Broomall Manor

In the surveyor’s words

From the most serious findings on record at Broomall Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF684Jan 16, 2026

  Based on clinical records review and staff interview, it was determined that the facility failed to ensure medication was correctly administered to the resident and the physician's order regarding vital sign monitoring after a medication error incident was followed for one of two residents reviewed (Resident R1).Findings include: Clinical records review revealed Resident R1 was admitted to the facility on [DATE], with a diagnosis of small bowel obstruction and bladder cancer. A review of the progress notes dated December 19, 2025, at 5:46 a.m., revealed Medication error occurred this evening involving not prescribed medication Keppra (A medication used to treat seizures) PO (by mouth) and prescribed medication Lactulose (A medication used to treat constipation). […]

• No harm, potential for more than minimal, isolatedF684Oct 31, 2024

  Based on review of clinical records, facility documentation, and staff interview, it was determined the facility failed to provide appropriate and consistent treatment for a skin tear for one of the 24 residents reviewed (Resident 54). Findings include: Review of Resident 54's nursing progress notes dated October 8, 2024, at 8:34 p.m., revealed while changing and repositioning Resident 54, a circular skin tear to the left elbow, approximately 2.5 cm. in size, was observed. The physician and the responsible party were notified. Review of the facility's documentation titled, Skin Integrity Events, dated October 8, 2024, at 8:31 p.m., revealed the resident had a 2.5 x 2.5 cm skin tear to the left elbow. […]

• No harm, potential for more than minimal, isolatedF656Oct 27, 2023

  Based on clinical record review and staff interview it was determined the facility failed to develop comprehensive care plans for one of 24 residents reviewed. Findings Include: Review of Resident 43's Bladder Continence documentation from September 27, 2023 to October 26, 2023 revealed the resident had 10 episodes of bladder incontinence and 7 episodes of bowel incomitance. Review of Resident 43's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated September 22, 2023 revealed the resident was occasionally incontinent of bladder and frequently incontinent of bowel and was not on a toileting program. […]

• No harm, potential for more than minimal, isolatedF684Oct 27, 2023

  Based on review of facility policy and clinical record review, it was determined that the facility failed to notify the physician of a change in condition in a timely manner resulting in a delay in hospitalization for one of 21 residents reviewed (Resident 39). Findings include: Review of facility policy, Seizure Management Policy, last revised July 19, 2023, revealed that if a resident has convulsions that last longer than five minutes or has subsequent seizures, the provider should be notified, or if not immediately available, emergency transfer should be initiated. Review of Resident 39's clinical record revealed a diagnosis of epilepsy (brain disorder that causes recurring, unprovoked seizures). […]

• No harm, potential for more than minimal, isolatedF690Oct 27, 2023

  Based on facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to provide care and service for residents to attain and maintain highest practicable bowel and bladder continence and provide care for a foley catheter for two of four residents reviewed. (Residents 43 and 76) Findings Include: Review of facility policy and procedure titled Continence Management Program, last revised on June 7, 2023, revealed the purpose of the Continence Management Program is to establish and maintain a pattern for control of bladder or bowel function. […]