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 Page 1 of 4 395352 395352 10/06/2023 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for one of one resident sampled for activities of daily living (Resident 74). Residents Affected - Few Findings include: Resident 74 was unable to be interviewed due to his current cognitive status. A clinical record review revealed the facility admitted Resident 74 on August 2, 2023. A review of Resident 74's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated August 8, 2023, indicated nursing staff assessed Resident 74 as requiring extensive physical help from one staff for bathing. A review of Resident 74's task documentation (ADL, activities of daily living charting) revealed he has not received a shower since August 5, 2023. Nursing staff documented Resident 74 refused showers since August 5, 2023. Further review revealed that 74's bathing preference was identified as preferring a shower once a week. A review of Resident 74's plan of care revealed no documentation that the facility addressed or implemented individualized interventions for Resident 74's refusal to shower. The facility failed to provide activities of daily living as scheduled and per their preference for Resident 74. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services 395352 Page 2 of 4 395352 10/06/2023 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of five residents reviewed (Resident 65). Residents Affected - Few Findings include: Clinical record review revealed the facility admitted Resident 65 on November 10, 2022. Further review of Resident 65's clinical record revealed the following weight assessments: August 26, 2023, 147 pounds September 12, 2023, 141 pounds September 15, 2023, 137 pounds October 2, 2023, 135 pounds (a 12-pound, 8.16 percent significant weight loss) A review of a nutrition progress note dated September 18, 2023, confirmed significant weight loss, and the dietician's intervention included a re-weight to confirm Resident 65's significant loss, and to notify Resident 65's physician. There was no evidence that staff obtained a re-weight or notified Resident 65's physician. Interview with the Director of Nursing on October 6, 2023, at 9:44 AM confirmed she was unable to provide any documentation that the facility obtained a re-weight or notified Resident 65's physician of his significant weight loss. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395352 Page 3 of 4 395352 10/06/2023 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the main kitchen. Residents Affected - Some Findings include: Observation of the facility's kitchen on October 3, 2023, at 11:07 AM revealed the following in the facility's dry storage area: Two unopened double chocolate boxed cake mixes with a manufacture's date of August 13, 2022 An unopened bag of vanilla wafers/cookies with a use by date of April 7, 2023 Three-quarters of a case of individual servings of Jiff peanut butter with a use by date of June 29, 2023 Four unopened containers of thickened orange juice with a use by date of April 23, 2023. Interview with Employee 3, dietary manager on October 3, 2023, at 11:07 AM and again on October 5, 2023, at 9:30 AM confirmed the items in the dry storage were out of use by dates and should not be available for resident use. Employee 3 also indicated that the double chocolate cake was to be used within one year of the manufacture's date (August 13, 2023). This surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing during an interview on October 4, 2023, at 1:00 PM. 28 Pa. Code 211.6(c)(f) Dietary services 395352 Page 4 of 4