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Inspection visit

Health inspection

BROAD ACRES HEALTH AND REHABILITATIONCMS #3953521 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395352 05/28/2025 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901
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. Page 1 of 3 395352 395352 05/28/2025 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901
F 0725 May 26, 2025, activated at 7:55 PM, response time of 26 minutes. Level of Harm - Minimal harm or potential for actual harm May 27, 2025, activated at 8:36 AM, response time of 16 minutes. May 27, 2025, activated at 11:25 AM, response time of 16 minutes. Residents Affected - Some May 27, 2025, activated at 3:54 PM, response time of 18 minutes. In an interview with Resident 2 on May 28, 2025, at 11:20 AM she stated that she waits an hour at times for staff to answer her call bell when she wants to transfer between her bed and chair or when she needs them to reach something she can't get. Resident 2 stated she waited a while for staff to answer her call bell as recent as this morning. A review of electronic call bell activation and response time logs for Resident 2's room from May 15 to 28, 2025, revealed the following call bell response times greater than 15 minutes: May 16, 2025, activated at 11:00 AM, response time of 16 minutes. May 17, 2025, activated at 7:38 AM, response time of 18 minutes. May 17, 2025, activated at 11:23 AM, response time of 17 minutes. May 17, 2025, activated at 1:19 PM, response time of 17 minutes. May 17, 2025, activated at 9:47 PM, response time of 28 minutes. May 19, 2025, activated at 7:42 AM, response time of 18 minutes. May 19, 2025, activated at 9:39 PM, response time of 18 minutes. May 22, 2025, activated at 8:38 AM, response time of 21 minutes. May 28, 2025, activated at 9:16 AM, response time of 25 minutes. In an interview with Resident 4 on May 28, 2025, at 1:15 PM, he pointed to a call bell lying on his tray table when asked how he got a hold of staff if he needed help. Resident 4 stated staff come to help him in an hour or in minutes, I just deal with it. A review of electronic call bell activation and response time logs for Resident 4's room from May 15 to 28, 2025, reveled the following call bell response time greater than 15 minutes: May 17, 2025, activated at 5:03 PM, response time of 41 minutes. May 17, 2025, activated at 6:43 PM, response time of 31 minutes. May 17, 2025, activated at 8:02 PM, response time of 47 minutes. May 17, 2025, activated at 8:52 PM, response time of 1 hour and 9 minutes. 395352 Page 2 of 3 395352 05/28/2025 Broad Acres Health and Rehabilitation 1883 Shumway Hill Road Wellsboro, PA 16901
F 0725 May 18, 2025, activated at 12:03 PM, response time of 22 minutes. Level of Harm - Minimal harm or potential for actual harm May 19, 2025, activated at 11:42 PM, response time of 25 minutes. May 21, 2025, activated at 4:33 AM, response time of 24 minutes. Residents Affected - Some May 21, 2025, activated at 6:56 PM, response time of 26 minutes. May 21, 2025, activated at 7:50 PM, response time of 16 minutes. May 23, 2025, activated at 7:07 PM, response time of 24 minutes. May 26, 2025, activated at 8:48 PM, response time of 22 minutes. May 26, 2025, activated at 9:11 PM, response time of 24 minutes. May 28, 2025, activated at 4:45 AM, response time of 19 minutes. The above call bell response times were reviewed with the Nursing Home Administrator and Director of Nursing on May 28, 2025, at 2:30 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services 395352 Page 3 of 3

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0725GeneralS&S Epotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

FAQ · About this visit

Common questions about this visit

What happened during the May 28, 2025 survey of BROAD ACRES HEALTH AND REHABILITATION?

This was a inspection survey of BROAD ACRES HEALTH AND REHABILITATION on May 28, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BROAD ACRES HEALTH AND REHABILITATION on May 28, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.