing Home Administrator on November 17, 2023, at 1:15 PM, confirmed these findings. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.19(6)(8) Personnel policies and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 5 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing that included the required contents, of a transfer to the hospital for six out of 10 residents reviewed (Residents 40, 67, 72, 110, 112, and 114). Findings include: A review of Resident 110's clinical record revealed that the facility transferred her to the hospital on May 10, 2023, due to sepsis (an infection of the blood stream). There was no documented evidence to indicate that the facility provided a written notice to Resident 110's responsible party regarding his transfer to the hospital that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address (mailing and email) information for the Office of the State Long-Term Care Ombudsman, and information (mailing and email address and telephone number) for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and a statement of resident's appeal rights, including name, address (mailing and email) and telephone number of entity, which receives requests. Clinical record review for Resident 40 revealed that she was transferred to the hospital from [DATE] to October 3, 2023, due to her altered mental status. There was no evidence to indicate that Resident 40's responsible party was provided written notification to include the above required contents. Clinical record review for Resident 67 revealed that the resident was transferred to the hospital on October 12, 2023, due to critical lab values. There was no documentation that the facility provided written notification to the resident or their responsible party regarding the above required contents. Clinical record review for Resident 72 revealed that the resident was transferred to the hospital on October 5, 2023, due to becoming unresponsive in his wheelchair. There was no documentation that the facility provided written notification to the resident or their responsible party regarding the transfer that included the above required contents. Clinical record review for Resident 112 revealed that the resident was transferred to the hospital on July 25, 2023, related to altered mental status and instability after a fall earlier in the day, and on August 30, 2023, related to nausea and dizziness with complaints of the room spinning. There was no documentation that the facility provided written notification to the resident or their responsible party regarding the above required contents. Clinical record review for Resident 114 revealed that the resident was transferred to the hospital on October 12, 2023, related to a fall with right hip pain with X-rays indicating a fractured hip. There was no documentation that the facility provided written notification to the resident or their responsible party regarding the transfer that included the above required contents. The above information for these residents was reviewed with the Nursing Home Administrator on November 17, 2023, at 10:00 AM who confirmed that the transfer notices do not have all the required components that are identified in the regulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 6 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 28 Pa. Code 201.14(a) Responsibility of license Level of Harm - Potential for minimal harm 28 Pa. Code 201.29(a) Resident rights Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 7 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set assessment for one of two residents reviewed (Resident 85). Residents Affected - Few Findings include: Interview with Employee 14, Registered Nurse assessment Coordinator (RNAC), on November 16, 2023, at 2:37 PM confirmed that the facility follows the guidelines from the Centers for Medicare and Medicaid's (CMS) Resident Assessment Instruction (RAI) for completing the Minimum Data Set assessment (MDS, an assessment tool utilized to determine resident care needs). Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Clinical record review for Resident 85 revealed a quarterly MDS dated [DATE], that indicated she required limited assistance with bed mobility, transfers, dressing, and toilet use. Review of Resident 85's annual MDS assessment dated [DATE], indicated that she now required extensive assistance with bed mobility, transfers, dressing, and toilet use. Review of the RAI revealed that the staff should complete a significant change MDS when a resident has a decline or improvement that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and or revision of the care plan. Interview with Employee 14, on November 16, 2023, at 2:37 PM confirmed that a significant change MDS should have been completed on Resident 85. The Director of Nursing was made aware of the concerns related to a significant change MDS not being completed on Resident 85 on November 17, 2023, at 9:42 AM. 483.20(b)(2)(ii) Comprehensive assessments and timing Previously cited 12/09/2022 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 8 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure a discharge summary for two of three discharged residents reviewed (Residents 114 and 117). Findings include: Closed clinical record review for Resident 114 revealed nursing