Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bryn Mawr Village during CMS and state inspections, most recent first.
A resident who needed setup assistance with eating was served two bowls of hot broth on a meal tray. An aide removed the lid from one bowl, partially lifted the lid on the hotter bowl, and left the room after telling the resident to wait. The resident then picked up the hot soup, spilled it onto the lap, and sustained a burn to the thigh that later was documented as blistered, red, warm, and painful.
Failure to Review Medication Risks and Benefits at Admission: The facility did not document that two newly admitted residents or their representatives were informed in advance about the risks and benefits of ordered meds and treatments, including side effects and adverse reactions. One resident had diagnoses including acute respiratory failure, parkinsonism, CHF, DM2, depression, hypoxemia, and AKI, with orders for insulin, pramipexole, Eliquis, nifedipine ER, and metoprolol ER. The other resident had cognitive communication deficit, MDD, and anemia, with orders for lansoprazole, acetaminophen, Fleet enema, Dulcolax, and mirtazapine. The Administrator, DON, and Regional Nurse confirmed the required review was not done at admission.
Failure to provide a baseline care plan summary and document a baseline pain plan. The DON and Social Services Director confirmed that residents or representatives did not automatically receive a written baseline care plan summary, and an alert and oriented resident stated she was not offered one on admission. Another resident with HF, PVD, respiratory failure, muscle weakness, and pain management needs had frequent pain and was identified as at risk for pain, but the record lacked evidence of a baseline care plan with individualized pain goals and interventions.
A resident with cancer, DM, muscle wasting, and dysphagia was assessed as at nutrition risk due to poor intake and requested more Ensure. The RD recommended Ensure TID to support weight maintenance, but the record showed no documented evidence the supplement was provided as ordered, and the resident experienced a 19% weight loss and was later noted to be underweight and at risk for malnutrition.
Unclean Resident Rooms and Soiled Care Areas: A resident’s room had an unmade bed, trash bags with soiled linens and used brief/gloves, a toilet with feces on the interior surfaces, and a wound VAC machine left on the floor for days after it was no longer in use. In another room, a resident receiving enteral feeding had dried brown and yellow feeding spills and drips on the wall, dresser, bed rails, floor, and feeding pole.
A resident with a BIMS score of 15 and diagnoses including DM2, dysphagia, muscle weakness, and gait abnormalities reported being verbally abused by staff. The NHA and DON were notified the same day, but the facility did not submit the required report to the State Survey Agency within 24 hours.
Failure to Develop Comprehensive Care Plans for Heel Off-Loading and Oxygen Therapy: The facility failed to develop person-centered care plans for two residents. One resident with a hip fracture developed redness to the heel and later a DTPI, but the care plan did not include the ordered heel off-loading intervention until later. Another resident with stroke-related deficits and multiple comorbidities was receiving O2 therapy, but no comprehensive care plan for O2 was in place before the record revision.
A resident with asthma and COPD was ordered Symbicort inhalation aerosol twice daily, but the inhaler was not available for administration. The resident reported not receiving the puffs since the prior Friday, one nurse documented the med as not available/on order, and another nurse later said the treatment had been charted as given even though she could not locate the inhaler in the med cart and stated it had not actually been administered. The DON confirmed the inhaler was not available.
Failure to Maintain Proper Nail Care: A resident with stroke, dementia, hemiplegia, aphasia, dysphagia, and HTN was totally dependent on staff for ADLs, including hygiene. The resident's representative reported the nails had been long and dirty, and during an observation with the DON, the resident was found to have long fingernails on both hands with dirt under the nails on the left hand.
Failure to use pressure reduction device for an at-risk resident: A resident with HF, hypoxemia, weakness, and impaired mobility was identified as at risk for pressure ulcers and had erythema to the sacral area on admission. Although the care plan called for a pressure reduction device on the bed/chair, the resident was observed sitting in a wheelchair without a cushion or pressure reduction device and complained of buttock discomfort; an LPN confirmed the device was missing.
A resident with a feeding tube and diagnoses including stroke, dementia, hemiplegia, aphasia, and dysphagia was observed receiving enteral feeding with a bag that was not labeled with the resident’s name, date, or time of initiation. Unsanitary enteral feeding caps were also present, and the feeding bottle was empty even though the order indicated the feeding should have been stopped earlier.
A resident with a history of stroke, weakness, dementia, hemiplegia, aphasia, dysphagia, and HTN was observed receiving oxygen at 1.5 L/min, but the tubing was not labeled and the concentrator filter was dirty. The DON later confirmed there was no MD order for oxygen therapy.
Failure to provide effective pain management for a resident with heart failure, PVD, respiratory failure, and muscle weakness. The resident had an order for oxycodone oral solution and oxycodone tablets, but the oral solution was not available because no script had been sent, the PRN tablet was documented as ineffective, and the resident continued to report pain, complained about the pain regimen, and even dialed 911 due to dissatisfaction with pain control.
A resident with HF, hypoxemia, weakness, and mobility impairment had an order for carvedilol BID for HTN, but the MAR showed 7 of 10 doses were omitted and charted as other/see progress notes. Nursing notes repeatedly stated the facility was awaiting pharmacy or delivery, and the record did not show MD notification, alternate orders, or documented efforts to determine why the med was unavailable or how long the delay would last.
