Health inspection·October 6, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation and staff interview, it was determined that the facility failed to provide dignity with dining for one of two main dining rooms (Assisted Dining Room, Residents 21 and 22), and for one of one resident reviewed for dignity in toileting (Resident 41) Findings include: Observation of the dining area on October 3, 2023, from 11:55 AM to 12:20 PM revealed that the staff failed to provide resident dignity based on the following: Observation of Employee 1, registered nurse, revealed that she attempted to feed Resident 21 with a spoon while standing up on the resident's left side. The surveyor briefly left the dining room where residents were being fed or assisted with feeding to observe the adjacent dining room where residents feed themselves. On return to the assisted dining room, Employee 1, was standing up attempting to feed Resident 22 with a spoon on the left side of the resident. Employee 1 voiced that is all she could get the resident to take. It is undignified for staff to stand over a resident to feed them. The surveyor reviewed the findings for Residents 21 and 22 with the Nursing Home Administrator and Director of Nursing during a meeting on October 4, 2023, at 1:15 PM. Observation on October 4, 2023, at 2:33 PM revealed that the door to Resident 41's room was open. Resident 41 resided in the semi-private room next to the window. The surveyor entered Resident 41's room after receiving permission from the responsible party. The bathroom door was open, and Resident 41 was sitting on the toilet with the lower part of her body undressed. Employee 2, nurse aide, was bending over and was removing the resident's incontinent brief, which was down to her feet at the time. Resident 41 was visible to the surveyor, responsible party, and roommate. During an interview with Employee 2 on October 4, 2023, at 2:40 PM she confirmed that she should have closed the door to Resident 41's room to provide her privacy and dignity. The surveyor reviewed the findings for Resident 41 during a meeting with the Director of Nursing on October 5, 2023, at 9:00 AM. 28 Pa. Code 201.29(a) Resident rights 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 4 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 10/06/2023 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)