Pennsylvania Department of Health
BROOMALL MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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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 September 29, 2025, 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# 023102Component 01 Based on a Medicare/Medicaid Recertification Survey completed on September 29, 2025, 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 construction, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 document review and interview, it was determined the facility failed to provide accurate, portable floor plans as required, affecting the entire facility. Findings include: 1. Document review on September 29, 2025, at 8:30 a.m., it was determined the facility failed to provide portable Life Safety Code Floor Plans that included the following information: a. Smoke Barrier Walls (outside wall to outside wall) b. Fire Barrier Walls (2-hour walls) c. Horizontal Exits d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan; e. Required Exits should be clearly noted; and f. Shafts Walls In addition to the above, the following information is required on the portable floor plans for facilities utilizing the Fire Safety Evaluation System (FSES): Zone dimensions (length and width) Resident Room numbers and number of residents in each room Nurses station locations to include number of nurses at each location Directional arrows for emergency movement routes Each room use must be identified (dining, soiled linen, housekeeping, office, etc.) Identify where FSES deficiency exists on floor plans. Exit interview with the Administrator on September 29, 2025, at 11:30 a.m., confirmed the lack of accurate plans.

Plan of Correction - To be completed: 12/10/2025

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 to review current floor plans to update as needed.

Floor plans color printed and available for view, both in life safety binder and posted in facility.

Maintenance team education provided on the importance of having plans available.

NHA audit completed monthly x 2 months to ensure color plans are available and posted.

QAPI review as needed.

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 September 29, 2025, between 8:00 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 to direct discharge public way. Exit interview with the Administrator on September 29, 2025, at 11:30 p.m., confirmed the lack of acceptable basement exits.

Plan of Correction - To be completed: 12/10/2025

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 Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BLDG 01 (ORIG BLDG AND SUNROOM ADDITION) - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting one of two levels. Findings include: 1. Observation on September 29, 2025, at 9:30 a.m., revealed smoke doors on the first floor, North Wing by room 53 failed to close smoke tight when tested. Exit interview with the Administrator on September 29, 2025, at 11:30 a.m., confirmed the doors failed to close smoke tight.

Plan of Correction - To be completed: 12/10/2025

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.

1st floor smoke doors by room 53 were corrected to close smoke tight when tested.

Audit of all smoke doors conducted to ensure all close smoke tight when tested.

Maintenance team education completed to ensure understanding on proper smoke door closure during testing and report any issues to NHA.

DOM/designee will do random smoke door closure checks weekly x 2 months to ensure proper closure.

Audit results will be reviewed with QAPI.

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