A resident with glaucoma had Dorzolamide HCl ophthalmic solution left unsecured in the resident’s bed and on a dresser, rather than stored in the locked med cart. The resident said the nurse left the eye drops at the bedside, while an RN and the DON stated the resident was unable to self-administer meds and the medication should have been secured.
Infection control standards were not followed during wound care for a resident with an unhealed pressure ulcer and a left chest abrasion. An LPN wore gloves and a mask, used sterile gloves to remove scissors from a scrub pocket and cut open calcium alginate, then applied the dressing without changing to a clean pair of gloves; the LPN also confirmed no EBP signage was posted and a gown was not worn during care.
Call Light Not Within Reach for Resident Needing Extensive Assistance. A resident with HF, hypoxemia, muscle weakness, gait and mobility issues, and an ADL self-care deficit was repeatedly observed sitting in a wheelchair next to the bed with the call light on the floor or otherwise out of reach. An LPN and a nurse aide confirmed the call light was not within reach during multiple observations.
Facility Assessment Lacked Required Input: The facility failed to include direct care staff and input from residents, resident representatives, and family members in the annual facility assessment. The policy called for leadership, direct staff, and, when applicable, residents and family members to participate, but the assessment showed only a leadership team review, and the Administrator could not provide documentation that direct care staff or resident input was included.
Two residents reported verbal and physical abuse by nurse's aides, including rough care, yelling, and being left in bed for extended periods. Despite these allegations and facility policy requiring prompt investigation, there was no documented evidence that a thorough investigation was conducted or that findings were recorded by the DON or Social Worker.
A resident with severe protein calorie malnutrition, who was cognitively intact, reported multiple times that a night shift nurse's aide was rough and yelled during care. Despite the resident and a medication nurse submitting written complaints, the facility's grievance log showed no record of these grievances, and staff interviews confirmed that no investigation was conducted as required by facility policy.
The facility did not maintain and inspect its kitchen hood suppression systems, impacting the entire facility. Reports from July 2024 and January 2025 indicated failures in the system, and an interview with the Administrator and Maintenance Director confirmed that corrective actions were not completed.
The facility did not maintain the required testing of its automatic sprinkler system components, affecting the entire facility. A document review revealed that the last full flow trip test for the dry system was conducted in 2019, which was confirmed during an exit interview with the Administrator and Maintenance Director. This testing was out of the required three-year cycle.
The facility was found to be improperly using a 75-foot extension cord to power a sump pump on the front lawn. The cord was wrapped around facade lights and plugged into an external outlet, violating regulations. The Administrator and Maintenance Director confirmed this prohibited use.
The facility failed to maintain proper exit signage, as observed in the East Wing near the nursing station. Multiple illuminated exit signs led to a back courtyard with no egress, and the exterior doors had signs indicating they were not fire exits. This was confirmed in an interview with the Administrator and Maintenance Director.
The facility failed to ensure portable fire extinguishers were accessible, as observed in the multi-purpose room where two wall-mounted extinguishers were blocked by large tables. This was confirmed during an exit interview with the Administrator and Maintenance Director, indicating non-compliance with NFPA 10 standards.
The facility was found to be non-compliant with NFPA 101 standards due to exceeding the maximum allowable story height for its construction type. A two-story, Type III (200) building and a two-story, Type II (000) building, both fully sprinklered, exceeded the permitted story height by one story. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain emergency generator components, as the generator set location lacked battery back-up emergency lighting, and the 3-year, 4-hour load test report was unavailable. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the required fire resistance rating for vertical openings, affecting two levels. The stairway between the Lower Level Kitchen and the First Floor lacked one-hour fire resistive construction. Additionally, the north side exit from the Basement had a staircase with unsheathed walls, lacking the required fire resistance. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director.
The facility was found to lack two acceptable emergency exits in the basement, as the north exit is a communicating stair that does not lead to an exterior exit discharge. This deficiency was confirmed by the Administrator and Maintenance Director.
The facility was found to be non-compliant with NFPA 101 Life Safety Code as the north exit from the second floor requires passage through an intervening dining room, violating the requirement for corridors to provide access to at least two approved exits without passing through other rooms. This was confirmed during a survey and exit conference with the Administrator and Maintenance Director.
Bryn Mawr Village failed to ensure advance directives were in place for two residents, as revealed by clinical record reviews and staff interviews. One resident, admitted with COPD, and another with Acute Respiratory Failure and Multiple Sclerosis, both lacked advance directives on their face sheets and documentation of related discussions. Interviews confirmed the absence of advance directives, and no physician orders were present for either resident.
The facility failed to recognize the placement of beds against the wall as a restraint for three residents, violating their right to be free from unnecessary restraints. Observations and interviews confirmed the bed placements, which were not documented in care plans or assessments as safety measures or preferences, despite the residents' medical conditions and risks.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple diagnoses, including COPD and Depression. Despite having physician orders for medications, the only care plan addressed an ADL self-care performance deficit, initiated eight days post-admission. This was confirmed by the Unit Manager.
A resident experienced significant weight loss, dropping from 180 lbs to 150.4 lbs, without a comprehensive care plan being developed to address this issue. The facility's policy mandates the creation of such plans to meet residents' needs, but no documentation was found for this resident's weight management.
The facility failed to provide necessary grooming services for two residents requiring assistance with activities of daily living. One resident, with severe cognitive impairment, had an inadequately groomed beard, and family intervention was needed for shaving. Another resident, with intact cognition, had an overgrown beard affecting his ability to eat properly. Staff confirmed the lack of grooming assistance and documentation for both residents.
