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Inspection visit

Health inspection

BROAD MOUNTAIN HEALTH AND REHABILITATION CENTERCMS #39528611 citations on this visit
11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of Food Committee Minutes (completed in addition to Resident Council meetings) and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during resident group meetings, including those voiced by three of the six residents interviewed during a group interview (Residents 32, 62, and 69) and one resident out of the 20 sampled (Resident 54). Residents Affected - Some Findings include: A review of minutes from Food Committee meeting dated March 20, 2024, with 12 residents in attendance, revealed that residents brought up a concern that they were not being provided snacks prepared by the baker and a choice or variety of snacks were not being provided by the facility. A review of minutes from Food Committee meeting dated April 22, 2024, with 7 residents in attendance, revealed that residents brought up a concern that nighttime were not being offered. During a resident group interview on May 8, 2024, at 10:00 AM, three of the six residents in attendance (Residents 32, 62, and 69) stated that they still have concerns with the variety of snacks the facility offers. Resident 32 stated that she would like to have fresh fruit, like bananas or oranges, as a regular snack option. Resident 69 stated that sometimes there are no choices available for evening snacks, explaining that the only choice is ice cream. Residents 32, 62, and 69 stated that they have raised this concern regarding snack variety with the facility in the past but explained that the facility has not addressed their preferences for snacks. During an interview on May 8, 2024, at 10:10 AM Resident 54 stated that bedtime snacks are offered but that there is not enough variety of snacks to choose from. Resident 54 stated that it is mostly the same flavor cookie or same flavor of ice cream over and over again. Resident 54 confirmed that she had requested more variety of snacks including fresh fruit in the past but nothing has been done yet to increase the variety available to residents. The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding the variety of snacks being offered. During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at approximately 10:00 AM, the NHA was unable to provide documented evidence that the facility had followed up with the residents to ascertain the effectiveness of the facility's efforts in resolving their concerns regarding the variety of snacks being offered. (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 22 Event ID: 395286 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0565 28 Pa. Code 201.18 (e)(1)(3)(4) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29 (a) Resident Rights Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 2 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to provide the required advance notice, a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the three residents sampled (Resident 241). Residents Affected - Some Findings include: A review of the Centers for Medicare and Medicaid Services Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed that the NOMNC must be delivered at least two calendar days before Medicare-covered services end or on the second to last day of service if care is not being provided daily. A clinical record review revealed that the facility provided Resident 241 with a Notice of Medicare Non-Coverage (CMS 10123-NOMNC) letter dated April 24, 2024. The notice indicated that Medicare would likely not pay for the resident's skilled services after April 26, 2024. Further clinical record review revealed that Resident 241's effective date for current skilled nursing facility services ended on March 26, 2024, not April 26, 2024. During an interview on May 9, 2024, at approximately 11:30 AM, the Nursing Home Administrator confirmed that the facility provided Resident 241 with inaccurate dates for Medicare non-coverage and failed to provide the required advance notice to Resident 241 regarding non-coverage of Medicare services. 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: 395286 If continuation sheet Page 3 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident (Resident 25) out of 20 sampled residents was free from sexual abuse perpetrated by another resident (Resident 46). Findings include: A review of facility policy titled Pennsylvania Resident Abuse, last reviewed by the facility on March 24, 2024, revealed the facility will not tolerate abuse of residents by anyone. The policy defines sexual abuse as includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. A review of the clinical record revealed Resident 46 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood), major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts), and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 27, 2024, revealed that Resident 46 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). Resident 46's care plan, initiated March 21, 2023, revealed that the resident displayed behaviors of threatening to punch staff, alleged perpetrator of sexual abuse towards roommate, and verbal {aggression} with staff. Planned interventions were noted as approaching calmly, speaking in a calm voice, discussing with him that either doing an act of violence towards others or making threats may result in police involvement, remaining with the resident when anxiety is high, and protecting others from injury by removing other residents if needed. A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks ). A review of an annual MDS assessment dated [DATE], revealed that Resident 25 was severely cognitively impaired with a BIMS score of 6 (a score of 0-7 indicates severe cognitive impairment). Resident 25's care plan, initiated November 11, 2020, revealed that Resident 25 can become hyper-fixated on male residents and the planned approach was for staff to redirect at these times with an activity of preference, and consult a medication management provider. An incident report dated January 3, 2024, at 3:25 PM indicated that Resident 25 and Resident 46 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 4 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 