Broad Mountain Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Broad Mountain Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 17, 2025

  Based on clinical record review, facility policy review, staff interviews, and observation, it was determined the facility failed to ensure adequate supervision and implementation of safety interventions to prevent elopement for one resident (Resident 1). These failures placed 12 residents identified at risk for wandering and elopement (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) in an Immediate Jeopardy situation in which the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death.Findings include: A review of a facility policy for Elopement/Unauthorized \Absence Policy reviewed July 2, 2025, revealed the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through… […]

• Actual harm, isolatedF600May 10, 2024

  Based on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident (Resident 25) out of 20 sampled residents was free from sexual abuse perpetrated by another resident (Resident 46). Findings include: A review of facility policy titled Pennsylvania Resident Abuse, last reviewed by the facility on March 24, 2024, revealed the facility will not tolerate abuse of residents by anyone. The policy defines sexual abuse as includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. […]

• Actual harm, isolatedF692May 10, 2024

  Based on a review of clinical records and staff interviews, it was determined that the facility failed to provide enteral feedings as ordered to maintain acceptable nutritional parameters and prevent a significant unplanned weight loss for one resident out of 20 residents sampled (Resident 83). Findings include: A clinical record review revealed that Resident 83 was admitted to the facility on [DATE], with diagnoses that included intracranial injury (brain dysfunction caused by an outside force) and cognitive communication deficit (brain damage that results in language and cognition impairment). […]

• Actual harm, isolatedF760Jul 14, 2023

  Based on review of clinical records, information submitted by the facility and select facility incident reports, and staff interview it was determined that the facility failed to assure that two residents of six sampled (Resident 8 and 93) were free from a significant medication errors that compromised one resident's clinical condition and health (Resident 8). Findings include: Clinical record review revealed that Resident 8 had diagnoses which included unspecified convulsions. A physician order dated May 16, 2022 for Phenytoin Sodium Extended capsule (an anticonvulsant medication) 100 mg every 8 hours for a diagnosis of unspecified convulsions. […]

• Actual harm, isolatedF689May 25, 2022

  Based on a review of clinical records, information submitted by the facility, select facility policy and incident investigations and staff interviews, it was determined that the facility failed to implement the planned intervention of staff supervision necessary to prevent a fall with injury, a fractured elbow, for one of four sampled residents (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include, Alzheimers disease and a history of wandering and falls. […]