A resident at risk for pressure ulcers due to immobility and bowel incontinence developed multiple pressure injuries while under care. The facility failed to implement a turning and positioning program, as confirmed by the absence of documentation and staff interviews.
The facility failed to obtain and document weekly weights as ordered by physicians for two residents. One resident, admitted with a femur fracture and muscle weakness, had no documented weekly weights or refusal to be weighed. Another resident, with pleural effusion and dysphagia, showed gaps in weight records exceeding seven days, with no documentation of attempts to weigh or refusal. The Unit Manager confirmed these documentation lapses.
A facility failed to adhere to a Registered Dietitian's recommendations for a resident receiving enteral nutrition. The resident, admitted with conditions like dysphagia, required tube feeding. Despite a recommendation for a specific feeding regimen, the facility did not promptly implement it, and there was no documented rationale for the delay in meeting the resident's caloric needs.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen at a higher flow rate than prescribed, while another received oxygen therapy without a physician's order. Both issues were confirmed by the DON and Unit Manager.
A resident with chronic pain syndrome did not receive prescribed Oxycodone for severe pain on two occasions, despite documented pain levels of 10 and 8. The facility's policy on pain management was not followed, as there was no rationale for the non-administration, no physician notification, and no alternative pain management strategies documented.
A resident with documented opioid allergies was prescribed oxycodone and tramadol, despite known allergies. Interviews confirmed the oversight, and the facility lacked a policy addressing allergies, contributing to the medication management failure.
The facility failed to meet the required NA to resident ratios for 21 consecutive days across all shifts. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short. The evening and overnight shifts also experienced significant staffing deficiencies, with shortfalls ranging from 2.18 to 13.09 hours in the evening and 3.2 to 9.53 hours overnight. These consistent staffing inadequacies were confirmed by the facility's administrator.
The facility failed to meet the required LPN staffing levels during day and evening shifts on 9 out of 21 days. The regulation requires one LPN per 25 residents during the day and one per 30 residents in the evening. However, staffing records showed insufficient LPN hours, such as 8 hours for 37 residents when 11.84 were needed. The administrator confirmed the shortfall, indicating a pattern of non-compliance with staffing regulations.
The facility did not meet the required 3.2 hours of direct resident care per resident in a 24-hour period on 12 out of 21 days reviewed. Staffing sheets from February to March 2025 showed several days with insufficient care hours, with the lowest being 2.93 hours. This was confirmed by the facility's administrator.
A resident experienced significant weight loss due to the facility's failure to implement nutritional interventions and notify the physician. Despite recommendations from the dietician to liberalize the diet and add supplements, these were not followed. The facility also did not adhere to the approved vegetarian menu, and meal intake was inadequately monitored.
The facility did not adhere to professional standards for food service safety, as observed during a kitchen tour. The main cook was not wearing a hair net, and food items in the refrigerator were improperly labeled with a single date, indicating the open date, rather than the required use-by date. Interviews with staff confirmed the labeling did not meet professional standards.
The facility did not ensure that five nursing assistants received the required 12 hours of annual training to maintain competence. A review of documentation and interviews revealed that the facility failed to track or complete the necessary in-service training, violating state regulations.
The facility failed to maintain confidentiality and privacy for two residents. A resident's POA received medical records containing another resident's information due to improper review by staff. Additionally, a staff member provided incontinence care with the door open, exposing a resident, which was confirmed by the DON.
A facility failed to follow physician orders for weekly weight monitoring of a resident, resulting in an undocumented significant weight loss of 8% over eleven days. The last recorded weight was 170.5 pounds, and upon reweighing, the resident weighed 157 pounds. This deficiency was confirmed by a Registered Dietitian.
A resident requiring assistance with daily living activities had long and thick toenails, as observed on a specific date. Despite multiple requests from the resident's representative for a podiatrist consultation, no action was taken until the issue was confirmed by the DON. The facility had a podiatry service available, but no appointment was made until after the deficiency was noted.
Hot liquid spill caused resident burn
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for one resident who was served hot liquid during a meal and sustained a burn. Resident R47 was cognitively intact and required setup or clean-up assistance with eating. The resident also had diagnoses of malnutrition, muscle wasting, and muscle weakness. Facility policy stated staff should check that hot foods are hot but not scalding temperature. On October 3, 2025, a nurse aide delivered a dinner tray containing two bowls of chicken broth to Resident R47, who was positioned upright in bed with an overbed table over the resident’s lap. The nurse aide removed the lid from one bowl and pushed it closer to the resident, and partially lifted the lid from the second bowl, telling the resident to wait because it was hotter than the first bowl. The nurse aide then left the room to assist other residents. Shortly after, the resident cried out, and staff found that a bowl of chicken broth had spilled onto the resident’s lap. Facility documentation and interviews indicated the resident reported dropping the cup of soup because it was too hot. A nursing assessment found a raised area on the left inner thigh, and subsequent notes described the area as a superficial burn that was blistered, red, warm to touch, and painful. A wound care consult later described a partial-thickness burn to the left thigh.