documentation dated [DATE], at 9:08 AM that indicated she was discharged to the hospital as of [DATE]. Further clinical record review revealed that Resident 114 was discharged to the hospital because she returned from a leave of absence with family on [DATE], at 3:21 PM and they indicated that she had a fall and complained of right hip pain. A new order was received at 3:47 PM for an X-ray to be completed as soon as possible on the right hip and pelvis. A progress note dated [DATE], at 11:29 PM indicated that the X-ray results revealed an acute right femoral neck fracture. An order was received to transfer her to the ER. Interview with the Director of Nursing on [DATE], at 2:45 PM revealed that Resident 114 was discharged to the hospital on [DATE], and since then was discharged from the hospital but did not return to the facility. Further clinical record review for Resident 114 revealed a physician's Discharge summary dated [DATE], that only noted that Resident 114 was discharged related to heart failure. Resident 114's closed clinical record did not include a recapitulation of her stay in the facility that included her response to treatments or therapy; pertinent lab, radiology, and consultation results; or the course of illnesses listed in her admission diagnoses list: metabolic encephalopathy (an alteration in consciousness caused by a brain dysfunction causing a change in mental state), Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), Arterial sclerotic heart disease (damage of the blood vessels carrying oxygen away from the heart), and heart failure (the heart does not pump blood as it should). The facility failed to ensure a discharge summary that included a recapitulation of Resident 114's stay at the facility that included the required components listed above. Closed clinical record review for Resident 117 revealed the facility admitted him on [DATE]. Nursing documentation dated [DATE], at 8:24 AM revealed Resident 117 ceased to breathe at 8:10 AM. Resident 117's physician Discharge summary dated [DATE], only listed his discharge diagnosis as deceased . The facility failed to ensure a discharge summary that included a recapitulation of Resident 117's stay at the facility that included the required components listed above. The above-noted findings related to the discharge summaries not being complete for Residents 114 and 117 were reviewed with the Director of Nursing on [DATE], at 10:15 AM. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 9 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide treatment and services, consistent with professional standards of practice, regarding skin assessments, for two of five residents reviewed (Residents 40 and 110). Residents Affected - Few Findings include: The policy entitled Skin Integrity, last reviewed July 21, 2023, revealed the facility will develop a routine to review residents with wounds, or if they are at risk on a weekly basis. Clinical record review for Resident 40 revealed nursing documentation dated November 1, 2023, at 3:30 PM indicating staff noted an open area to her right buttock measuring 1.5 centimeters (cm) by 1.5 cm. There was no documentation that the facility assessed Resident 40's wound weekly until the surveyor questioned them on November 15, 2023. Clinical record review for Resident 110 revealed wound physician documentation dated November 2, 2023, noting Resident 110's pressure wound of the right heel measured 0.6 cm by 1.0 cm. There was no further documentation that the facility assessed Resident 110's wound after November 2, 2023. Observation of Resident 110's right heel with the Director of Nursing on November 17, 2023, at 11:10 AM revealed a healing Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising). There was loose skin remaining attached to the healing skin. These findings for Residents 40 and 110 were reviewed with the Director of Nursing on November 17, 2023, at 11:50 AM. 483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer Previously cited deficiency 12/09/22 and 08/09/23 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(iv)(ix) Medical records 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 10 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to assess and evaluate interventions to prevent fall reoccurrence for one of nine residents reviewed for falls (Resident 82). Findings include: The facility policy entitled, Resident Accidents and Injuries, last reviewed without changes on July 21, 2023, revealed a purpose to ensure all incidents involving a resident are reported, documented, and an investigation initiated after the incident is identified. An incident is defined in the policy as .any happening that is not consistent with the routine operation of the facility or the routine care of a particular resident. It may be an accident or a situation that could result in an accident. Clinical documentation for Resident 82 dated November 2, 2023, at 2:35 PM revealed a BIMS (Brief Interview for Mental Status) assessment was completed on October 23, 2023, that indicated the resident scored a score of six out of 15 and was not capable. Current care plan review revealed the resident was at a high risk for falls related to a history of falls and a high fall score. Several interventions were dated October 16, 2023: