Health inspection·October 27, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Few 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). Review of Resident 39's progress notes revealed a nurse's note on September 17, 2023, at 6:36 a.m. which stated: Resident had a mild seizure x1 @ 0415 am and stopped at 0430 am. Per staff it was her normal baseline seizure activity. Further review of Resident 39's progress notes revealed a nurse's note on September 17, 2023, at 6:43 p.m., which stated that the resident was noted to have a seizure this afternoon at 4:30. She was laying on her back on her bed, snoring very loudly. She was unresponsive until I sternal rubbed her. Her eyes opened and then looked at me then closed again. After about 20 minutes she was responding to her name and eating her dinner. [Her] only complaint was a headache to which she received tylenol which was effective. Nursing staff will continue to monitor the resident's status. Further review of Resident 39's progress notes revealed a nurse's note on September 17, 2023, at 10:08 p.m. which stated, Resident sent to [hospital] at [9:55 p.m. status post] epilepsy episode. Resident exhibited seizure activity which entailed uncontrollable jerk movement & decreased [level of consciousness] x 3 lasting more than 5 minutes. Review of Resident 39's history and physical from the emergency room revealed that the resident was noted by nursing home staff to have a total of 8 seizures today which prompted [emergency medical services] to be called. Clinical record review failed to reveal evidence that the physician was notified of Resident 39's seizures until the three seizures noted in the 10:08 p.m. progress note. The above findings were conveyed to the Nursing Home Administrator and Director of Nursing on October 27, 2023, at 11:05 a.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395202 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broomall Manor 43 Church Lane Broomall, PA 19008 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. 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. The following residents should be considered for a bladder or bowel incontinence program, those who: are usually continent but have episodes of incontinence, have recently had a Foley catheter removed, requires limited to extensive assistance in toilet use, could benefit from a prompted or scheduled toileting plan. 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. Resident 43 was also coded as needing only supervision for transfers and the limited assistance of one person for toileting. Review of Resident 43's entire clinical record revealed the resident had not been assessed for continence or appropriateness of a training program since admission to the facility on August 30, 2023 at which time Resident 43 as documented as having a Foley catheter (tube inserted into the bladder to allow drainage) and had orders for a foley catheter and care. Interview with the Nursing Home Administrator and the Director of Nursing on August 28, 2023 at 9:30 a.m. confirmed there was no assessment to determine the cause of Resident 43's incontinence or the appropriateness of a training program. Review of Resident 76's physician orders revealed an order dated October 3, 2023 to document Foley output every shift. Review of Resident 76's Medication Administration Record revealed the nursing staff were signed off they were completing this order but there was no amount of output documented. Review of Resident 76's entire clinical record failed to reveal documentation of the Foley output as ordered. Interview with the Nursing Home Administrator and the Director of Nursing on August 28, 2023 at 9:30 a.m. confirmed Resident 76's Foley output was not documented as ordered on October 3, 2023. 28 Pa. Code 211.5 (f) Clinical record 28 Pa. Code 211.10 (d) Resident care policies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395202 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broomall Manor 43 Church Lane Broomall, PA 19008 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395202 If continuation sheet Page 4 of 4