Failure to Review Medication Risks and Benefits at Admission
Penalty
Summary
The facility failed to discuss the risks and benefits of newly ordered medications and treatments in advance with two newly admitted residents, Resident R1 and Resident R23, as required under 28 Pa. Code 201.29(a) Resident Rights. For Resident R1, who was admitted with diagnoses including acute respiratory failure with hypoxia, parkinsonism, shortness of breath, heart failure, type 2 diabetes mellitus, depression, hypoxemia, and acute kidney failure, the record showed physician orders for insulin glargine, pramipexole, Eliquis, nifedipine ER, and metoprolol succinate ER. The clinical record contained no documentation that the facility provided education to the resident or representative about the risks, benefits, side effects, or other adverse reactions associated with these medications at the time of admission. For Resident R23, who was admitted with diagnoses of cognitive communication deficit, major depressive disorder, and anemia, the record showed physician orders for lansoprazole, acetaminophen, Fleet enema, Dulcolax suppository, and mirtazapine. The clinical record likewise contained no documentation that the facility provided education to the resident or representative about the risks and benefits of these medications, including side effects and other adverse reactions, at admission. During interview, the Administrator, DON, and Regional Nurse confirmed that the review of risks and benefits for both residents was not conducted in advance with the resident or representative at the time of admission.
Failure to Provide Baseline Care Plan Summary and Document Baseline Pain Plan
Penalty
Summary
The facility failed to provide the resident and/or their representative with a written summary of the baseline care plan for two newly admitted residents. The facility policy titled Care Plans-Baseline stated that a baseline plan of care is to be developed within 48 hours of admission and that the resident and/or representative are to be provided a written summary in a language they can understand. On February 11, 2026, the DON and the Social Services Director both confirmed that copies of the baseline care plan were not automatically provided and were given only if requested. Resident R38, who was alert and oriented, stated that she was not offered a copy of her baseline care plan when she was admitted on January 2, 2026. For Resident R45, the clinical record showed the resident was a new admission with diagnoses including heart failure, peripheral vascular disease, respiratory failure, and muscle weakness. A nursing note identified the resident as a new admission with pain management needs, and a pain evaluation showed the resident received scheduled and PRN pain medication, reported frequent pain over the last five days, and was identified as at risk for pain. The record did not contain documented evidence that a baseline care plan was developed and implemented with individualized goals and interventions for pain management.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to implement interventions consistent with Resident R19’s assessed nutritional needs to maintain acceptable nutritional status. Resident R19 had diagnoses including cancer, diabetes mellitus, muscle wasting, and dysphagia, and the comprehensive MDS documented signs and symptoms of a swallowing disorder, including holding food in the mouth/cheeks and complaints of difficulty or pain with swallowing. A nutrition assessment found the resident at nutrition risk related to poor intake, and the resident requested more Ensure oral nutritional supplement. The Registered Dietitian recommended Ensure three times per day to support weight maintenance, but the clinical record contained no documented evidence that the supplement was provided as recommended. The resident’s weight decreased from 149 pounds to 120.5 pounds, reflecting a 19% weight loss, and a later nutrition note identified the resident as underweight for age and at risk for malnutrition related to poor intakes and low BMI. The record again showed no documented evidence that Ensure three times per day was provided per recommendations.
Unclean Resident Rooms and Soiled Care Areas
Penalty
Summary
The facility failed to maintain a clean and homelike environment in resident care areas on one of two nursing units observed, the CE Unit. In Room CE40, Resident R35 was seated in a wheelchair while the bed had no sheets, blanket, or pillowcase. Two clear trash bags were next to the resident, one containing soiled linens and the other containing a soiled brief and used gloves. The resident’s toilet was observed to have brown feces on the interior surfaces, and a wound VAC machine was on the floor next to the window. The resident’s family member stated the wound VAC machine was no longer in use and had been left on the floor for several days, and that Resident R35 was no longer receiving treatment with the device. The observations in Room CE40 were confirmed by RN E7, who removed the two trash bags from the room and placed them in the designated soiled utility area. Further observation showed the toilet was clogged with feces, and when RN E7 attempted to clear the obstruction, the water level rose and did not drain appropriately. In Room CE45, Resident R6 was observed lying in bed receiving enteral feeding, and the wall behind the bed, bedside dresser, bed rails, floor, and enteral feeding pole had dried brown and yellow feeding spills and drips present. The same-day observation was confirmed by the Regional Nurse, E3.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to notify the State Survey Agency within 24 hours of an allegation of verbal abuse involving one resident. Resident 41’s MDS showed a BIMS score of 15, indicating the resident was cognitively intact and able to accurately report concerns. The resident’s clinical record also listed Type 2 diabetes mellitus without complications, dysphagia, muscle weakness, and other abnormalities of gait and mobility. During an interview on February 9, 2026 at 12:19 PM, Resident 41 reported being verbally abused by staff. The NHA and DON were notified of the allegation later that day at 1:46 PM, but review of the Pennsylvania Electronic State Reporting System showed the facility did not submit the required report until February 11, 2026, which was not within 24 hours of the allegation.
Failure to Develop Comprehensive Care Plans for Heel Off-Loading and Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident R31 related to the physician-ordered intervention to off-load bilateral heels as tolerated. Resident R31 was admitted with a diagnosis of a periprosthetic fracture around the internal prosthetic left hip joint. Nursing progress notes on January 7, 2026, documented redness to the right heel, with no visible open area, no pain, and no itching; an order was entered for skin preparation to the right heel daily and a voicemail was left for the physician. The wound tracking sheet later documented a right heel deep tissue pressure injury measuring 3.5 cm by 3.8 cm on January 14, 2026. The comprehensive care plan dated December 29, 2025, did not reflect the heel off-loading intervention, and documentation showed that this care plan item was not developed until January 20, 2026. The facility also failed to have a comprehensive care plan in place for Resident R6 related to oxygen therapy. Resident R6 was admitted with diagnoses including cerebral infarction, muscle weakness, unspecified dementia, hemiplegia, aphasia, dysphagia, and hypertension. During an observation on February 9, 2026, Resident R6 was receiving oxygen therapy at 1.5 liters per minute. A review of the clinical record with the DON confirmed that Resident R6 did not have a comprehensive care plan related to oxygen therapy in place prior to its last revision on January 19, 2026.
