Pennsylvania Department of Health
BROOMALL MANOR
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BROOMALL MANOR
Inspection Results For:

There are  54 surveys for this facility. Please select a date to view the survey results.

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BROOMALL MANOR - 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 November 20, 2024, at Broomall Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BLDG 01 (ORIG BLDG AND SUNROOM ADDITION) - Component: 01 - Tag: 0000


Facility ID# 023102
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on November 20, 2024, it was determined that Broomall Manor was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BLDG 01 (ORIG BLDG AND SUNROOM ADDITION) - Component: 01 - Tag: 0100

Based on observation, interview, and documentation review, it was determined the facility failed to obtain required Pennsylvania Department of Health plan approval for changes to the facility's existing fire alarm system, affecting the entire facility.
Findings include:
Observation, interview, and documentation review on November 20, 2024, between 8:30 a.m. and 10:45 a.m., revealed that the facility failed to obtain REVISED plan approvals to approved drawing H-24-0488 by the Department of Health (Department) prior to initiating alterations to the facilities fire alarm system by adding additional wiring and smoke detection devices into resident rooms.
Interview via telephone conversation with the Adminstrator on November 22, 2024 at 3:10 p.m., confirmed the facility failed to secure REVISED plan approvals by the Department of Health prior to initiating additional device alterations.
Reference: 28 Pa Code 51.3. Notification (d)








 Plan of Correction - To be completed: 12/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposed of general liability, professional malpractice or any court proceeding.

Updated H paperwork received and submitted to Dept of Health.

DOM/NHA educated on obtaining required Pennsylvania Department of Health plan approval for changes to the facility's existing fire alarm system.

Request for visit approval has been submitted to DOH.

Facility will wait for re-visit from Dept of health for inspection.

DOM/designee will oversee and review in QAPI

NFPA 101 STANDARD Number of Exits - Story and Compartment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: MAIN BLDG 01 (ORIG BLDG AND SUNROOM ADDITION) - Component: 01 - Tag: 0241

Based on document review, observation, and interview, it was determined the facility failed to provide two acceptable exits located remote from each other, affecting one of two floors within the facility.

Findings Include:

Document review and observation on November 20, 2024, between 8:30 a.m. and 11:00 a.m., revealed both basement exit stairways were remotely located from each other. However, both stairways led to the First-Floor corridor and neither led directly outside.

Exit interview with the Administrator and Director of Maintenance on November 20, 2024, at 1:15 p.m., confirmed the lack of acceptable basement exits.




 Plan of Correction - To be completed: 12/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposed of general liability, professional malpractice or any court proceeding.

Facility engaged architect in regard to basement egress in attempt to bring the egress features in compliance with the NFPA2012 life safety code.

Plan was submitted to PA division of safety inspection on 9/2019.

Updated facility FSES completed by 3rd party vendor and submitted to life safety while a means of correcting this deficiency continues to be determined.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: MAIN BLDG 01 (ORIG BLDG AND SUNROOM ADDITION) - Component: 01 - Tag: 0353

Based on observation and interview, facility failed to ensure sprinkler system would activate in a timely manner in one of two levels.

Observation and interview on November 20, 2024, at 12:15 p.m., revealed one sprinkler head recessed into ceiling grid in corridor outside Therapy Office.

Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 1:15 p.m., confirmed the recessed in ceiling, sprinkler head .







 Plan of Correction - To be completed: 12/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposed of general liability, professional malpractice or any court proceeding.

Sprinkler head outside Therapy office was corrected by vendor.

DOM reviewed corrected sprinkler head with vendor.

Vendor provided paperwork indicating sprinkler issue corrected.

DOM/designee will check sprinkler head monthly x3 months to ensure sprinkler head in place and no issues.

DOM/designee oversees and review in QAPI.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BLDG 01 (ORIG BLDG AND SUNROOM ADDITION) - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical equipment on one of two levels.

Findings include:

Observation on November 20, 2024, at the following times and locations revealed the following electrical equipment deficiencies:

a) 11:00 a.m., Hair dresser room had an extension cord plugged into an electrical outlet that is hardwired to a powered recessed gfci receptacle and light fixture inside a stationary sink vanity.

b) 12:00 p.m., inside Assistant Director of Nursing office, there was a refrigerator and microwave plugged into a power strip.


Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 1:15 p.m., confirmed the above electrical cord deficiencies.







 Plan of Correction - To be completed: 12/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Power strip removed. Extension cord removed.

Office audit done to ensure additional power strips and extension cords are not inappropriately in use.

Re-education to admin staff conducted on use of power strips and extension cords.

Random office audits conducted 2x/per week x 5 weeks.

DOM/designee will oversee and review in QAPI.


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