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 (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 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 09/13/2024 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)