Medication Not Available for Ordered Inhaler
Penalty
Summary
The facility failed to ensure that medication services were provided in accordance with professional standards of quality for one resident observed during the medication administration pass. Resident R31, who had diagnoses of asthma and COPD, was ordered Symbicort Inhalation Aerosol 160-4.5 mcg/act, 2 puffs orally twice daily. The facility policy stated that medications are to be administered in a safe and timely manner as prescribed, including within any required time frame. Resident R31 reported that the inhalation aerosol puffs had not been received since the prior Friday and stated that the facility had notified the resident that the inhaler was not available. A nurse documented that the medication was not available and was on order, and another nurse later documented that the inhaler was not available for the morning medication pass, that the entry was struck out, and that the medication was reordered and awaiting pharmacy delivery. During observation, a nurse stated the inhalation aerosol treatment had been administered and documented as given, but was unable to locate the inhaler in the medication cart and then stated she would strike through the medication administration entry because the treatment had not been administered. The DON also confirmed that Symbicort was not available to Resident R31.
Failure to Maintain Proper Nail Care
Penalty
Summary
The facility failed to provide the necessary assistance with ADLs to maintain proper nail care for Resident R6. The resident was admitted with diagnoses including cerebral infarction, muscle weakness, unspecified dementia, hemiplegia, aphasia, dysphagia, and hypertension. The quarterly MDS dated November 18, 2025, showed the resident was totally dependent on staff for ADLs including hygiene, bed mobility, transfers, toilet use, and showers, and the BIMS was not recorded, indicating the resident was unable to participate due to severe cognitive impairment. During a telephone interview, the resident's representative reported that the resident's nails had been long and dirty in the past and stated that the resident uses the left hand to scratch the neck, so the nails should be kept short. During an observation with the DON, the resident was noted to have long fingernails on both hands, and the fingernails on the left hand were dirty.
Failure to Use Pressure Reduction Device for At-Risk Resident
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after staff failed to implement the planned pressure reduction intervention for a resident at risk for altered skin integrity. Resident R49 was newly admitted with diagnoses including heart failure, hypoxemia, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. The resident’s MDS identified the resident as at risk for pressure ulcers/injuries, and the admission skin evaluation documented erythema to the sacral area. The care plan dated February 1, 2026 identified the resident as at risk for alterations in skin integrity and included an intervention to use a pressure reduction device on the bed/chair. However, during an observation on February 9, 2026, the resident was seated in a wheelchair next to the bed, complained of discomfort in the buttock area, and requested repositioning. At that time, no cushion or pressure reduction device was on the wheelchair seat. An LPN confirmed the wheelchair did not have a cushion or pressure reduction device and then retrieved and applied the wheelchair seat cushion.
Unlabeled Enteral Feeding and Unsanitary Supplies
Penalty
Summary
Enteral feedings for Resident R6 were not labeled in accordance with professional standards of practice. Resident R6 was admitted with diagnoses including cerebral infarction, muscle weakness, unspecified dementia, hemiplegia, aphasia, dysphagia, and hypertension. A physician order dated September 16, 2025 directed Glucerna 1.2 to run at 85 mL/hour for 18 hours, from 4:00 p.m. until 10:00 a.m. During an observation on February 9, 2026 at 11:06 p.m. with an LN, the resident was observed in bed receiving enteral feeding, but the feeding bag was not labeled with the resident's name, date, or time of initiation. The bedside table also contained multiple enteral feeding caps that were observed to be unsanitary, and the enteral feeding bottle was empty even though the order indicated the feeding should have been discontinued at 10:00 a.m.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen as ordered for one resident. The resident was admitted with diagnoses including cerebral infarction, muscle weakness, unspecified dementia, hemiplegia, aphasia, dysphagia, and hypertension. During an observation with an RN, the resident was receiving oxygen therapy at 1.5 liters per minute, but the oxygen tubing was not labeled and the filter behind the concentrator was dirty with a layer of dust. A later review of the clinical file with the DON confirmed that the resident did not have a physician order for oxygen therapy.
Failure to Provide Effective Pain Management
Penalty
Summary
Safe, appropriate pain management was not provided for Resident R45, who was admitted with diagnoses including heart failure, peripheral vascular disease, respiratory failure, and muscle weakness. The resident’s hospital after-visit summary recommended oxycodone oral solution as needed, and the physician ordered oxycodone oral solution 10 ml every 12 hours as needed for pain along with oxycodone 5 mg tablets every 6 hours as needed for severe pain. The resident refused Tylenol and was waiting for narcotics, and a pain evaluation identified the resident as at risk for pain and noted frequent pain over the prior five days. The resident continued to report significant pain after receiving PRN oxycodone tablets, which were documented as ineffective. Nursing documentation stated the oxycodone oral solution was unavailable because no script had been sent, requiring the on-call physician to phone the prescription to the pharmacy. The resident later complained of abdominal pain and discomfort and stated dissatisfaction with the pain regimen, and then dialed 911 because of unsatisfied pain. The resident returned from the hospital and requested to leave against medical advice, and the medication administration record showed the resident never received the oxycodone oral solution recommended by the hospital.
