Health inspection·September 13, 2024

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for five of nine residents reviewed (Residents 11, 16, 24, 30, and 50). Findings include: Clinical record review for Resident 16 revealed that they were transferred to the hospital on August 31, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, contact, email, and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. Clinical record review for Resident 30 revealed that they were transferred to the hospital on January 27, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party as required regarding the transfer that included the required contents listed above. Clinical record review for Resident 50 revealed that they were transferred to the hospital on December 29, 2023, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party, or the State Ombudsman as required regarding the transfer that included the required contents listed above. The surveyor reviewed the above information for Residents 16, 30, and 50 during an interview with the Nursing Home Administrator and Director of Nursing on September 12, 2024, at 2:20 PM. Clinical record review for Resident 11 revealed that she was transferred to the hospital on January 30, 2024, after there was a change in her condition. There was no documentation that the facility provided written notification to her responsible party as required regarding the transfer that included all the required contents as listed above. Clinical record review for Resident 24 revealed that they were transferred to the hospital on June 13, 2024, after there was a change in his condition. There was no documentation that the facility provided written notification to his responsible party, or the State Ombudsman as required regarding Page 1 of 4 395352 395352 09/13/2024 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901

F 0623 the transfer that included the required contents listed above. Level of Harm - Potential for minimal harm Interview with Employee 1 (business office manager) on September 13, 2024, at 9:16 AM confirmed these findings. Residents Affected - Many 28 Pa. Code 201.14 (a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights 395352 Page 2 of 4 395352 09/13/2024 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901

F 0699 Provide care or services that was trauma informed and/or culturally competent. 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 identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of six residents reviewed for mood/behavior (Residents 7). Residents Affected - Few Findings include: Clinical record review revealed the facility admitted Resident 7 on April 19, 2024, and added a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) on May 1, 2024. Review of Resident 7's social history and evaluation completed on April 23, 2024, revealed a trauma screening questionnaire (a group of questions related to symptoms that may occur due to a traumatic event) that indicated Resident 7 had difficulty concentrating at least twice in the past week. The questionnaire did not include questions related to her diagnosis of PTSD or triggers that may mitigate re-traumatization. Review of Resident 7's current care plan revealed a history of depression, PTSD, and anxiety. The care plan indicated that the PTSD was related to her husband's death and that she had panic attacks at times. The care plan did not identify what triggers her panic attacks related to her husband's death that occurred approximately 20 years ago or how she deals with them. Further review of Resident 7's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to identify triggers to develop and implement individualized interventions to prevent re-traumatization. Resident 7's care plan was revised on September 13, 2024, and a progress note was entered into her clinical record on September 12, 2024, at 7:57 PM indicating a conversation was held with her to determine her potential triggers. This was after the surveyor made the facility aware that her clinical record failed to identify her potential triggers on September 12, 2024, at 2:00 PM. These findings were confirmed with the Director of Nursing on September 13, 2024, at 2:00 PM. 28 Pa Code 211.12 (d)(3)(5) Nursing services 395352 Page 3 of 4 395352 09/13/2024 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to ensure daily nurse staff data was posted for both nursing units (A and B wing). Residents Affected - Few Findings include: Observation on September 11, 2024, at 1:46 PM revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts. Subsequent observations on September 12, 2024, at 2:48 PM, and September 13, 2024, at 11:12 AM again revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts. The posting did not include the facility's name. Interview with the Director of Nursing on September 13, 2024, at 11:42 confirmed these findings. 28 Pa. Code 201.14(a) Responsibility of licensee 395352 Page 4 of 4