were observed kissing in the east lounge. The incident report indicated that Resident 46 was observed with his hand up Resident 25's shirt with his hand touching her breast. Level of Harm - Actual harm Residents Affected - Few A witness statement dated January 3, 2024, provided by Employee 1, Licensed Practical Nurse (LPN), indicated that around 1:45 PM she observed Resident 46 and Resident 25 kissing in the East resident lounge. Employee 1, LPN, explained that Resident 46's hand was on Resident 25's breast. A witness statement dated January 3, 2024, provided by Employee 2, LPN, indicated that she observed Resident 25 and 46 kissing in the dining room. Employee 2, LPN, indicated that Resident 46's hand was inside Resident 25's shirt as he touched her breasts. Employee 2, LPN, indicated that the residents were immediately separated. A witness statement dated January 3, 2024, at 4:15 PM revealed that Employee 3, Social Worker (SW), met with Resident 46 to discuss the incident. Resident 46 indicated that Resident 25 kissed him, and he did not touch her inappropriately or in any way. Resident 46 indicated Resident 25 kissed him because he looked good today. A witness statement dated January 3, 2024, at 4:15 PM revealed that Employee 3, SW, met with Resident 25 to discuss the incident. Resident 25 indicated that nothing happened and that she feels safe in her surroundings. The Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists- American Bar Association Commission on Law and Aging- American Psychological Association indicates that the most widely accepted criteria, which are consistent with those applied to consent to treatment, are: (1) knowledge of relevant information, including risks and benefits; (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence); and (3) voluntariness (a stated choice without coercion). A clinical record review failed to find evidence that the facility assessed Resident 25 or 46's capacity to consent to a sexual relationship. Applying the reasonable person concept, in the case of Resident 25, who was unable to recall the incident, and the assessment of how most people would react to the situation of being sexually abused by Resident 46, Resident 25 would have suffered psychosocial harm and humiliation. A nursing evaluation form dated January 3, 2024, at 4:21 PM revealed that Resident 25 was assessed to be disoriented, pleasant, and without indications of pain or complaints of pain. A nursing evaluation form dated January 3, 2024, at 4:42 PM revealed that Resident 46 was assessed to be disoriented, pleasant, and without indications of pain or complaints of pain. Resident 46 declined to be interviewed during the week of the survey, ending on May 10, 2024. During an interview on May 10, 2024, at approximately 11:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) verified that the facility had no evidence that Residents 25 or 46 were assessed to determine if they had the cognitive capacity to consent to a sexual relationship. The NHA and DON confirmed that the facility failed to ensure that Resident 25 was free from sexual abuse perpetrated by another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 5 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 This deficiency is cited as past non-compliance. Level of Harm - Actual harm The facility's corrective action plan was to assess Residents 25 and 46 for physical injuries or harm, provide both residents with emotional support, and notify the resident's physician and representatives. Residents Affected - Few The facility's corrective action plan was to identify residents who had the potential to be affected. The DON or designee reviewed residents with past sexual behavior to ensure appropriate personalized interventions were in place. The social worker or designee interviewed residents with BIMS scores 12-15 (BIMS score of 13-15 indicates the resident is cognitively intact) to ensure they were not inappropriately touched and felt safe. Licensed nursing staff completed skin evaluations on incapable residents with BIMS 99-11 to ensure there were no signs or symptoms of abuse. The residents' evaluations and interviews revealed no additional findings of sexual abuse. To prevent this from reoccurring, the Assistant Director of Nursing (ADON) will educate current staff on the abuse prevention policy. The ADON will educate licensed nurses and the interdisciplinary team to ensure all care plans are individualized and related to residents' sexual behaviors. To monitor and maintain ongoing compliance, the DON or designee reviewed residents with sexual behaviors weekly x 4 then monthly x 2 to ensure appropriate personalized interventions were in place. To monitor and maintain ongoing compliance, the social worker or designee will interview five cognitively intact residents (BIMS 12-15) weekly x 4 then monthly x 2 to ensure they are not touched inappropriately and feel safe. To monitor and maintain ongoing compliance, the ADON or designee will complete skin evaluations on five incapable residents (BIMS 99-11) weekly x 4 then monthly x 2 to ensure there are no signs or symptoms of abuse. The facility's corrections were completed on January 5, 2024, which was verified during the survey of May 10, 2024. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.12 (d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 6 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 20 sampled (Residents 7 and 13). Residents Affected - Some Findings include: According to the RAI User's Manual dated October 2023, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change, or annual assessment. The annual MDS Assessment of Resident 7 dated October 1, 2023, revealed Section A 1500 was coded as 0, indicating that the resident was not considered by the state to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability, mental retardation, or a related condition. A review of Resident 7's clinical record revealed that a Level I PASRR was completed on March 7, 2018, indicating that the resident met the criteria for a Level II PASRR. A further review of the resident's clinical record, revealed a letter of determination dated April 11, 2018, indicating the resident met the criteria for specialized services. An interview with the Social Services Director on May 8, 2024, at