Missed carvedilol doses due to unavailable medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident reviewed. Facility policy stated that when medications are unavailable, the licensed nurse should urgently initiate action with the attending physician and pharmacy provider, determine the status of the order, and if needed obtain the medication from emergency stock, request an emergency delivery, or contact the physician for alternate orders or holding instructions. For Resident R49, who was newly admitted and had diagnoses including heart failure, hypoxemia, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility, there was a physician order for carvedilol by mouth twice daily for hypertension. The medication administration record showed that from February 2 through February 6, 2026, carvedilol was omitted 7 of 10 scheduled doses and documented as other/see progress notes. Nursing notes on each of those days stated the facility was awaiting pharmacy or awaiting delivery of the carvedilol. The clinical record did not show that the physician was notified of the missed doses, that alternate treatment was requested, or that specific monitoring orders were obtained while the medication was unavailable. The record also did not show documentation that the licensed nurse determined why the medication was unavailable, how long it would be unavailable, or what efforts were made to obtain it.
Unsecured Eye Drop Medication Found at Resident Bedside
Penalty
Summary
The facility failed to properly secure Dorzolamide HCl ophthalmic solution for one resident with glaucoma. The resident’s record showed an admission date of January 2, 2026, and a physician’s order for Dorzolamide HCl ophthalmic solution 2%, one drop in both eyes twice daily for glaucoma. On February 9, 2026, observation found the medication in the resident’s bed, and the resident stated that the nurse had left the medication at the bedside during the night shift. Later that day, two bottles of Dorzolamide HCl ophthalmic solution were observed, one in the resident’s bed and one on the dresser across from the bed. The resident reported that nursing staff sometimes gave the eye drops and the resident would administer them. However, the RN and the DON both stated that the resident was unable to self-administer medications and that the medication should have been stored in the locked medication cart.
Infection Control Lapses During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors found that infection control standards were not followed during wound care for Resident R5. Review of facility policy showed staff were to use a disposable cloth to create a clean field on the overbed table and to wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Review of CMS guidance on enhanced barrier precautions also showed gown and glove use was recommended for residents with chronic wounds during high-contact care activities regardless of multidrug-resistant organism status. Resident R5’s record showed the resident had at least one unhealed pressure ulcer and a wound care consult for an abrasion to the left chest with orders to cleanse with normal saline, apply calcium alginate, and cover with a clean dry dressing daily and as needed. During wound care observation, the LPN wore gloves and a mask, used sterile gloves to remove scissors from a scrub pocket, used the scissors to cut open the calcium alginate, and then applied the clean bandage to the open wound. The LPN confirmed a new clean pair of gloves should have been applied after using the scissors and before applying the clean bandage. The LPN also confirmed there was no signage on the resident’s room door indicating enhanced barrier precautions and that a gown was not worn during wound care.
Call Light Not Within Reach for Resident Needing Extensive Assistance
Penalty
Summary
The facility failed to ensure that Resident R49’s call light was within easy reach while the resident was in bed or confined to a chair, as required by facility policy. The policy titled "Answering the Call Light," revised October 2010, stated that when a resident is in bed or confined to a chair, the call light should be within easy reach of the resident. Resident R49’s comprehensive MDS dated February 6, 2026, showed the resident was newly admitted and had diagnoses including heart failure, hypoxemia, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. Resident R49’s care plan dated February 2, 2026, identified an ADL self-care deficit related to physical limitations and directed extensive staff assistance with toileting, transfers, bed mobility, and dressing. During observations on February 9, February 11, February 12, and February 13, 2026, Resident R49 was seen sitting in a wheelchair positioned next to the bed, and the call light was observed on the floor or otherwise out of reach. On each occasion, staff members including an LPN and a nurse aide confirmed that the call light was not within reach.
Facility Assessment Lacked Required Input
Penalty
Summary
The facility failed to ensure that direct care staff and input from residents, resident representatives, and family members were included when conducting the facility assessment. The facility policy titled Facility Assessment, last revised in June 2024, states that the annual assessment is used to determine and update the facility’s capacity to meet resident needs during day-to-day operations, including nights, weekends, and emergencies. The policy also identifies the team responsible for conducting, reviewing, and updating the assessment, including leadership and management, direct care staff, and, when applicable, residents, resident representatives, and family members. Review of the facility’s assessment showed a last revision date of December 8, 2025, but there was no indication that direct care staff or input from residents were involved. During an interview on February 13, 2026, at 1:00 p.m., the Administrator stated that the leadership team conducted the facility assessment. When asked whether direct care staff, residents, or resident representatives provided input during the meetings in which the assessment was revised, the Administrator did not provide documentation or other evidence showing that such individuals participated in the process.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of verbal and physical abuse for two residents, despite both residents being cognitively intact and able to report their concerns. One resident reported that a night shift nurse's aide was rough during care and yelled at him, and stated that he had submitted written complaints twice, including one written by a medication nurse on his behalf. However, the Director of Nursing and the Social Worker both confirmed that they were unaware of any grievances from this resident, and no investigation was conducted into his allegations. Another resident reported that nurse's aides were rough during care, yelled at her, and ignored her call bells, with one incident involving being left in bed for hours in feces. The resident's husband also reported concerns about his wife being manhandled. Although a Resident Concern Report was completed, there was no documented evidence of a thorough investigation, such as staff statements, findings, conclusions, or disciplinary actions. The Social Worker acknowledged interviewing the nurse's aide involved but did not document the interview or include it in the investigation file. Facility policy requires prompt reporting and thorough investigation of all abuse allegations, including interviews with all relevant parties and documentation of findings. In both cases, the facility did not follow its own policies or regulatory requirements, as there was no evidence of a complete investigation or appropriate documentation regarding the residents' allegations of abuse.
