Health inspection·October 28, 2022

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 Based on review of clinical records, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding wound assessments and diabetes management for three of three residents reviewed (Residents 2, 40, and 55). Residents Affected - Some Finding include: Review of the policy entitled admission and Weekly Skin Observations, indicates that the facility should monitor skin impairment, which can include abrasions, excoriations, skin tears, and surgical wounds weekly on the Open Lesion progress note until healed. Review of Resident 2's clinical record revealed a nursing note dated September 29, 2022, at 3:07 PM indicating that Resident 2 had an area between buttocks 6 cm (centimeters) by 0.25 cm. Review of the facility's investigation into Resident 2's open wound dated September 30, 2022, at 4:00 PM indicated that Resident 2 had an open area 6 cm by 0.25 cm on his coccyx. The Director of Nursing added a comment to the investigation on October 3, 2022, that Resident 2's sacral slit was moist, red, and open. There was no documented evidence in the facility's investigation to indicate that the facility determined a clinical basis for Resident 2's wound for differentiating type of wound. A nursing note dated September 30, 2022, at 9:55 PM indicated that Resident 2's crease of 6 cm by 0.25 cm in the coccyx area was cleaned, and A&D ointment applied. A physician's order dated October 2, 2022, instructed nursing staff to cleanse Resident 2's open area between his buttocks, apply Silvadene 1% cream (a topical antimicrobial drug used for the prevention and treatment of infections in wounds) and leave open to air. There was no clarification in the order to indicate what nursing staff were to clean Resident 2's open area with. An In-service Training Record, dated October 4, 2022, indicated that the facility provided education to staff regarding Resident 2's gluteal fold skin tear, educating staff to utilize a pull sheet with repositioning and turning in bed to prevent shearing and/or tearing of the skin. Review of the facility's Skin Observation sheets dated October 5, 12, 19, and 26, 2022, revealed that an assessment was completed on Resident 2 to determine if any new skin alterations were present. The Skin Observation assessments did not include any documented evidence to indicate that the facility reassessed Resident 2's open wound to his gluteal crease. There was no documented evidence in Resident 2's clinical record to indicate that the facility monitored his open wound using the Open Lesion report. The last documented assessment of Resident 2's open wound was October 3, 2022. The facility continued to provide wound care to Resident 2's open wound until October 26, 2022, when this surveyor questioned the assessments and treatments. Interview with the Director of Nursing on October 27, 2022, at 10:40 AM, confirmed the above findings. Clinical record review for Resident 55 revealed current physician orders for staff to complete the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395352 If continuation sheet Page 2 of 8 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 395352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901 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 Check Resident 55's blood glucose twice daily Level of Harm - Minimal harm or potential for actual harm Notify Resident 55's physician if her blood greater than 400 mg/dL Review of Resident 55's blood glucose revealed that her levels on the following dates were: Residents Affected - Some August 17, 2022, 4:00 PM, 408 mg/dL (Milligrams per Deciliter) September 14, 2022, 4:00 PM, 530 mg/dL September 20, 2022, 4:00 PM, 413 mg/dL September 23, 2022, 4:00 PM, 436 mg/dL October 16, 2022, 4:00 PM, staff indicated NA (not applicable) October 18, 2022, 4:00 PM, 461 mg/dL There was no documentation that staff notified Resident 55's physician after identifying a blood glucose level greater than 400 mg/dL. Clinical record review for Resident 40 revealed current physician orders for staff to complete the following: Humalog (insulin for high blood glucose) mix 75/25 suspension 100 u/ml (units per milliliter) inject 60 units SQ (subcutaneously, just under the skin) in the morning and inject 46 units SQ in the evening for diabetes If Resident 40's blood glucose was 60 to 80 mg/dL give 120 ml (milliliters of juice and recheck the blood glucose in 15 minutes. Repeat treatment if her blood glucose was less than 80 mg/dL. Notify Resident 55's physician if her blood glucose is greater than 400 mg/dL Review of Resident 40's blood glucose revealed that her levels on the following dates were: August 6, 2022, 5:00 PM, 433 mg/dL August 19, 2022, 7:00 AM, 80 mg/dL September 11, 2022, 5:00 PM, no documentation of Resident 40's blood glucose level October 8, 2022, 7:00 AM, 80 mg/dL October 14, 2022, 7:00 AM, 60 mg/dL There was no documentation that staff notified Resident 40's physician after identifying a blood glucose level greater than 400 mg/dL. On August 19, 2022, at 7:00 AM, and on October 8, 2022, at 7:00 AM, staff administered 60 units of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395352 If continuation sheet Page 3 of 8 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 395352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901 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 Level of Harm - Minimal harm or potential for actual harm Humalog 75/25 insulin for Resident 40's blood glucose level of 80 mg/dL. There was no documentation that they provided 120 ml of juice or rechecked Resident 40's blood glucose per her physician's order. On September 11, 2022, at 5:00 PM there was no documentation indicating that staff administered Resident 40's Humalog 75/25 insulin. Residents Affected - Some On October 14, 2022, at 7:00 AM staff administered 60 units of Humalog 75/25 insulin for Resident 40's blood glucose level of 60 mg/dL. There was no documentation that they provided 120 ml of juice or rechecked Resident 40's blood glucose per her physician's order. The surveyor reviewed the above information during an interview on October 27, 2022, at 2:05 PM with the Nursing Home Administrator and Director of Nursing. 