Occupational Therapy consult, Physical Therapy evaluate and treat as ordered, non-skid socks, call light and frequently used items within reach, and orient the resident to surroundings. One intervention was dated October 30, 2023: a sign to remind resident to use the call bell for assistance. Clinical record review for Resident 82 revealed nursing documentation dated October 19, 2023, at 6:35 AM that revealed the nurse was alerted at 5:15 AM that the resident was on the floor. The documentation noted the resident was lying on the right side of the bed with his head at the foot of the bed. The resident was in the supine position with his head resting on a gown that the nurse aide stated that she had placed for comfort. The resident reported right hip pain. The nurse initiated neurological checks and assisted other staff with getting the resident back into bed. The nurse aide was then advised to get the resident washed up for the day and to place the resident into his wheelchair per the documentation. Nursing documentation for Resident 82 dated October 19, 2023, at 7:46 AM revealed that it was reported that the resident had a fall this AM. The documentation noted the resident currently denied any discomfort. Neurological checks (a physical assessment to determine if an injury such as a fall impacted the brain, spinal cord, or nerves) were put into place due to the fall. Clinical record review for Resident 82 revealed nursing documentation dated November 2, 2023, at 5:48 PM that noted the resident was observed lying on his back on the floor by the night stand due to an unwitnessed fall. The resident was unable to state what happened. There was a skin tear to the left elbow being treated by the licensed practical nurse. The resident was transferred to the wheelchair by staff. The resident's neurological exam was intact and neurological checks were put into place. The vital signs were normal, and the responsible party and physician were made aware of the fall by the licensed practical nurse. Clinical record review for Resident 82 revealed no evidence that there was an investigation to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 11 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few determine a potential cause of the incident or any evidence that interventions were placed at the time after the falls on October 19, 2023, and November 2, 2023, to prevent future occurrences of falls. An interview with the Nursing Home Administrator on November 17, 2023, at 2:21 PM revealed that there was no evidence that the facility investigated the falls for Resident 82 on October 19, 2023, and November 2, 2023, and no evidence that further interventions were implemented to prevent future falls. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 12 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of three residents reviewed (Resident 25). Residents Affected - Few Findings include: A review of a current diagnoses list for Resident 25 revealed the resident is dependent on supplemental oxygen. A current physician's order for Resident 25 dated May 10, 2023, instructed staff to administer oxygen via nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) continuously at two liters per minute. The current care plan for Resident 25 revealed that the resident is at risk for respiratory failure due to the medical history. Observation of Resident 25 on November 14, 2023, at 11:00 AM revealed the resident's electric wheelchair was in the hallway outside of the resident's room. A nasal cannula was draped over the back of the wheelchair. The nasal cannula was not bagged or protected from the ambient environment. Observation of Resident 25 on November 14, 2023, at 1:33 PM revealed the nasal cannula remained draped over the back of the electric wheelchair located in the hallway. The nasal cannula remained unbagged and unprotected from the ambient environment. An interview with Employee 11, licensed practical nurse, on November 14, 2203, at 1:44 PM regarding Resident 25's oxygen cannula revealed that it should be bagged. Observation of Resident 25's room on November 15, 2023, at 2:20 PM revealed an unused nasal cannula and nebulizer mask laying unprotected on the bed. The resident was not in the room at the time. The above information for Resident 25 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 2:30 PM. 483.25(i) Respiratory/tracheostomy Care and Suctioning Previously cited 12/09/22 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 13 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for three of three nurse aides reviewed (Employees 3, 4 and 5). Residents Affected - Few Findings Include: During a meeting with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:00 PM the surveyor asked for annual performance reviews for Employees 3, 4, and 5. The Director of Nursing confirmed that the employees have been employed for at least a year. Interview with the Nursing Home Administrator on November 17, 2023, at 11:15 AM confirmed there was no documented evidence that annual performance reviews were completed for the above employees. 