Broad Mountain Health And Rehabilitation Center

Based on observations, review of clinical records, review of select facility policies, review of job descriptions, documentation provided by the facility, and interviews with residents and staff, it was determined the facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental well-being of residents.

The facility failed to ensure that measures were implemented to prevent one of twelve residents identified as being at risk for wandering (Resident 1) from exiting the building unattended into an unsafe environment.

This deficient practice placed all residents at risk for harm and resulted in immediate jeopardy to residents' health and safety.Findings include:A review of the job description for the Nursing Home Administrator (NHA) dated and signed September 12, 2024, indicated the administrator will lead and manage the overall operations of the facility in accordance with policies, procedures, and current federal, state, and local standards, guidelines, and regulations.

The NHA's essential duties and responsibilities include hiring, training, and developing department staff, verifying the physical environment is maintained appropriately, and directs overall activities and programs in accordance with current rules and regulations.

The job description for Director of Nursing (DON) Services dated and signed May 11, 2025, documents the DON directs the overall operations of nursing service and collaborates with the NHA and medical director to ensure the highest degree of quality of care for all residents.

The DON maintains maintenance of the master staffing schedule, ensuring daily work assignments are in place and appropriate staffing levels are present. In the absence of the NHA, the job description writes the DON will assume responsibility for the daily facility operations.

The facility failed to ensure administrative responsibilities were carried out to maintain resident safety. On October 11, 2025, Resident 1 exited the facility without staff supervision and entered an unsafe area outside.

This demonstrated that facility systems and oversight were not effective in preventing residents from leaving the building unsupervised.

Residents identified as being at risk for wandering were not adequately protected, placing them in danger of injury or harm.

Interviews with staff, residents, and facility the Nursing Home Administrator and Director of Nursing on October 16, 2025, at 3:00 PM confirmed that established safety measures were not followed and that both equipment and staff procedures failed.

Staff reported uncertainty about their roles in monitoring exit doors and about communication protocols when a resident was missing.

This lack of coordination and communication delayed identification of the incident and assessment of other residents at risk for wandering or elopement (leaving the facility or safe area without staff knowledge or supervision) and the potential for harm.

The Administrator and Director of Nursing failed to fulfill their essential administrative duties to monitor departmental operations, identify systemic risks, and ensure the implementation of facility policies to maintain resident safety.

This lack of oversight and failure to use available resources to identify and correct system problems resulted in conditions that placed residents in immediate jeopardy. 28 Pa.

Code: 201.14 (a) Responsibility of licensee. 28 Pa.

Code: 201.18 (e)(1) Management. 28 Pa.

Code 211.12 (d)(3) Nursing services

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