Failure to Address Resident Grievances in a Timely Manner
Penalty
Summary
The facility failed to address a resident's grievances in a timely manner, as required by its own grievance policy. The policy states that residents and their representatives have the right to file grievances orally or in writing, and that the Grievance Officer must review and investigate any allegations, submitting a written report to the Administrator within five working days. In this case, a resident with severe protein calorie malnutrition, who was cognitively intact according to the most recent MDS assessment, reported that a night shift nurse's aide was rough during care and yelled at him. The resident stated that he had submitted written complaints twice, and that a medication nurse had also written a complaint on his behalf the previous week. Despite these actions, the facility's grievance log contained no record of grievances from this resident. Interviews with staff revealed that the DON was unaware of any investigation into the resident's complaints, and the social worker, who regularly checks the grievance box, reported not finding any grievance forms related to the resident. The social worker also confirmed that no investigation had been conducted because no grievance was received. The DON further confirmed that no investigation was initiated regarding the resident's complaints about the night shift nurse's aide.
Failure to Maintain Kitchen Hood Suppression Systems
Penalty
Summary
The facility failed to maintain and inspect its kitchen hood suppression systems, which affected the entire facility. During a document review on March 17, 2025, it was found that the kitchen hood suppression system report from July 3, 2024, indicated a failure with the 'Cylinder'. Additionally, a subsequent report dated January 6, 2025, showed a failure of the 'Kitchen System'. An exit interview with the Administrator and Maintenance Director confirmed that corrective actions had not been completed.
Plan Of Correction
The kitchen hood suppression system repair is scheduled for 4/11/2025. Maintenance Director will report completion and compliance to QAPI committee.
Failure to Maintain Sprinkler System Testing
Penalty
Summary
The facility failed to maintain the required testing of automatic sprinkler system components, which affected the entire facility. During a document review on March 17, 2025, it was revealed that the quarterly sprinkler inspection reports for both wet and dry systems, dated January 20, 2025, indicated that the last full flow trip test for the dry system was conducted in 2019. This finding was confirmed during an exit interview with the Administrator and Maintenance Director on the same day, highlighting that the testing was out of the mandated three-year testing cycle.
Plan Of Correction
Full flow trip test is scheduled for 4/28/2025. A task will be entered in TELS work order system to ensure tests are completed timely. Maintenance director will report on the results and compliance to QAPI committee.
Improper Use of Extension Cord for Sump Pump
Penalty
Summary
The facility failed to comply with regulations regarding the use of extension cords, as evidenced by an observation made on March 17, 2025. A 75-foot extension cord was found wrapped around two facade fixed sconce lights above an egress exit door, outside the main entrance. This extension cord was plugged into an external electrical outlet fixed to the building and was being used to power a sump pump on the front lawn. During an interview at the exit conference, both the Administrator and Maintenance Director confirmed the prohibited use of the extension cord, which affected one of the two levels of the facility.
Plan Of Correction
The installation of an exterior outlet for the sump pump is scheduled for 4/21/2025. Maintenance director will report on completion of job to QAPI committee.
Conflicting Exit Signage in East Wing
Penalty
Summary
The facility failed to ensure proper exit signage, which is a requirement for maintaining unobstructed egress. During an observation on March 17, 2025, at 11:50 a.m., it was noted that in the East Wing near the nursing station, there were multiple illuminated exit signs in the corridor leading to a back courtyard that did not provide an egress route. Additionally, the exterior doors leading to the back courtyard had signage indicating that it was not a fire exit and should not be used in case of fire. This conflicting signage was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
All exit signs were audited and corrected by 4/7/2025. Maintenance director will report on compliance to QAPI committee.
Fire Extinguishers Obstructed by Tables
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were accessible on one of its two levels. During an observation on March 17, 2025, at 12:15 p.m., it was noted that in the multi-purpose room, which was formerly used for Physical Therapy, two wall-mounted fire extinguishers were obstructed by large tables on each side of the room. This obstruction was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 2:00 p.m., indicating a failure to comply with the requirements for fire extinguisher accessibility as per NFPA 10 standards.
Plan Of Correction
Obstructions were corrected immediately on 3/17/2025, and staff was educated on compliance. Maintenance director will report to QAPI committee on compliance of this regulation.
Building Construction Type Exceeds Allowable Story Height
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as per NFPA 101 standards. During a document review and interview conducted on March 17, 2025, it was discovered that the facility was classified as a two-story, Type III (200), unprotected ordinary construction, which was fully sprinklered. However, this classification exceeded the maximum allowable story height by one story, as the construction type only permits a maximum of two stories when sprinklered. This discrepancy was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, another component of the facility was identified as a two-story, Type II (000), unprotected noncombustible construction with a basement, which was also fully sprinklered. This component similarly exceeded the maximum allowable story height by one story, as the construction type does not allow for any stories when non-sprinklered and only permits one story when sprinklered. This finding was also confirmed during the exit interview with the facility's Administrator and Maintenance Director.
