Broad Mountain Health And Rehabilitation Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a safe, clean and homelike environment in resident areas on two of two resident floors (first floor shower room and second floor dining room and residential units).Findings included:An observation on November 19, 2025, at 8:55 AM in the first-floor shower room revealed a large hole in the wall along the baseboard trim near the toilet and a missing ceiling tile in front of

the privacy curtain. An observation on November 19, 2025, at 12:00 PM on the second floor East Wing revealed a 4-inch brown stain, resembling a water stain, with noted black stains within the brown on a ceiling tile near the nurses station.An observation on November 19, 2025, at 12:35 PM of the second floor East Wing dining room revealed three ceiling tiles that contained large brown stains, resembling water stains.An observation on November 19, 2025, at 12:40 PM of Resident 5's room revealed a used rubber glove, a used plastic cup, a towel, and multiple crumbs and debris under the resident's bed. An observation

on November 19, 2025, at 12:45 PM of Resident 8's room revealed a Kennedy cup (lightweight, spill-proof drinking cup designed to be easy to hold and grip) with the lid removed on the floor containing brown liquid.

The brown liquid was splattered on the floor between Resident 8 and Resident 6's bed and was also noted to be splattered on Resident 6's fitted bed sheet. Under Resident 8's nightstand were multiple used tissues, napkins, and a used face mask. Interview with Resident 7, Resident 6 and 8's roommate, during the time of

the observation, reported that housekeeping does not come into their room to clean every day. The residents stated, somedays the floor is so bad, it's embarrassing.Continued observation of Resident 7's room revealed a tabletop oscillating fan positioned on top of a transfer board (a flat, smooth board used in therapy and rehabilitation to help a person move safely from one surface to another when they cannot stand or bear full weight) which was on top of the push handles of her roommate's wheelchair. The fan was plugged into the wall outlet. When questioned about the unsafe location and position of the fan, Resident 7 stated that the fan had previously been on an over-the-bed table, but staff removed the table to give it to another resident and propped the fan on the back of the wheelchair handles. Further observation revealed two positioning wedges (wedges utilized to support a resident to maintain a side lying position to offload pressure on their backside) in direct contact with floor in the corner of her room by the window. Interview with the Nursing Home Administrator and Director of Nursing on November 19, 2025, at 3:50 PM confirmed

the facility's environment should be kept in good repair and maintained in a clean and homelike manner. 28 Pa Code 201.18(e)(2.1) Management

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Broad Mountain Health and Rehabilitation Center

500 West Laurel Street Frackville, PA 17931

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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

of nursing schedules, resident census data, and staff interview information revealed that the facility did not meet the minimum licensed practical nurse (LPN) staffing ratios on five of fourteen reviewed dates (October 25, November 12, November 15, November 16, and November 17, 2025). A review of staffing schedules revealed that the number of LPNs scheduled on those dates was below the minimum required ratios for the applicable shifts, and there was no documentation that additional higher-level staff were available to compensate. During an interview with the NHA on November 18, 2025, at 3:45 PM, the findings regarding LPN staffing ratios were reviewed, and no additional information was provided to demonstrate that required staffing levels were met.A review of nursing staffing documentation, resident census data, and staff

interview information revealed that the facility did not consistently provide the minimum 3.2 hours of general nursing care per resident per day as required under Pennsylvania state licensure regulations. A review of

the facility's weekly staffing records revealed general nursing care hours below the required 3.2 hours on October 25, October 26, October 28, and October 30, 2025. During an interview with the NHA on November 18, 2025, at 3:45 PM, the findings regarding general nursing hours were reviewed, and no additional information was provided to demonstrate that the required hours were met. A review of clinical records, staffing schedules, census data, and interview information revealed the facility did not ensure sufficient nursing staff, based on actual resident census and acuity (the level of care and supervision required), to provide necessary services and supervision, and staffing documentation showed state minimum staffing ratios and required nursing hours per resident per day were not met on multiple reviewed dates. 28 Pa. Code 211.12 (c)(d)(1)(3)(4)(5) Nursing services 28 Pa. Code 201.18(b)(1)(e)(1)(2)(3)(6) Management

Event ID:

Facility ID:

If continuation sheet