Pennsylvania Department of Health
WATSONTOWN REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WATSONTOWN REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 153 surveys for this facility. Please select a date to view the survey results.

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WATSONTOWN REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to three Complaint Investigations, completed on March 6, 2025, it was determined that Watsontown Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to notify the physician of a resident's change in condition requiring interventions for one of five residents reviewed (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed nursing documentation dated March 1, 2025, at 9:35 PM that indicated he was unable to swallow.

A nursing progress note dated March 2, 2025, at 10:11 AM indicated that Resident CR1's medications were not given because it was not safe due to him not responding.

A nursing progress note dated March 2, 2025, at 11:32 AM revealed that Resident CR1's daughter called and wanted updates on the resident. The resident was assessed by the documenting nurse and indicated his vital signs were within normal limits, his heart rate (HR) was regular, and he had no edema. His feet were cool to touch, and he had coarse lung sounds. He was mouth breathing. His HR was 98 beats per minute, his temperature was 96.6 degrees Fahrenheit, and his blood pressure was unable to be obtained. The daughter declined for Resident CR1 to go to the emergency room at this time and said she would be coming in.

A nursing progress note for Resident CR1 dated March 2, 2025, at 12:36 PM revealed that he was not responding and was dead weight. He had no response to a drink or spoon touching his mouth.

A nursing progress note for Resident CR1 dated March 2, 2025, at 12:41 PM indicated the resident was in no distress, he was breathing even, his pulse was thready (weak and difficult to feel), and his blood pressure was not able to be obtained.

A nursing progress note for Resident CR1 dated March 2, 2025, at 12:45 PM revealed that Resident CR1's blood sugar was checked per the daughter's request. His blood sugar was 374 mg/dL (milligrams per deciliter; normal range is between 70 to 100 mg/dL). The daughter requested the resident be sent to the emergency room.

A progress note for Resident CR1 dated March 2, 2025, at 1:06 PM revealed that Resident CR1 left for the ER due to being lethargic, arousable only to physical stimuli, unable to administer meds, no intake by mouth, and a blood sugar of 374 mg/dL.

Further clinical record review revealed that the only notification to the physician during Resident CR1's change of condition occurred on March 2, 2025, at 12:39 PM when the facility faxed a form entitled "Physician Call Report" (a form used to communicate with physicians) to the physician's office. The form indicated that Resident CR1 was lethargic, responding to physical stimuli, vital signs were within normal limits, blood sugar was 374 mg/dL, staff were unable to give morning medications, resident had coarse lung sounds, his apical pulse was regular, positive bowel sounds, and he had no intake by mouth. The form was faxed back to the facility signed and dated by the physician on March 2, 2025, at 2:30 PM. The form indicated to send Resident CR1 to the emergency room, which the nurse had already done at 1:06 PM the same day.

Closed clinical documentation for Resident CR1 revealed that he had a change in condition that started March 1, 2025, at 9:35 PM that required interventions, and the facility failed to notify his physician in a timely.

Interview with the Nursing Home Administrator on March 6, 2025, at 12:15 PM confirmed the above noted findings related to physician notification for Resident CR1's change in condition that required intervention.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/31/2025

Step 1:
CR1 has been discharged from the facility.

Step 2:
A 30-day lookback will be conducted for current residents ensure change in conditions were reported to the physician

Step 3:
Licensed nursing staff will be re-educated on the facility's policy for reporting changes in residents' condition to the physician.

Step 4:
DON or designee will complete weekly audits x 4 weeks of residents with change in conditions to ensure timely physician notification was completed. The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical records for one of five residents reviewed (Resident CR1).

Findings include:

Clinical record review revealed the facility admitted Resident CR1 on February 14, 2025, for a respite (a short stay to give his caregiver a break from their responsibility) stay.

Review of the admission orders provided by Resident CR1's physician from the community, revealed that he was to have his blood sugar monitored four to five times a day.

Review of Resident CR1's physician orders revealed that the order for his blood sugar checks never got transcribed to his physician orders on admission and his blood sugars were not being monitored.

Interview with the Nursing Home Administrator on March 6, 2025, at 12:30 PM confirmed the above noted findings related to Resident CR1's order to monitor his blood sugars.

The facility failed to ensure a complete and accurate clinical record for Resident CR1.

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 03/31/2025

Step 1:
CR1 has been discharged from the facility.

Step 2:
A look back will be conducted for current residents that were admitted within the last 30 days to ensure orders were correctly and completely transcribed.

Step 3:
Licensed nursing staff will be re-educated on ensuring orders are transcribed correctly and completely upon admission.

Step 4:
DON or designee will complete weekly audits x 4 weeks of new admissions orders against current active orders in PCC to ensure correct and complete transcription. The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

LICENSURE Qualified social worker:

Qualified social worker-As defined in 42 CFR 483.70(p).

Observations:

Based on staff interview, it was determined that the facility failed to employee a qualified social worker on a full-time basis.

Findings:

Interview with the Nursing Home Administrator (NHA) on March 6, 2025, at 9:30 AM revealed that the facility does not currently employee a social worker and has not employed a social worker since November 15, 2024. The NHA indicated that he hired a social worker in December, but they backed out. The NHA indicated that they have another social worker helping with the building, they are doing the admission paperwork, and the registered nurse assessment coordinators are helping with care planning for social work needs.

The facility failed to employee a qualified social worker on a full-time basis.

Plan of Correction - To be completed: 03/31/2025

Step 1:
The facility has hired a full time qualified social worker.

Step 2:
No house wide corrective action needed.

Step 3:
Nursing Home Administrator was re-educated on the regulation to have a full-time qualified social worker.

Step 4:
NHA or designee will complete monthly audit x 4 to ensure there is a qualified social worker employed at the facility. The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 03/31/2025

Step 1:
Facility cannot retroactively correct deficiency.

Step 2:
Staffing coordinator will schedule facility staff as well as contracted staff to ensure adequate ratio staffing.

Step 3:
Administration and Nursing management, including staffing coordinator, will be re-educated on regulation for maintaining adequate CNA staffing ratios.

Step 4:
NHA or designee will complete weekly audits of nursing schedules to ensure CNA ratios are met. The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

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