Health inspection·May 8, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to obtain physician ordered medications for two of five residents reviewed (Residents 1 and 3). Findings include: Clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE], at 3:36 PM. Review of Resident 1's admission physician orders for medications to be administered to the resident revealed the following medication were ordered on April 19, 2024: Bupropion HCL ER 150 mg (milligrams) tablet two times a day for depression to start April 19, 2024, at 8:00 PM Phos-NaK oral packet 280-160-250 mg (Potassium and Sodium Phosphate) one packet with meals to start April 19, 2024, at 6:00 PM A review of Resident 1's medication administration record for April 2024, revealed no evidence the above medications were administered as ordered. The medication administration log was blank for the administration dates and times indicated. There was no evidence to indicate why the doses were not administered. Clinical record review for Resident 3 revealed the resident was admitted to the facility on [DATE], with nursing admission assessment completed at 2:00 PM. A review of Resident 3's admission physician ordered medications revealed the resident was ordered the following medications on May 3, 2024, to start at 9:30 PM: Amitriptyline HCL 25 mg to be given at bedtime for depression. Calcium-Vitamin D 600-200 mg unit two times a day for supplementation Diclofenac Potassium 50 mg one tablet three times a day for back pain Lorazepam tablet 1 mg at bedtime for anxiety (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 2 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 05/08/2024 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)