483.25 Quality of Care Previously cited 11/5/21 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395352 If continuation sheet Page 4 of 8 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 395352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to store supplemental oxygen equipment and CPAP equipment per professional standards of practice for two of 18 residents reviewed (Residents 63 and 8). Residents Affected - Few Findings include: A review of the policy titled Oxygen Therapy / Pulse Oximetry, last reviewed without changes on January 7, 2022, revealed the purpose is to administer oxygen in a safe sanitary manner in conditions in which insufficient oxygen is caried by the blood to the tissues. Further review indicated that all tubing and respiratory equipment not in use will be placed in a plastic bag and stored neatly with the machine. Observation of Resident 63's oxygen equipment on October 26, 2022, at 9:30 AM, 11:30 AM, and 12:16 PM revealed a nasal cannula (device used to deliver supplement oxygen into the nostrils) that was not bagged and observed draped over the oxygen concentrator in the resident's room. Observation of Resident 63 on October 26, 2022, at 2:00 PM revealed the resident was in bed with the nasal cannula in her nose. Clinical record review for Resident 63 on October 26, 2022, at 2:05 PM revealed a current physician's order that instructed staff to administer oxygen at two liters per minute (LPM) to keep the oxygen saturation greater than 90 percent and staff may titrate. A review of the clinical documentation for Resident 8 revealed a current physician's order dated September 26, 2022, that indicated the resident is to wear the CPAP (continuous positive airway pressure machine worn during sleep where air is pumped into the lungs through the nose and or/mouth during breathing and used in the treatment of sleep apnea and other respiratory issues) at bedtime with two liters per minute (LPM) of oxygen at the previous settings prior to hospitalization for obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep and results in brief episodes where breathing stops). Observation of Resident 8's oxygen equipment on October 26, 2022, at 9:40 AM revealed a CPAP mask unbagged and draped over a drawer with crossword puzzle books. Observation of Resident 8's oxygen equipment on October 26, 2022, at 1:53 PM revealed the CPAP mask was unbagged and in the drawer. A concurrent interview with Resident 8 revealed that staff would put the mask on top of the bedside dresser, but it would fall off, so staff started putting the mask in the drawer. An interview with Employee 2, Licensed Practical Nurse, revealed the CPAP mask should be in a bag. The above findings were reviewed with the Director of Nursing (DON) and Nursing Home Administrator on October 26, 2022, at 2:08 PM. The DON further indicated it is an expectation that the mask and cannula should be bagged when not in use. 28 Pa. Code 211.10(a) Resident care policies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395352 If continuation sheet Page 5 of 8 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 395352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901 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 0695 28 Pa. Code 211.12(d)(1)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395352 If continuation sheet Page 6 of 8 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 395352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident 168). Residents Affected - Few Findings include: The facility's medication error rate was 11.11 percent based on 27 medication opportunities with three medication errors. The facility policy entitled, Medication Administration - General Guidelines, last reviewed without changes on January 7, 2022, revealed that medications are prepared by licensed nursing staff utilizing the five rights: right resident, right drug, right dose, right route, and right time, in accordance with written orders of the prescriber. Medications are administered within 60 minutes of the scheduled time according to the established medication administration schedule for the facility. Observation of a medication administration pass on October 25, 2022, at 10:26 AM revealed that Employee 1, licensed practical nurse, administered the following medications, without food, to Resident 168: Pregabalin (for pain) 100 milligrams (mg) two tablets PO (by mouth) Cyclobenzaprine Hydrochloride (for muscle spasms/pain) 5 mg one tablet PO Metoprolol Tartrate (for high blood pressure) 100 mg 1.5 tablets PO Clinical record review for Resident 168 revealed current physician orders for Pregabalin 100 mg two tablets PO TID (three times daily scheduled at 8:00 AM, 2:00 PM, and 8:00 PM) for pain, Cyclobenzaprine Hydrochloride 5 mg one tablet PO TID (three times daily scheduled at 8:00 AM, 2:00 PM, and 8:00 PM) for muscle spasms/pain, and Metoprolol Tartrate 100 mg 1.5 tablets PO BID (twice daily scheduled at 8:00 AM and 8:00 PM) for Hypertension (high blood pressure). Take with food. Employee 1 administered Resident 168's 8:00 AM medications at 10:26 AM, 2 hours, 26 minutes after the physician ordered times and without food. The surveyor reviewed the above information during an interview on October 26, 2022, at 1:42 PM with the Nursing Home Administrator. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395352 If continuation sheet Page 7 of 8 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 395352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901 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 - Few 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 review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to dispose of expired medications, bandages, sterile water, and saline solution on one of two nursing units (200 nursing unit). Findings include: A review of the policy and procedure titled Medication Storage in the Facility, last reviewed without changes on January 7, 2022, revealed that medications and biologicals are to be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The policy revealed the following regarding expired medications: outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of, and reordered from pharmacy if a current order exists; drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date; no expired medications will be administered to a resident and all expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Observation of the 200 nursing unit treatment cart on October 27, 2022, at 10:20 AM with Employee 2, licensed practical nurse, revealed a container of expired normal saline solution (a solution that can be used to irrigate wounds). Employee 2 confirmed the saline expired as of October 19, 2022. Observation of the 200 nursing unit supply closet on October 27, 2022, at 10:34 AM with Employee 2, revealed 20 bottles (250 milliliter ml each) of sterile water that expired on June 9, 2022, five bottles (100 ml each) of sterile water that expired on October 21, 2022, and a box of plastic adhesive bandages that expired in May of 2022. Further observation of the 200 nursing unit treatment cart on October 27, 2022, at 10:41 AM with Employee 2 revealed one bottle (100 ml) of normal saline solution that expired on August 26, 2021, and Miconazole powder (topical antifungal) two percent that expired on October 24, 2022. The above findings were reviewed with the Director of Nursing and Nursing Home Administrator on October 28, 2022, at 10:30 AM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(i) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395352 If continuation sheet Page 8 of 8