Health inspection·May 28, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility documents and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs on one of two nursing units (B unit), and three of four residents reviewed (Residents 2, 3, and 4). Findings include: In an interview with Resident 3 on May 28, 2025, at 11:11 AM she stated she completes a lot of her care needs herself but does have to ring the call bell for staff and occasionally must wait some time for them. The resident was not specific on dates or times. A review of electronic call bell activation and response time logs for Resident 3's room from May 15 to 28, 2025, revealed the following call bell response times greater than 15 minutes: May 15, 2025, activated at 10:22 AM, response time of 21 minutes. May 15, 2025, activated at 1:07 PM, response time of 20 minutes. May 15, 2025, activated at 10:26 PM, response time of 16 minutes. May 15, 2025, activated at 10:49 PM, response time of 28 minutes. May 16, 2025, activated at 4:57 AM, response time of 22 minutes. May 18, 2025, activated at 10:13 AM, response time of 28 minutes. May 19, 2025, activated at 8:12 AM, response time of 16 minutes. May 19, 2025, activated at 7:06 PM, response time of 21 minutes. May 20, 2025, activated at 10:20 AM, response time of 32 minutes. May 20, 2025, activated at 1:30 PM, response time of 22 minutes. May 31, 2025, activated at 6:00 PM, response time of 31 minutes. May 22, 2025, activated at 7:59 AM, response time of 21 minutes. (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 3 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 05/28/2025 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)