Cycle 1
Health 2024-09-13 · Fire 2024-09-13
4 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Wellsboro, PA
Broad Acres Health And Rehabilitation
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1883 Shumway Hill Road, Wellsboro, PA
(570) 724-3913
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
82
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,924
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0076
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.46
Baseline 18.93% · Performance 18.90% · Measure score 5.46 · Achievement 5.46 · Improvement 0
Healthcare-associated infections
8.63
Baseline 4.32% · Performance 5.26% · Measure score 8.63 · Achievement 8.63 · Improvement 0
Total nurse turnover
3.75
Baseline 42.53% · Performance 48.35% · Measure score 3.75 · Achievement 3.75 · Improvement 0
Adjusted total nurse staffing
3.36
Baseline 3.88 hours · Performance 4.03 hours · Measure score 3.36 · Achievement 3.36 · Improvement 0.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.72% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 150 · Observed rate 12.67% · Lower 95% interval 8.73% |
| Discharge to community | 51.28% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 47.54% · Lower 95% interval 42.18% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 84.44% |
95.27%
10.8 pts worse
|
Numerator 76 · Denominator 90 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 90 |
| Discharge self-care score | 40.85% |
53.69%
12.8 pts worse
|
Numerator 29 · Denominator 71 |
| Discharge mobility score | 54.93% |
50.94%
4 pts better
|
Numerator 39 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 6 · Denominator 90 · Adjusted rate 5.89% |
| Healthcare-associated infections requiring hospitalization | 5.26% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 0% · Lower 95% interval 2.7% |
| Staff COVID-19 vaccination coverage | 6.77% |
8.2%
1.4 pts worse
|
Numerator 9 · Denominator 133 |
| Staff flu vaccination coverage | 45.81% |
42%
3.8 pts better
|
Numerator 82 · Denominator 179 |
| Discharge function score | 54.93% |
56.45%
1.5 pts worse
|
Numerator 39 · Denominator 71 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 40.38% |
25.2%
15.2 pts better
|
Numerator 21 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.2
1.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
3.2%
3.7 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.9% · Q3 8.2% · Q4 10.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.5%
1.7 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.4% · Q3 6.5% · Q4 1.5% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
19.9%
1.5 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 19.5% · Q3 15.9% · Q4 20.0% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
18.7%
0.1 pts better
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 19.7% · Q3 22.6% · Q4 22.4% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.0% |
19.6%
1.6 pts better
|
16.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 19.1% · Q3 20.2% · Q4 21.6% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
18.3%
6.8 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 33.3% · Q3 24.7% · Q4 26.5% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.9%
2.1 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 3.8% · Q4 3.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
1.7%
2.3 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.5% · Q3 7.5% · Q4 4.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
26.4%
2.3 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 29.4% · Q3 29.3% · Q4 31.2% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.3%
3.4 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 11.9% · Q3 8.2% · Q4 8.7% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
68.9%
31.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
9.8%
2.6 pts worse
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 11.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
68.7%
26.4 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
23.1%
3.7 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 19.7% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-06 · Fire 2023-10-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-10-28 · Fire 2022-10-28
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-01
E · Potential for more than minimal harm
2023-10-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-10-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-12-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-07-11
D · Potential for more than minimal harm
2024-09-13
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-01
C · Minimal harm
2024-09-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-05-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-14
E · Potential for more than minimal harm
2023-10-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-08-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-20
E · Potential for more than minimal harm
2022-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-10-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-10-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-10-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-10-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-12-09
Penalties and ownership
What sits behind the stars
Ownership
Chr Consulting Services Inc
Operational/Managerial Control · Organization
Dresser, Brandon
W-2 Managing Employee · Individual
Hazelton, Deborah
Corporate Officer · Individual
Mosher, Calvin
Corporate Officer · Individual
Mosher, Calvin
Contracted Managing Employee · Individual
Olson, Sandra
Corporate Officer · Individual
Pino Ii, Richard
Corporate Officer · Individual
Roscoe, Brandon
Contracted Managing Employee · Individual
Wilson, Sandra
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Green Home, Inc, The
Wellsboro, PA
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Bradford Hills Nursing & Rehabilitation Center
Troy, PA
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Absolut Center for Nursing and Rehabilitation at T
Painted Post, NY
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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