Health inspection·January 5, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility documentation and resident responsible party and staff interview, it was determined that the facility failed to resolve resident grievances related to respect, incontinence issues, and resident safety for one of five residents reviewed (Resident 1). Findings include: Review of the facility Concern Forms for the month of December 2023, revealed the Log for December 2023, had 5 concern forms submitted related to Resident 1. Review of the Resident Concern reports related to Resident 1 revealed that all 5 were filed by her daughter/responsible party. Review of the concern forms for Resident 1, filed by her daughter/responsible party revealed the following: December 12, 2023, Concern form filed related to the resident being in pants all day that had a dried urine mark on them suggesting that they did not put her in dry pants all day. The form indicated the findings and disposition that a toileting program would be evaluated, and a family meeting scheduled. The investigation was completed by Employee 1 (Social services) on December 14, 2023. The form was incomplete as the following information was left blank: was concern confirmed or not, was the responsible party notified and how the responsible party was notified, was a written concern follow-up requested, any follow-up (if applicable), and the Administrator's signature and date. December 12, 2023, Concern form filed related to the resident not being changed timely on December 7, 2023, and her clothes from that date were found in a plastic bag soaked on December 8, 2023, when the daughter came into the facility. Findings and disposition indicated that a family meeting was held with the daughter and Resident documentation was reviewed related to toileting and staff educated. The investigation was completed by Employee 1 (Social services) on December 13, 2023. The form was incomplete as the following information was left blank: was concern confirmed or not, was the responsible party notified and how the responsible party was notified, was a written concern follow-up requested, any follow-up (if applicable), and the Administrator's signature and date. December 17, 2023, Concern form filed related to a nurse aide and a supervisor being disrespectful to Resident 1's daughter/responsible party. There was no signature to indicate indicating what employee was investigating the concern. There were no findings/disposition noted on the form. The form was incomplete as the following information was left blank: was concern confirmed or not, was the responsible party notified and how the responsible party was notified, was a written concern follow-up (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395825 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 01/05/2024 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)