Inspection·December 11, 2023

F 0600 with a diagnosis of closed fracture of the right tibial plateau and had a knee immobilizer to be on at all times, with an appointment scheduled with orthopedics. Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's Results History from the hospital dated November 19, 2023, at 4:40 PM revealed and X-ray of the right knee confirmed findings of a nondisplaced fracture of the lateral tibial plateau as noted in the nursing note above. Resident 1 was seen by orthopedics on November 21, 2022, at 10:30 AM with recommendations to continue the knee immobilizer for six weeks. A review of Resident 1's clinical record task/[NAME] revealed Resident 1 was noted to have a transfer status of maximum assistance of two, with pivot disc due to right lower extremity limited mobility from April 14, 2023, to November 22, 2023, after the incident at which time the resident was changed to a Hoyer lift for transfers. An annual MDS (Minimum Data Set, an assessment completed at periodic intervals of time to determine resident care needs) dated November 16, 2023, revealed facility staff assessed the resident as having a BIMS (brief interview of mental status), score of 13, indicating the resident is cognitively intact, and requiring extensive assistance of two persons plus physical assistance for transfers. A resident concern form dated November 17, 2023, completed by a licensed practical nurse with initials matching Employee 3, licensed practical nurse, for Resident 1 noted a concern the resident was transferred with only one nurse aide on November 17 at 8:15 PM and the resident complains of pain in right leg and lower knee. A review of the facility's staff deployment sheet for November 17, 2023, revealed Employee 1, nurse aide, was scheduled on the upper-level north hall where Resident 1 resided and Employee 2, nurse aide was scheduled on the upper-level south hall and Employees 1 and 2 were doing the north and south hall together. Employee 3, licensed practical nurse, was also scheduled on the upper-level north hall with Resident 1. A review of a witness statement completed by Employee 3, licensed practical nurse, which was not dated, noted an incident date of November 17, 2023, at 8:00 PM stating Resident 1 was injured during transfer and the resident was transferred with one nurse aide. The statement indicated the resident told Employee 3 his leg was twisted, and he felt instant pain and a nurse aide told her she did transfer the resident alone. The statement did not indicate a name for the nurse aide. In an interview with Employee 3 during the onsite investigation on December 11, 2023, at 10:33 AM, regarding the evening shift of November 17, 2023, Employee 3 indicated the statement referenced above was written by her, and she did forget to sign the statement. Employee 3 indicated she completed the statement before she left for her shift at 9:00 PM. Upon interview Employee 3 stated Employee 1 was scheduled on the north hall where Resident 1 resided and close to when she was getting ready to leave her shift Employee 1 came to her and said Resident 1 was having pain in his leg, probably because I had to transfer him myself. Employee 3 stated Employee 1's reason for transferring the resident herself was because they were short staffed. Employee 3 stated Employee 2, and herself were scheduled on the north and south hall and all work together to help each other for transfers. Employee 3 stated she was getting ready to leave for the night, but she went to check on Resident 1 and did not see any apparent injury and asked him what his pain level was which she indicated he stated a 3. Resident 1 declined need for any pain medication and then Employee 3 stated she reported off to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 2 of 4 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 12/11/2023 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 0600 registered nurse, wrote a statement, and left for the night. Level of Harm - Actual harm There was no evidence of any documentation in Resident 1's record dated November 17 ,2023, regarding an assessment of the resident by Employee 3, or any registered nurse assessment of the resident until the nursing note referenced above dated November 18, 2023, at 4:38 AM, which noted the new onset of pain and per the facility staffing deployment sheet for November 17, 2023, was the night shift registered nurse. The registered nurse scheduled for the evening shift on November 17, 2023, was attempted to be reached by telephone by the surveyor during the onsite investigation and was not able to be reached. Residents Affected - Few Employee 3's documentation in Resident 1's record dated November 18, 2023, at 1:33 PM noted while administering 2100 medications to the resident he told this nurse that he was having right knee pain, and when asked what happened, the resident stated he was transferred with one assist and his knee twisted, RN was notified. Employee 3 then documented on November 18, 2023, at 1:52 PM that the facility attempted to call the son last evening regarding injury and the son was unable to be reached due to his number being disconnected and the nurse supervisor spoke with the son today. In an interview with Employee 3 at 11:41 AM on December 11, 2023, she stated she did not provide documentation in Resident 1's record on November 17, 2023, because she was in a hurry to get out of the facility and just forgot to document that night. There was no evidence an investigation into Employee 1 who was assigned to Resident 1 on the evening shift on November 17, 2023, was completed until November 20, 2023. Employee 3 stated Employee 1 reported to her that she transferred him by herself, and the resident was having leg pain before Employee 3 left for the end of her shift at 9:03 PM, which was verified upon observation of Employee 3's time card. Review of a timecard for Employee 1, the alleged nurse aide, revealed she continued to work on the evening shift through the night shift for November 17, 2023, until 2:00 AM. In an interview with the Nursing Home Administrator and Director of Nursing on December 11, 2023, at 3:00 PM they indicated they were not aware of the incident or allegation regarding Resident 1 until they returned to work after the weekend on Monday, November 20, 2023, and began the investigation into the incident. A statement from Employee 1, nurse aide, dated November 20, 2023, stated the gentleman was ready to go to bed, but she was the only aide down the north hall and she asked another aide down the other hallway if she could help her and she said he was a one person and she does him by herself, and a nurse said, no, he is not, he is a two person, so the lady helped her put him in bed, but when they were standing him up he said his leg was hurting. Employee 1 stated the lady helped her change him in bed. Employee 1 stated she let the nurse know he was in pain. Employee 1 stated she did not remember the lady's name and assumed it was the regular nurse that works the north hallway. Further interviews conducted by facility administration revealed Employee 2 who was working the south hall and who was to help Employee 1 on north hall, stated she was not in the room during Resident 1's transfer into bed and was called to help roll him in bed after the resident was already in the bed, and Employee 3, the licensed practical nurse on the unit also did not assist Employee 1, or have any recollection of a conversation about transferring Resident 1 to bed as Employee 1 indicated in her statement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 3 of 4 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 12/11/2023 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 0600 Level of Harm - Actual harm A review of a report submitted by the facility on November 29, 2023, indicated Employee 1 stated she did transfer Resident 1 appropriately with two assist, but all other staff involved stated this was false and no one was in the room with Employee 1 at the time of the injury. Resident 1 was noted in that report as competent and confirmed he was transferred by one person and neglect was substantiated. Residents Affected - Few Employee 1 was noted in the above mentioned report to be agency nursing staff and was placed on a do not return list for the facility and the employee's agency was contacted. There was no evidence the facility conducted any plan of correction to the facility staff regarding timely reporting and timely investigation of allegations of abuse/neglect and protecting other residents from the potential of abuse/neglect upon report of an allegation as Employee 1 continued to work in the facility until 2:00 AM after Employee 3 indicated she reported the incident prior to leaving for her shift at 9:03 PM. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on December 11, 2023, at 3:00 PM who confirmed neglect was substantiated regarding the incident above with Resident 1, resulting in a fracture. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395825 If continuation sheet Page 4 of 4