Health inspection·April 11, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the Nursing Home Administrator (NHA) on April 10, 2025, at approximately 1:00 PM the NHA confirmed that Resident 35 should have been showered as scheduled and was unable to state why showers were not provided as scheduled and desired. A review of Resident 103's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include diffuse large B-cell lymphoma (aggressive, fast growing form of non-Hodgkin's lymphoma cancer of the lymphatic system) that affects B-cells, (a type of white blood cell that produces antibodies), and dysphagia (difficulty swallowing food or liquid). An admission MDS dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 6 (0-7 represents severe cognitive impairment) and the resident performed eating tasks (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) with supervision. Observation conducted on April 8, 2025, at 11:47 AM in the 2nd floor East dining room revealed Resident 103 seated upright in a Geri lounger (large padded cushioned reclining chair with a wheeled base designed to assist residents with limited mobility) at a table with a blanket on his lap. At 11:49 AM staff placed Resident 103's lunch tray on the table in front of him, which consisted of meatloaf, mashed potatoes with gravy, green beans and fruited gelatin. Staff provided setup assistance (cut meat, removed lid from dessert bowl, and removed lids from beverage cups) and walked away to continue to deliver lunch trays to other residents in the dining room. Continued observation of Resident 103 during lunch in the dining room revealed the resident grabbed the blanket on his lap and placed it in his mouth. The resident continued to put the blanket into his mouth and chew on the blanket for the next 24 minutes. At 12:13 PM the resident pulled the blanket out of his mouth and placed it on top of his food. At 12:14 PM, 25 minutes after his tray was setup in front of him, a staff member approached Resident 103 and offered to assist him with eating. The resident made no attempts to initiate or engage in self-feeding and allowed the staff member to feed him. A review of Resident 103's care plan dated March 24, 2025, identified a problem area related the resident's ADL functional status/rehabilitation potential with interventions to include: transfers with assist of two with a rolling walker (walker with front wheels); do not rush the resident, allow extra time to complete ADLs; follow PT/OT/ST recommendations; have consistent approach amongst caregivers; monitor for presence of pain/intolerance during self-care; provide adequate rest periods between activities; provide assistance as needed; and report any further deterioration in status to the physician. The current care plan, in effect at the time of the survey ending April 11, 2025, failed to identify Resident 103's functional ability to participate in activities of daily living such as eating, grooming, oral hygiene and dressing, and the staff assistance required to safely and successfully engage in these daily tasks. Review of nurse documentation dated April 1, 2025, at 12:00 PM revealed that Resident 103 was sent to the emergency room due to abnormal laboratory values. Nursing documentation dated April 4, 2025, at 6:18 PM revealed Resident 103 was readmitted to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Occupational Therapy Evaluation dated April 6, 2025, revealed the resident's self-feeding ability was assessed as total dependence (level of support where a person requires constant and complete assistance from another to complete a task- the resident is unable to perform the task while the caregiver performs 100% of the task). Interview with the Nursing Home Administrator on April 10, 2025, at 10:30 AM revealed the residents' self-feeding ability is documented in the care plan, Point of Care History and the CNA huddle binder located at each nursing station. Review of the facility's Point of Care History (care tasks completed for the resident) for Resident 103 failed to identify the level of staff assistance required for the resident to safely perform self-feeding tasks. Interview with Employee 2 (Registered Nurse Supervisor) on April 10, 2025, at 1:45 PM revealed the residents' functional statuses (ability to self-feed, bathe, transfer, ambulate) are communicated to the nursing staff via a CNA huddle binder. Employee 2 explained that the huddle binder contains a document for each resident indicating the level of staff assistance required to perform activities of daily living. Review of the CNA huddle binder revealed that Resident 103 did not have a current file in the huddle binder. Employee 2 confirmed that based upon the current huddle binder information, staff would not know the functional status, or the level of staff assistance required, to safely and appropriately feed Resident 103. Review of an Occupational Therapy treatment encounter note dated April 10, 2025, revealed nursing staff requested re-assessment of self-feeding and beverage management. Resident with intermittent alertness but demonstrated no functional ability to grasp utensils or cups despite simple cueing and hand over hand assistance from therapist. Resident demonstrated no functional ability to load utensils in prep for placement of food item on utensil. Resident with periods of inattention and confusion noted throughout AM breakfast meal with inability to follow 1-step commands for utensil management or beverage management. Reviewed with primary caregivers for need of supportive feeding and beverage management. Interview with Employee 1 (Occupational Therapist) on April 11, 2025, at 8:50 AM indicated Resident 103 exhibited a significant decline in his functional status since returning from the hospital on April 4, 2025. She noted that Occupational Therapy did not establish self-feeding goals because therapy was asked to establish safe in and out of bed positioning so that staff could safely feed the resident. She reported that when a decline in functional status is noted by therapy, the Director of Rehab notifies the IDT team (interdisciplinary team) who then notifies the charge nurse, unit managers and primary caregivers. The physician orders and care plan would then be updated to reflect the resident's status. The facility was unable to provide documented evidence the facility communicated Resident 103's decline in self-feeding ability and the required staff assistance to the IDT team, nursing staff and his primary caregivers. The facility failed to effectively communicate Resident 103's functional decline and increased need for staff assistance for self-feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator on April 11, 2025, at approximately 11:30 AM confirmed the facility failed to document Resident 103's self-feeding status and the level of staff assistance required in the resident's care plan, physician orders and CNA huddle binder to provide the necessary services to maintain good nutrition for Resident 103. Residents Affected - Some 28 Pa. Code 211.12 (c)(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 4 of 4