28 Pa. Code 201.19 (2) Personnel policies and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 14 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, clinical record review, and staff and family interview, it was determined that the facility failed to ensure proper medication storage and labeling for two of two residents reviewed (Residents 40 and 113). Findings include: Observation of a medication administration pass on November 16, 2023, at 8:35 AM revealed Employee 12, Licensed Practical Nurse, administered Vitamin D 50 micrograms (mcg) one tablet to Resident 113. Clinical record review for Resident 113 revealed his current order was for Vitamin D 25 mcg, not 50 mcg. Interview with Employee 12 on November 16, 2023, at 10:09 AM confirmed that Resident 113 should have only received 25 mcg of Vitamin D. She indicated that she did give 50 mcg because the lids on the stock bottles of Vitamin D, the 25 mcg and the 50 mcg, got switched. Observation of both bottles of Vitamin D, at this time, revealed that the bottle of Vitamin D 25 mcg had 1000 written with black marker on the lid of the bottle and the Vitamin D 50 mcg had 2000 written on the lid in black marker. Employee 12 confirmed that staff labeled the Vitamin D bottles for easier identification during medication administration. She also acknowledged at this time that she knows she should be reading the labels. The Nursing Home Administrator and the Director of Nursing were made aware of concerns with medication labeling during a meeting on November 16, 2023, at 2:20 PM. During a family interview with Resident 40's representative on November 14, 2023, at 11:54 AM it was noted that there was a bottle of zinc oxide (preventative skin care treatment) on Resident 40's bedside dresser. Resident 40's representative stated that the staff apply that treatment to Resident 40's groin area. Further observation on November 15, 2023, at 11:19 AM revealed that the zinc oxide remained on Resident 40's bedside dresser. Interview with the Director of Nursing on November 15, 2023, at 2:55 PM revealed that Resident 40's zinc oxide should be stored in the locked treatment cart. 28 Pa. Code 211.9(l)(1) Pharmacy services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 15 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a safe and sanitary condition in the main kitchen and lower level pantry. Findings include: An observation of the facility's main kitchen on November 14, 2023, at 9:12 AM with Employee 10 (food service director) revealed the following: The floor in the kitchen was dirty with numerous black sticky spots from spillage, dried food messes, and trash on the floor. The sink in the food prep area had the following items stored underneath: a tub of peanut butter, a box of potato pearls, a container of jelly, a jug of vinegar and Worcestershire sauce, a container of vanilla, and two trays of spices. The jug of Worcestershire sauce expired on August 26, 2023. There was no date on the container of vanilla. There was a dirty towel on the floor in the dish room. There was a tray with dirty oatmeal bowls in the food prep area. The trash can by the paper products was overflowing and had no lid on it. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:00 PM. Observation of the Lower Level pantry area on November 15, 2023, at 9:03 AM revealed the following: a microwave with a significant accumulation of stains and crusted food on each side of the interior of the microwave, there was a hair on the back interior wall of the microwave, there was an accumulation of debris on the bottom of a plastic container in the freezer, the floor of the freezer had an accumulation of debris, four milk chocolate packets in a cupboard had brown stains, there were multiple dried brown colored drip stains on the wall under the area below the microwave. Observation of the Lower Level pantry area on November 15, 2023, at 2:08 PM revealed the same findings as above. There was now a significant accumulation of very fine, hairlike fibers covering the front exterior of the microwave. The above findings for the Lower Level pantry were reviewed with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 2:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 16 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Based on observation and resident and staff interview, it was determined that the facility failed to arrange for timely podiatry (foot doctor) services for three of four residents reviewed for podiatry services (Residents 35, 63, and 107). Findings include: Observation of Resident 35 on November 15, 2023, at 8:59 AM revealed he was lying in bed. His toenails were of unequal length, discolored, and a nail on the right foot was long. Review of a podiatry consultation for Resident 35 dated August 11, 2023, revealed that the resident has onychomycosis (thickened and discolored nails from a fungal infection, trimming nails is often a treatment). His toenails were trimmed and debrided (removal of diseased toenail bed). The resident was to have a podiatry follow up in nine weeks. There was no documented evidence that another podiatry consultation was completed on or after October 13, 2023 (nine weeks). Observation and interview with Resident 63 on November 15, 2023, at 2:10 PM revealed that his toenails were very long over the edges of his toes. Review of a podiatry consultation for Resident 63 dated July 5, 2023, revealed the resident has onychomycosis and peripheral vascular disease (poor circulation to the limbs). His toenails