approximately 1:35 PM confirmed that Resident 7's annual MDS Assessment Section A 1500 related to the PASRR, dated October 1, 2023, was inaccurate. The annual MDS Assessment of Resident 13 dated February 6, 2024 revealed Section A 1500 was coded as 0, indicating that the resident was not considered by the state to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability, mental retardation, or a related condition. A clinical record review revealed a Level II PASRR letter of determination dated August 5, 2016, indicating that Resident 13 met the criteria for specialized services related to a mental health condition. An interview with the Social Services Director on May 8, 2024, at approximately 1:35 PM confirmed that Resident 13's annual MDS Assessment Section A 1500 related to the PASRR, dated February 6, 2024, was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 7 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 accurately complete the PASRR (Preadmission Screening and Resident Review) according to the resident assessment for one of six residents reviewed related to PASRR assessments (Resident 58). Residents Affected - Few Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate. Review of the clinical record revealed that Resident 58 was admitted to the facility on [DATE], with diagnoses which included depression and anxiety. Review of Resident 58's Level I PASRR dated September 2, 2022, indicated the resident had a negative screen for serious mental illness. Further review of clinical record revealed that Resident 58 was discharged from the facility on January 17, 2023, and admitted to a behavioral unit. The resident was readmitted to the facility on [DATE]. Review of Resident 58's PASRR Level I assessment, dated February 2, 2023, indicated that the resident had a mental health condition, with diagnoses of bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression, and anxiety. The assessment indicated that the resident was 302'ed (involuntary admission for psychiatric care) based on threats to kill herself and mess up her arms. During further assessments, resident denied having suicidal ideation. The screening outcome indicated the resident was noted to have a positive screen for serious mental illness and requires a further PASRR Level II evaluation. Further review of Resident 58's clinical record revealed no documented evidence that a Level II PASRR evaluation had been completed. Interview with the social services director on May 10, 2024, at 11:30 AM confirmed that there was no documented evidence available for review at the time of the survey that a Level II PASRR evaluation was completed for Resident 58. 28 Pa. Code 201.14 (a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 8 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for two residents out 20 sampled (Residents 89 and 50) to promote normal bowel activity to the extent possible Residents Affected - Some Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). The facility policy titled Bowel Tracking Protocol, last reviewed by the facility, March 24, 2024, indicated the facility will record and monitor bowel activity of residents each shift and address issues identified. In the absence of resident specific orders, the facility will follow the suggested protocol as outlined below. If the resident has not had a bowel movement (BM) for 3 full days (72 hours), the nurse will determine if laxatives are indicated based on the resident's bowel habits and patterns: Step 1: Milk of Magnesia (MOM) 30 ml at bedtime the evening after 72 hours without a bowel movement. Step 2: If no BM by 10 am the following day, give bisacodyl suppository 10 mg PR. Step 3: If no BM within by next morning, contact provider for further orders. A review of the clinical record indicated Resident 89 was admitted to the facility on [DATE], with diagnosis to include diabetes, adult failure to thrive, cerebral infarction (stroke), and chronic kidney disease. A review of the clinical record revealed that Resident 89 had physician orders dated February 7, 2024, for the following bowel regimen: - Milk of Magnesia (MOM) Suspension 400 mg/5 ml (Magnesium Hydroxide), give 30 ml by mouth as needed for no BM X 3 days, give for no bowel movement in 3 days, start 3-11 shift. - Dulcolax Suppository 10 MG (Bisacodyl), insert 1 suppository rectally every 72 hours as needed for no BM, give if no BM from milk of magnesia on 7-3 shift. -Fleet Enema 7-19 gm/118 ml (Sodium Phosphates) insert 1 applicator rectally as needed for no BM. On 3-11 shift, give if no BM from suppository. A nursing progress note dated February 13, 2024, at 1401 (2:01 PM) revealed that the resident had not had a bowel movement since admission to the facility (on February 7, 2024). Nursing spoke with the physician and obtained a new order for MOM, to start at the beginning of our facility bowel protocol. The resident had physician orders upon admission for a bowel protocol and there was no documented evidence that nursing staff had administered the protocol as ordered in the seven days without a bowel movement from the time of the resident's admission on [DATE], until February 13, 2024, when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 9 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0684 nursing staff obtained another physician order to start at the beginning of the bowel protocol. Level of Harm - Minimal harm or potential for actual harm Resident 89's bowel activity noted on the Documentation Survey Report v2 for February 2024, revealed that the resident did not have a bowel movement on February 7, 8, 9, 10, 11, 12, 13, and 14, 2024, (8 days). Residents Affected - Some Review of Resident's Medication Administration Record (MAR) for February 2024, revealed that MOM was administered on February 13, 2024, at 1848 (6:48 PM), on day 7 without a BM (February 7, to February 13, 2024). A continued review of Resident 89's bowel activity for February 2024, revealed that he did not have a bowel movement on February 17, 18, 19, and 20, 2024, (4 days). Review of Resident's (MAR) for February 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period of February 17, 18, 19, and 20, 2024, without a bowel movement to promote bowel activity. A review of the clinical record indicated Resident 50 was admitted