Health inspection·August 31, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement interventions to maintain a resident's continence status for one of four residents reviewed (Resident 1). Findings include: The MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) Resident Assessment Indicators (RAI) 3.0 Manual, Section H indicated that each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. Clinical record review for Resident 1 revealed that the facility admitted him on August 11, 2023. Upon admission, the facility identified that Resident 1 was capable, with a BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; 13-15 indicates cognitively intact) of 15, was continent of bowel, and aware of the need to defecate. Resident 1 was ordered to be non-weight bearing on his right lower extremity due to a recent hip fracture with surgical repair, therefore requiring staff assistance for toileting. Review of Resident 1's task interventions (an action intended to improve the resident's health and comfort) revealed that he frequently needed limited to extensive assistance from one staff member with his toileting needs. Further review from August 11, 2023, through August 30, 2023, revealed that Resident 1 was incontinent of bowel 13 times, with evening and night shift incontinence occurring for 11 of the 13 times. Resident 1 had loose stool from August 12, 2023, to August 18, 2023. Review of Resident 1's nursing and physician documentation dated August 16, 2023, revealed that Resident 1 was complaining of diarrhea almost every time he eats with nine episodes over the past several days. The physician ordered Imodium for the diarrhea, with noted positive results and Resident 1's diarrhea ceased on August 18, 2023; however, Resident 1's incontinence continued. Interview with Resident 1 on August 30, 2023, at 12:49 PM confirmed that he was continent of bowel prior to admission and that he becomes incontinent of bowel when staff fail to respond to his call bell, especially on the evening and night shifts. He revealed that he notified staff after supper on August 29, 2023, of the need to defecate. Staff indicated that they could not provide assistance at that time. Resident 1 indicated that he waited over an hour for staff to return. By that time, he had become incontinent of bowel and was forced to sit in it while in his wheelchair, until staff returned to provide care. Resident 1 indicated that he could not access his call bell because of being in (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 3 Event ID: 395352 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 08/31/2023 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)