were trimmed and debrided. The resident was to have a podiatry follow up in nine weeks. There was no documented evidence that another podiatry consultation was completed on or after September 6, 2023 (nine weeks). Review of a podiatry consultation for Resident 107 dated July 5, 2023, revealed the resident had onychomycosis and peripheral vascular disease. Her nails were trimmed and debrided. The resident was to have a podiatry follow up in nine weeks. There was no documented evidence that another podiatry consultation was completed on or after September 6, 2023 (nine weeks). Interview with the Nursing Home Administrator and Director of Nursing on November 16, 2023, at 2:30 PM revealed the facility is currently in the process of obtaining a new podiatrist. The Director of Nursing indicated that the facility does not permit staff to trim toenails. The facility failed to provide evidence that outside resources for podiatry services was arranged for Residents 35, 63, and 107. 28 Pa. Code 201.21(c) Use of outside resources 28 Pa. Code 211.12(d)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 17 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on clinical record review and staff interview, it was determined that the facility failed to ensure an integrated care plan that included services provided by Hospice and those provided by the facility for two of two residents reviewed for Hospice concerns (Residents 9 and 30). Findings include: Clinical record review for Resident 9 revealed the facility admitted her to hospice services on October 16, 2023. During an interview with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:00 PM the surveyor was informed that Hospice documentation was located in binders at the nursing stations. During an interview with Employee 13, licensed practical nurse, and Employee 15, nurse aide, on November 16, 2023, at 12:03 PM it was revealed that they never know in advance when Hospice staff visits and provides care for Resident 9 and that the resident could have been washed by facility staff for the day and then the Hospice aide comes in and does it again. Review of the Hospice binder for Resident 9 revealed a calendar in the front of the notebook that was blank. Clinical record review for Resident 9 revealed her hospice care plan dated March 24, 2023, and November 14, 2023, did not include a delineation of who (the facility or the hospice service) would provide specific services and when the services would be provided for nurse aides, social worker, and clergy. Further clinical record review for Resident 9 revealed that she was on Hospice services previously and they were discontinued and restarted. During a meeting with the Nursing Home Administrator and Director of Nursing on November 16, 2023, at 3:05 PM it was confirmed that Resident 9's care plan did not include a delineation of services. Clinical record review for Resident 30 revealed the facility admitted him to hospice on October 26, 2023. The facility did not implement an integrated plan of care with Hospice until November 14, 2023. The facility failed to ensure the coordination of hospice services with facility services to meet the needs of Resident 30 for end-of-life care. An interview with the Director of Nursing on November 17, 2023, at 10:12 AM confirmed these findings. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 18 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to implement proper infection control practices during medication administration to prevent potential spread of infection on one of three residents observed for medication administration (Resident 113) Residents Affected - Some Findings include: Observation of a medication administration pass on November 16, 2023, at 8:35 AM with Employee 12, Licensed Practical Nurse, revealed her administering Systane ophthalmic drops (eye drops used to treat dry eyes) 0.6%, one drop in each eye to Resident 113. Employee 12 administered Resident 113's oral medications and then proceeded to administer the eye drops. She administered the eye drops with no gloves on. Concurrent interview with Employee 12 confirmed the above noted findings that she did not don gloves prior to administering Resident 113's eye drops. Interview with the Director of Nursing on November 16, 2023, at 12:50 PM confirmed that Employee 12 should have donned gloves to administer Resident 113's eye drops. The facility failed to implement proper infection control practices during medication administration to prevent potential spread of infection for Resident 113. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control Previously cited 12/09/2022 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 19 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsontown Rehabilitation and Nursing Center 245 East Eighth Street Watsontown, PA 17777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 3, 4, and 5). Findings include: During a meeting with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:00 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 3, 4, and 5. Interview with the Nursing Home Administrator on November 17, 2023, at 11:15 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training. 28 Pa. Code 201.20(a)(1-6)(d) Staff development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 20 of 20