to the facility on [DATE], with diagnosis to include diabetes, end stage renal disease, and constipation. A review of the clinical record revealed that Resident 50 had physician orders dated April 21, 2023, for the following bowel regimen: - MiraLAX Oral Powder 17 GM/scoop (Polyethylene Glycol), give 1 scoop by mouth as needed for PRN if no BM in 3 days. - Dulcolax Suppository 10 MG (Bisacodyl), insert 1 suppository rectally as needed for no BM, give if no BM day #4 on 7-3 shift. Resident 50's bowel activity noted on the Documentation Survey Report v2 for March 2024, revealed that she did not have a bowel movement on March 2, 3, 4, and 5, 2024, (4 days). Review of Resident 50's Medication Administration Record (MAR) for March 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period of March 2, 3, 4, and 5, 2024, without a bowel movement to promote bowel activity. During an interview with the Director of Nursing (DON) on May 10, 2024, at approximately 9:20 AM, confirmed that staff failed to consistently carry out physician orders for the bowel regimen prescribed for Resident 89, and 50 to prevent constipation and promote normal bowel activity, nor that the physician was timely notified of the extended time periods without bowel activity. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.5 (f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 10 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined that the facility failed to provide enteral feedings as ordered to maintain acceptable nutritional parameters and prevent a significant unplanned weight loss for one resident out of 20 residents sampled (Resident 83). Residents Affected - Few Findings include: A clinical record review revealed that Resident 83 was admitted to the facility on [DATE], with diagnoses that included intracranial injury (brain dysfunction caused by an outside force) and cognitive communication deficit (brain damage that results in language and cognition impairment). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 12, 2024 revealed that Resident 83 was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment). Resident 83's care plan initiated May 15, 2023, revealed that the resident had self-care deficits related to a motor vehicle accident resulting in traumatic brain injury and was dependent on staff assistance for toileting, dressing, bed mobility, and eating. Resident 83's care plan, initiated May 14, 2023, indicated that the resident require a feeding tube and will maintain adequate nutrition and hydration via feeding tube with planned interventions to administer feeding and hydration by way of feeding tube as ordered. A physician's order was noted October 31, 2023, for Resident 83 to receive Isosource 1.5 at 78 ml/hr for 16 hours (an enteral feeding formula providing a total of 1,248 ml, providing 1,872 kcal, 84 grams of protein, and 953 ml of water) three times a day for dysphagia. This order was discontinued on December 21, 2023. A physician's order was initiated on December 21, 2023, for Resident 83 to receive Isosource 1.5 enteral feeding, as needed, for a diet related to an injury to the small intestine with instructions to administer 240 bolus via PEG tube (a tube that is inserted through the wall of the abdomen directly into the stomach that can be used to provide medication, liquids, and liquid food) if 50% or less of the meal is consumed. A nutrition progress note dated December 21, 2023, at 1:09 PM noted that the interdisciplinary team discussed transitioning Resident 83 to bolus tube feeding to allow for increased oral intake of foods and fluids. The entry indicated that the resident depends on staff for feeding, with 50% of meals or more consumed per documentation. His most recent weight on December 4, 2023, was 154.8 lbs. It ws noted that with a steady feeding regimen, the resident had experienced a slow, necessary, and anticipated weight gain since admission. The note indicated that Resident 83's care plan will be updated to indicate that enteral feeding {Isosource 1.5 at 78 ml/hr} will be discontinued and the resident will receive Isosource 1.5 240 ml bolus feeding via PEG tube if he consumes 50% or less of his meal. A documentation survey report and Medication Administration Record (MAR) for the months of December (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 11 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0692 2023 and January 2024 revealed that: Level of Harm - Actual harm On December 23, 2023, the resident consumed 26-50% of his breakfast but there was no documented evidence on the December 2023 MAR that the facility administered a 240-ml bolus via PEG tube following the breakfast meal. Residents Affected - Few On December 23, 2023, the resident consumed 26-50% of his lunch, but there was no documented on the December 2023 MAR that the facility administered a 240-ml bolus via PEG tube following the lunch meal. On December 25, 2023, the resident consumed 0-25% of his breakfast and there was no documented evidence on the Resident 83's MAR for December 2023 that staff administered a 240-ml bolus via PEG tube following the breakfast meal. On December 25, 2023, the resident consumed 0-25% of his lunch but there was no documented evidenced on Resident 83's December 2023 MAR that staff administered a 240-ml bolus via PEG tube following the lunch meal. On December 27, 2023, the resident consumed 26-50% of his dinner but there was no documented evidence on the resident's December 2023 that staff administered the 240-ml bolus via PEG tube following the dinner meal. On December 29, 2023, the resident consumed 26-50% of his dinner but there was no documentation on Resident 83's MAR for December 2023 that staff 240-ml bolus via PEG tube following the dinner meal. On December 30, 2023, the resident consumed 26-50% of his breakfast but there was no documentation on the resident's December 2023 MAR to indicate that staff administered a 240-ml bolus via PEG tube following the breakfast meal. According to the resident's clinical record the Resident 83 weighed 157.9 lbs on October 4, 2023, 155.2 lbs on November 7, 2023, and 154.8 lbs on December 4, 2023. On December 28, 2023, Resident 83's weight had decreased to 112.0 lbs, indicating a 27.6% loss in weight in 24 days. There was no documented evidence that