Pennsylvania Department of Health
BROAD MOUNTAIN HEALTH & REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 41 surveys for this facility. Please select a date to view the survey results.

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BROAD MOUNTAIN HEALTH & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on April 22, 2025, it was determined that Broad Mountain Health & Rehabilitation Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006

Based on documentation review and interview, it was determined the facility failed to maintain Emergency Preparedness in one instance, affecting one of one floor.

Findings include:

1. Observation on April 22, 2025, at 12:10 p.m., revealed the facility had not reviewed the Emergency Preparedness Plan since March of 2024 (annual requirement).

Exit interview with the Facility Administrator and the Facilities Manager on April 22, 2025, between 12:30 p.m., and 12:40 p.m., confirmed the facility failed to maintain Emergency Preparedness.

Plan of Correction - To be completed: 05/20/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1. The Emergency Preparedness Plan was reviewed and updated on April 24, 2025. To prevent this from reoccurring, the NHA and Maintenance Director will be educated on the requirements for E0006.
2. To monitor and maintain compliance, the Emergency Preparedness Plan reviews will be monitored by the NHA and consultant on an annual basis. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #282802
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on April 22, 2025, it was determined that Broad Mountain Health & Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a two story, Type III (211), protected, ordinary building that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of two floors.

Findings include:

1. Observation on April 22, 2025, at 11:16 a.m., revealed a penetration of the rated ceiling assembly, located within the Sprinkler Room.

Exit interview with the Facility Administrator and the Facilities Manager on April 22, 2025, between 12:30 p.m., and 12:40 p.m., confirmed the building construction deficiency.

Plan of Correction - To be completed: 05/20/2025

1. The penetration of the rated ceiling assembly located within the sprinkler room was sealed. To prevent this from reoccurring, the Maintenance Director / designee will be educated on the requirements for K161 and the importance of maintaining building construction requirements throughout the building.
2. To monitor and maintain compliance, Maintenance Director / designee will audit one floor per week for 4 weeks, then both floors monthly for 2 months to ensure there are no additional penetrations in the ceiling. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain two stair tower enclosures, in two locations, affecting two of two floors.

Findings include:

1. Observation on April 22, 2025, between 11:22 a.m., and 11:48 a.m., revealed the following:

a. 11:22 a.m., the end cap was missing on fire exit hardware at the first floor portion of the center stair tower enclosure.
b. 11:48 a.m., the second floor, west stair tower enclosure door required adjustment to fully latch.

Exit interview with the Facility Administrator and the Facilities Manager on April 22, 2025, between 12:30 p.m., and 12:40 p.m., confirmed the stair tower deficiencies.

Plan of Correction - To be completed: 05/20/2025

1. The end cap that was missing on the fire exit hardware on the first floor portion of the center stair tower enclosure was repaired. The second floor west stair tower enclosure door was adjusted and is fully latching. To prevent this from reoccurring, the Maintenance Director will be educated on the requirements for K0225.
2. To monitor and maintain compliance, the Maintenance Director / designee will audit all end caps on fire exit hardware and stair tower doors to ensure they fully latch weekly for 4 weeks and monthly for 2 months. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to install and maintain exit signage in one location, affecting two of two floors.

Findings include:

1. Observation on April 22, 2025, at 11:29 a.m., revealed exit signage lacking at the exit discharge location within the back hall stair tower enclosure, located at the first floor.

Exit interview with the Facility Administrator and the Facilities Manager on April 22, 2025, between 12:30 p.m., and 12:40 p.m., confirmed the exit signage deficiency.

Plan of Correction - To be completed: 05/20/2025

1. An exit sign was placed at the exit discharge location within the back hall stair tower enclosure, located on the first floor. To prevent this from reoccurring, the Maintenance Director will be educated on the requirements of K0293.
2. To monitor and maintain compliance, the Maintenance Director / designee will audit all exit locations to ensure appropriate signage is present weekly for 4 weeks and then monthly for 2 months. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of two floors.

Findings include:

1. Observation on April 22, 2025, at 11:11 a.m., revealed cigarette butts were located within a conventional trash receptacle, located at the Employee Entrance.

Exit interview with the Facility Administrator and the Facilities Manager on April 22, 2025, between 12:30 p.m., and 12:40 p.m., confirmed the smoking regulations deficiency.

Plan of Correction - To be completed: 05/20/2025

1. The trash can with the cigarette butts at the employee entrance was removed. The Maintenance Director confirmed that there was a cigarette butt receptacle located at the smoking area. To prevent this from reoccurring, staff will be educated that they cannot place their cigarette butts in the trash receptacle.
2. To monitor and maintain compliance, the Maintenance Director / designee will audit the smoking area and the employee entrance area to ensure cigarette butts are disposed of appropriately weekly for 4 weeks and then monthly for 2 months. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #282802
Component 02
Therapy Building

Based on a Medicare/Medicaid Recertification Survey completed on April 22, 2025, it was determined that Broad Mountain Health & and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a one story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain one common wall, in one location, affecting two of two floors.

Findings include:

1. Observation on April 22, 2025, at 11:39 a.m., revealed the common wall door between the Therapy Addition and the Main Building required adjustment to fully latch (wall doubles as part of a protected passageway).

Exit interview with the Facility Administrator and the Facilities Manager on April 22, 2025, between 12:30 p.m., and 12:40 p.m., confirmed the common wall deficiency.

Plan of Correction - To be completed: 05/20/2025

1. The door between the Therapy addition and the main building was adjusted to fully latch. To prevent this from reoccurring, the Maintenance Director will be educated on the requirements of K0131.
2. To monitor and maintain compliance, the Maintenance Director / designee will audit 30 doors to ensure they fully latch weekly for 4 weeks and then monthly for 2 months. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of one floor.

Findings include:

1. Observation on April 22, 2025, at 11:43 a.m., revealed storage items located within eighteen inches of an adjacent sprinkler head assembly, located within the Therapy closet.

Exit interview with the Facility Administrator and the Facilities Manager on April 22, 2025, between 12:30 p.m., and 12:40 p.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 05/20/2025

1. The items located within 18 inches of an adjacent sprinkler head assembly were removed. The Maintenance Director and the Director of Rehab will be educated on the requirements of K0353.
2. To monitor and maintain compliance, the Maintenance Director / designee will audit one floor per week for 4 weeks, then both floors monthly for 2 months to ensure there are no additional items stored within 18 inches of the ceiling. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.

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