BROAD MOUNTAIN HEALTH AND REHABILITATION CENTER Inspection Report, Violations & Safety Grade (FRACKVILLE, Pennsylvania)

500 WEST LAUREL STREET, FRACKVILLE, Pennsylvania 17931

Phone: 5705708740

CMS Overall:2/5

Overview & Bed Count

Certified Beds

117

Avg Residents/Day

104.1

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Schuylkill

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall2/5

Health1/5

Staffing2/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	Pennsylvania Avg	Difference
RN Hours per Resident per Day	0.46	0.78	-0.31
Total Nurse Hours per Resident per Day	3.54	3.90	-0.36
CMS Staffing Rating	2/5	3.1/5	-
Nursing Staff Turnover	47.5%	44.6%	-

Health Citation History

41 health citations on record

Date	Category	Description	Severity
2026-08-27	Resident Rights Deficiencies	Protect a residents' right to refuse some types of non-requested transfers within the nursing home.	D – Moderate Harm Potential
2026-08-27	Quality of Life and Care Deficiencies	Provide activities to meet all resident's needs.	D – Moderate Harm Potential
2026-02-06	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2026-02-06	Resident Rights Deficiencies	Allow resident to participate in the development and implementation of his or her person-centered plan of care.	E – Moderate Harm Potential
2026-02-06	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	E – Moderate Harm Potential
2026-02-06	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	E – Moderate Harm Potential
2026-02-06	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2026-02-06	Environmental Deficiencies	Have policies on smoking.	E – Moderate Harm Potential
2026-02-06	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2026-02-06	Pharmacy Service Deficiencies	Ensure each resident’s drug regimen must be free from unnecessary drugs.	D – Moderate Harm Potential
2025-11-18	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2025-11-18	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	E – Moderate Harm Potential
2025-10-17	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	J – Immediate Jeopardy
2025-10-17	Administration Deficiencies	Administer the facility in a manner that enables it to use its resources effectively and efficiently.	D – Moderate Harm Potential
2025-09-10	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2025-04-11	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	E – Moderate Harm Potential
2025-04-11	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2025-04-11	Quality of Life and Care Deficiencies	Ensure the activities program is directed by a qualified professional.	E – Moderate Harm Potential
2025-04-11	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2025-04-11	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	E – Moderate Harm Potential
2025-04-11	Environmental Deficiencies	Have policies on smoking.	E – Moderate Harm Potential
2025-04-11	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2025-04-11	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2025-04-11	Resident Assessment and Care Planning Deficiencies	Plan the resident's discharge to meet the resident's goals and needs.	D – Moderate Harm Potential
2025-04-11	Pharmacy Service Deficiencies	Ensure each resident’s drug regimen must be free from unnecessary drugs.	D – Moderate Harm Potential
2025-04-11	Administration Deficiencies	Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.	D – Moderate Harm Potential
2025-04-11	Quality of Life and Care Deficiencies	Provide or obtain dental services for each resident.	D – Moderate Harm Potential
2024-05-10	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	G – Actual Harm
2024-05-10	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	G – Actual Harm
2024-05-10	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	E – Moderate Harm Potential
2024-05-10	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	E – Moderate Harm Potential
2024-05-10	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2024-05-10	Quality of Life and Care Deficiencies	Provide medically-related social services to help each resident achieve the highest possible quality of life.	E – Moderate Harm Potential
2024-05-10	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2024-05-10	Environmental Deficiencies	Have policies on smoking.	E – Moderate Harm Potential
2024-05-10	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2024-05-10	Quality of Life and Care Deficiencies	Provide care or services that was trauma informed and/or culturally competent.	D – Moderate Harm Potential
2024-05-10	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	B – Minimal Harm Potential
2023-10-17	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2023-10-17	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2023-10-17	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	E – Moderate Harm Potential

Fire Safety Citation History

14 fire safety citations on record

Date	Category	Description	Severity
2026-02-06	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2026-02-06	Egress Deficiencies	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	E – Moderate Harm Potential
2026-02-06	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2025-04-11	Emergency Preparedness Deficiencies	Conduct risk assessment and an All-Hazards approach.	F – Moderate Harm Potential
2025-04-11	Construction Deficiencies	Meet requirements for sections of health care facilities separated by fire resistive construction.	E – Moderate Harm Potential
2025-04-11	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2025-04-11	Egress Deficiencies	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	E – Moderate Harm Potential
2025-04-11	Egress Deficiencies	Have properly located and lighted "Exit" signs.	E – Moderate Harm Potential
2025-04-11	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2025-04-11	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2024-05-10	Egress Deficiencies	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	E – Moderate Harm Potential
2024-05-10	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2024-05-10	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2024-05-10	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential

Total Penalties & Fines

$45,678

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-09-10	Fine	$15,940	-
2024-05-10	Fine	$29,738	-

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