the resident's nutritional status was assessed by the registered dietitian at that time. On January 1, 2024, the resident consumed 0-25% of his dinner but Resident 83's MAR for January 2024 revealed no evidence that staff administered a 240-ml bolus enteral feeding via PEG tube following the dinner meal. A physician's order was initiated on January 2, 2024, at 2:47 PM for Resident 83 to receive 240 ml bolus enteral feeding with House 2.0 Med Pass supplement (a nutritional supplement drink) if meal completion less than 75%. The order was discontinued on January 3, 2024, at 10:09 AM. On January 2, 2024, the resident consumed 26-50% of his dinner but there was no documented evidence on Resident 83's Janaury 2024 MAR that staff administered a 240-ml of the House 2.0 Med pass supplement by means of a bolus enteral feeding via PEG tube following the dinner meal. A nursing progress note dated January 2, 2024, at 10:00 PM revealed that Resident 83's feeding tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 12 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0692 was pulled out and the physician was notified. The physician requested a consult with the dietitian. Level of Harm - Actual harm There was no documented evidence that the facility had timely identified and acted upon the resident's progressive weight loss. It was not until January 3, 2024, six days after the weight loss was noted on December 28, 2023, that the facility's registered dietitian had assessed the resident's nutritional status and parameters, and adequacy of the resident's current nutritional support regimen, in response to the physician ordered consult requested on January 2, 2024. Residents Affected - Few A nutrition progress note dated January 3, 2024, at 9:39 AM revealed that Resident 83's most recent weight was 112 lbs. The note indicated that the weight was questionable because the resident was receiving steady nutrition via his PEG tube. There was no documented evidence that the dietitian identified that the facility had not been consistently providing the bolus enteral feedings to the resident when the resident consumed 50% or less at meals from December 23, 2023, through January 1, 2024, and 75% or less on January 2, 2024. A nursing progress note dated January 3, 2024 at 2:16 PM indicated that Resident 83 was sent to the emergency department for PEG tube reinsertion. Clinical record documentation revealed that Resident 83 weighed 109.8 pounds on January 4, 2024, indicating a 29.1% weight loss in 31 days. There was no documented evidence that the facility had consistently provided the resident with bolus enteral feedings when the resident's oral intake was 50% or below at meals as ordered during the month of December 2023, resulting in the resident's significant progressive weight loss. During an interview on May 10, 2024, at approximately 11:15 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide evidence that the facility consistently provided the bolus enteral tube feedings, when the resident's oral intake was 50% or below at each meal, as ordered by the physician, to meet Resident 83's nutritional and daily caloric needs to prevent significant weight loss. The NHA and DON were unable to explain the six day delay in evaluating the resident's signifcant weight loss once identified, and confirmed that it is the facility's responsibility to ensure that the resident was provided the nutritional support feedings to maintain nutritional parameters. 28 Pa. Code 211.5 (f) Medical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 13 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 20 residents reviewed (Resident 58). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 58 was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD). The resident's current care plan, in effect at the time of review on May 10, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with the Nursing Home Administrator on May 10, 2024, at 10:00 AM confirmed the facility was unable to demonstrate that the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 14 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 resident and staff interviews, it was determined the facility failed to provide therapeutic social services to promote the highest practicable mental and psychosocial well-being of two of the 20 residents reviewed (Residents 46 and 54). Residents Affected - Some Findings include: According to regulatory guidance under §483.40(d) Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health, which include providing or arranging for needed mental and psychosocial counseling services and identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. A clinical record review revealed Resident 46 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood), major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts), and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 27, 2024, revealed that Resident 46 has moderate cognitive impairment with a BIMS score of 12 (Brief Interview for Mental Statusa tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). Resident 46's care plan, initiated March 21, 2023, revealed that the resident displayed behaviors of threatening to punch staff, alleged perpetrator of sexual abuse towards roommate, verbal {aggression} with staff, and kissing and touching a female resident inappropriately. Planned interventions were approaching calmly, speaking in a calm voice, discussing with him that either doing an act of violence towards others or making threats may result in police involvement, remaining with the resident when anxiety is high, and protecting others from injury by removing other residents if needed. A progress note dated November 12, 2023, at 2:52 PM that staff found sharp pieces of glass in the resident's bed. Resident 46 stated that he did not know where the glass came from, but noted a broken picture frame was found in his room. A progress note dated November 23, 2023, at 9:36 AM indicated that Resident 46 was attempting to leave the facility, get to his niece's car, and pick her up. The resident became belligerent with staff when redirected back to his nursing unit. A progress note dated November 27, 2023, at 8:10 PM indicated that Resident 46 removed his code alert bracelet (the code alert bracelet signals the facility if a resident attempts to elope). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 15 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0745 Level of Harm - Minimal harm or potential for actual harm A progress note dated November 28, 2023, at 1:13 PM indicated that Resident 46 was refusing his medication, swinging at facility staff, and becoming belligerent. A progress note dated December 2, 2023, at 11:32 AM indicated Resident 46 was refusing all medications and using foul language at staff. Residents Affected - Some A progress note dated December 7, 2023, at 12:56 PM indicated that staff found a large bowel movement in Resident 46's closet. A progress note dated January 3, 2024, at 4:39 PM indicated that Resident 46 was seen kissing and inappropriately touching a female resident's breast under her clothing, leading to immediate separation, an increased level of supervision, and notification of law enforcement authorities. A progress note dated January 4, 2024, at 1:13 PM indicated Resident 46 punched a female nurse aide's arm. A medication management note dated January 12, 2024 revealed that Resident 46 was receiving services for behaviors that included inappropriate defecation and urination, sexual behaviors towards a peer, and aggression towards a nurse aide. The provider discharged Resident 46 from medication management consultation for consistently refusing medication over a significant period of time. A progress note dated January 21, 2024, at 10:53 PM indicated Resident 46 was verbally and physically aggressive towards nursing staff. A progress note dated February 5, 2024, at 10:01 AM indicated a scratched area and bruise were found on Resident 46's buttocks. The resident refused nail care despite being educated on the associated risks. A progress note dated February 11, 2024, at 7:07 AM indicated that Resident 46 urinated on his floor (in his room) and bed, and hit staff when attempting to help him with hygiene care. A progress note dated February 20, 2024, at 11:29 PM indicated that Resident 46 soiled himself in a common area and became physically aggressive with staff. A progress note dated February 24, 2024, at 04:25 indicated that a bowel movement was found in a water cup in the resident's bedroom. Resident 46 denied responsibility and refused incontinent care despite repeated attempts from staff. A progress note dated February 25, 2024, at 1:59 AM indicated Resident 46 had voided on his call bell. A progress note dated February 25, 2024, at 1:54 PM indicated that Resident 46 refused medication and care, and was smearing and throwing his feces. He became agitated and used profanity towards staff when approached. A progress note dated February 28, 2024, at 10:45 PM indicated that the resident soiled his bed, but refused to allow staff to change the linens despite staff providing education on risks and benefits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 16 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0745 Level of Harm - Minimal harm or potential for actual harm A progress note dated March 9, 2024, at 18:06 indicated Resident 46 was throwing large pieces of feces on the floor. A progress note dated March 13, 2024, at 05:31 observed Resident 46 continuing to throw feces, despite denial and blaming it on his ex-wife. Residents Affected - Some A progress note dated March 13, 2024, at 10:53 PM indicated Resident 46 called 911 emergency services and reported that his Jeep was stolen. The note indicated that facility staff assured the resident that he did not have a Jeep at the facility. A progress note dated March 15, 2024, at 9:31 PM indicated that Resident 46 was requesting staff call 911 emergency services to report his green bronco had been stolen. A progress note dated April 6, 2024, at 2:35 PM indicated that Resident 46's family visited and encouraged the resident to allow staff to provide him care. The note indicated that the resident continued to refuse care and became agitated. A progress note dated April 8, 2024, at 6:49 PM indicated that Resident 46 was lying naked on his bed, with soiled clothing on the floor. The note also indicated that the resident refused care. An observation on May 8, 2024, at 11:37 AM revealed Resident 46 lying on his bed. His sheets were stained with yellow urine-like and brown fecal-like stains. Resident 46 declined to participate in an interview with the surveyor. A clinical record review revealed a current physician's orders for amlodipine 10 mg for hypertension once a day, clonidine 0.1 mg/24-hour patch for hypertension once a day, hydralazine 100 mg tablet for hypertension three times a day, and metoprolol succinate 50 mg for hypertension once a day. A medication administration record from April 11, 2024, through May 9, 2024, revealed that Resident 46 refused amlodipine 10 mg tablet six times and clonidine 0.1 mg/24-hour patch one time, hydralazine 100 mg tablet 14 times, and metoprolol succinate 50 mg tablet six times. During an interview on May 10, 2024, at approximately 11:15 AM, the Nursing Home Administration (NHA) and Director of Nursing (DON) confirmed that it is the facility's responsibility to provide therapeutic social services to promote residents' highest practicable mental and psychosocial well-being. The DON and NHA were unable to provide evidence that Resident 46 was assessed as a danger to himself with continual refusals of medications and care, since being evaluated by his medication management provider on January 12, 2024. The NHA and DON were unable to provide evidence that any additional behavioral health consultations were arranged for Resident 46 following his discharge from behavioral medication management, despite ongoing behavioral issues he was displaying. Clinical record review revealed that Resident 54 had diagnoses which included depression and PTSD (post-traumatic stress disorder- a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events, or set of circumstances). A review of Resident 54's annual MDS assessment dated [DATE], indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognitively intact). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 17 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0745 Level of Harm - Minimal harm or potential for actual harm During interview on May 8, 2024, at 10:45 AM Resident 54 stated that at times she does feel sad and would like to have a therapist or someone to talk to about her feelings. Review of a medication management note dated April 10, 2024, indicated that Resident 54 has had recent medical issues and depression concerns. Close monitoring of mood by nursing was recommended. Residents Affected - Some Further review of the clinical record revealed no documented evidence that further supportive social service interventions were implemented to assist the resident with her medical issues and depression concerns. Interview with the director of nursing on May 10, 2024, confirmed that based on the resident's medical issues and depression diagnosis there was no documented evidence that medically-related social services were being provided to Resident 54 to meet the residents' mental, and psychosocial needs. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.16 (a) Social Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 18 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 - Some 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 observation, a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medication and herbal supplements on one of three medication carts and one of three medication storage rooms observed (west short cart, first floor storage room - Residents 9, and 77). Findings include: The facility policy Storage and Expiration Dating of Medications, Biologicals, with a policy review date March 24, 2024, indicated that facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Observation of [NAME] Short medication cart at approximately 9:13 AM, on May 7, 2024, in the presence of Employee 4, Licensed Practical Nurse (LPN) revealed the following opened multi-dose medications: one (1) Insulin Aspart flex pen (medication used for diabetes), belonging to Resident 9, was observed to be opened and available for use and dated March 24, 2024, when initially opened. One (1) Insulin Aspart flex pen, belonging to Resident 77, was observed to be opened and available for use and dated March 24, 2024, when initially opened and a second Insulin Aspart flex pen, belonging to Resident 77, was observed to be opened and available for use and dated February 20, 2024, when initially opened. Employee 4, (LPN), confirmed the medications belonged to Resident 9 and 77, and that the insulins were beyond the manufacturer recommended use by date (28 days), and had not been discarded within 28 days of opening. An observation of the first-floor medication storage room on May 8, 2024, at 1:04 PM, in the presence of Employee 5 (licensed practical nurse), revealed that stored within the medication refrigerator there was a multi-dose bottle of Tuberculin (solution used for screening for tuberculosis) that had been opened, available for use, and dated March 29, 2024, when initially opened. Employee 5 confirmed that the March 29, 2024, date was beyond the manufacturer's recommended use-by date to be discarded 30 days after opening. Continued observation of the first-floor medication storage room revealed an opened bottle of Saw Palmetto 160 mg (herbal supplement) with an expiration date of July 2022. Interview with the Director of Nursing (DON) on May 8, 2024, at approximately 1:50 PM, confirmed the facility failed to adhere to acceptable storage and use by dates for multi-dose medications and expiration date for the supplement. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 19 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 28 Pa. Code 211.12 (d)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 20 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the facility's smoking policy and staff interview, it was determined that the facility failed to implement established procedures to accurately assess residents for safe smoking ability for three residents out of three identified as a current smoker (Resident 50, 54, and 58). Residents Affected - Some Findings include: A review of the facility's policy titled Resident Smoking Policy last reviewed by the facility March 24, 2024, indicated that a smoking assessment would be completed with readmission, quarterly and with any significant change in resident's condition. During entrance conference meeting on May 7, 2024, at 9:18 AM the Nursing Home Administrator (NHA) provided a list of residents at the facility that currently smoke, which included three residents, Resident 50, 54, and 58. Review of Resident 50's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include diabetes and depression. The most recently completed quarterly smoking assessment was dated August 3, 2023. There was no documented evidence that a quarterly resident smoking assessment was completed since August 3, 2023. The facility failed to assess the resident's current ability to safely smoke according to facility policy. Review of Resident 54's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include diabetes and depression. The most recently completed quarterly smoking assessment was completed on August 11, 2022. There was no documented evidence that a quarterly resident smoking assessment was completed since August 11, 2022. The facility failed to assess the resident's current ability to safely smoke according to facility policy. Review of Resident 58's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include depression and anxiety. The most recently completed quarterly smoking assessment was completed on October 1, 2023. There was no documented evidence that a quarterly resident smoking assessment was completed since October 1, 2023. The facility failed to assess the resident's current ability to safely smoke according to facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 21 of 22 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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 0926 Level of Harm - Minimal harm or potential for actual harm Interview with the NHA on May 9, 2024, at 10:42 AM indicated that all current smokers should have had a quarterly smoking assessment. The NHA confirmed that the facility failed to timely complete a quarterly smoking assessment to ensure that smoking privileges remain safe and appropriate for the residents. 28 Pa. Code 209.3 (a)(c) Smoking. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 22 of 22

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Citations

11 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0565GeneralS&S Epotential for harm

    F565 - The resident has a right to organize and participate in resident groups in the

    Honor the resident's right to organize and participate in resident/family groups in the facility.

  • 0582GeneralS&S Bno actual harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0600SeriousS&S Gactual harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0641GeneralS&S Epotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0645GeneralS&S Dpotential for harm

    F645 - Preadmission Screening for individuals with a mental disorder and individuals

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0684GeneralS&S Epotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0692SeriousS&S Gactual harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0699GeneralS&S Dpotential for harm

    F699 - Trauma-informed care

    Provide care or services that was trauma informed and/or culturally competent.

  • 0745GeneralS&S Epotential for harm

    F745 - The facility must provide medically-related social services to attain or

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0926GeneralS&S Epotential for harm

    F926 - Establish policies, in accordance with applicable Federal, State, and

    Have policies on smoking.

FAQ · About this visit

Common questions about this visit

What happened during the May 10, 2024 survey of BROAD MOUNTAIN HEALTH AND REHABILITATION CENTER?

This was a inspection survey of BROAD MOUNTAIN HEALTH AND REHABILITATION CENTER on May 10, 2024. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BROAD MOUNTAIN HEALTH AND REHABILITATION CENTER on May 10, 2024?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.