Plan Of Correction
Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered. The story height exceeds the maximum allowance for this construction type one story. The facility has previously submitted a waiver for this deficiency. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee. Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered. The story height exceeds the maximum allowance for this construction type one story. The facility has submitted a TLW waiver for this deficiency. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain required emergency generator components, which affected the entire facility. During an observation on March 17, 2025, it was noted that the emergency generator set location inside the transformer room in the basement lacked battery back-up emergency lighting. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. Additionally, a documentation review revealed that the facility did not have the required 3-year, 4-hour load test report available for the generator that supports the emergency electrical system. This lack of documentation was also confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Emergency lighting installation is scheduled for 4/21/2025. A 4-hour load test was completed on 3/31/2025. A task will be entered in TELS work order system to ensure tests are completed timely. The maintenance director will report on results to the QAPI meeting.
Failure to Maintain Fire Resistance Rating for Vertical Openings
Penalty
Summary
The facility failed to maintain the required fire resistance rating for vertical openings, specifically affecting two levels within the building. During a document review and interview conducted on March 17, 2025, it was discovered that the communicating stairway between the Lower Level Kitchen and the First Floor did not have the necessary one-hour fire resistive construction. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, the facility did not maintain the fire resistance rating for stair towers, impacting one of two floors within the building. A document review revealed that the north side exit from the Basement was a communicating staircase with walls not sheathed on the room 2A side, lacking the required one-hour fire resistance rating. This issue was also confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee. The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Facility Lacks Two Acceptable Exits in Basement
Penalty
Summary
The facility failed to provide two acceptable exits, located remotely from one another, affecting one of two floors of the building. During a document review on March 17, 2025, it was revealed that the basement level of the facility lacked two acceptable emergency exits that are located remotely from each other. Specifically, the north exit from the basement is a communicating stair and does not lead to an exterior exit discharge. This deficiency was confirmed during an interview at the exit conference with the Administrator and Maintenance Director on the same day, where it was acknowledged that the basement level lacked two acceptable exits.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Exiting Deficiency Through Intervening Dining Room
Penalty
Summary
The facility failed to ensure compliance with the NFPA 101 Life Safety Code regarding the number of exits in corridors. Specifically, the deficiency was identified in the north exit from the second floor, which requires passage through an intervening dining room, contrary to the requirement that corridors provide access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies. This issue was observed and documented during a survey on March 17, 2025, at 11:30 a.m. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director later that day.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
Bryn Mawr Village was found to be non-compliant with the requirements of 42 CFR part 483, Subpart B, and the 28 PA Code related to the health portion of the survey process. The facility failed to ensure that advance directives were in place for two residents, Resident R149 and Resident R26, as evidenced by clinical record reviews and staff interviews. Resident R149, admitted with a diagnosis of Chronic Obstructive Pulmonary Disease, had no advance directives indicated on the face sheet, nor was there documented evidence of discussions regarding advance directives. Similarly, Resident R26, admitted with Acute Respiratory Failure with Hypoxia and Multiple Sclerosis, also lacked advance directives on the face sheet and documentation of related discussions. Interviews with Unit Manager Employee E3 confirmed the absence of advance directives for both residents. Additionally, there were no physician orders for advance directives for either resident. The facility's policy on advance directives, last revised in 2016, mandates that residents be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive upon admission. The policy also requires that information about advance directives be prominently displayed in the medical record and that the plan of care aligns with the resident's documented treatment preferences.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R26 and R149 are discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of the clinical records of current residents will be conducted to ensure that a code status is included, a physician order for code status is included, and the resident's family member is given an advance directive or clarification of the hospital code status to implement the residents wishes after admission to the facility. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Social Services regarding the components of this regulation and how to properly document this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ or designee of five clinical records to ensure that they include a code status, a physician order for code status and that the family was involved in the wishes. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Identify Bed Placement as Restraint
Penalty
Summary
The facility failed to identify the placement of beds against the wall as a restraint for three residents, which is a violation of their right to be free from physical restraints not required to treat medical symptoms. The facility's policy defines physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. Observations revealed that the beds of Residents R247, R248, and R249 were placed against the wall, which was not documented in their care plans or assessments as a safety measure or preference. Resident R247, diagnosed with Alzheimer's disease and at high risk for falls, had no care plan addressing the bed placement. Resident R248, with intact cognition and a history of respiratory failure and falls, also lacked documentation for the bed's position. Resident R249, with hypertensive urgency and intact cognition, confirmed that the bed's placement was not their preference. Interviews with staff, including an LPN and the Director of Nursing, confirmed the bed placements, indicating a failure to adhere to the facility's restraint policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R247, R248, R249 were interviewed by DON and NHA to obtain preferences for the placement of the beds and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents with beds near the wall were interviewed by DON and NHA regarding their preferences and beds were adjusted and care plan updated to reflect their request. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that bed placement preferences are in place and the care plan is being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Develop Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident, identified as R149, within the required 48-hour timeframe following admission. The resident was admitted with multiple diagnoses, including COPD, Centrilobular Emphysema, Generalized Anxiety Disorder, Alcohol Dependence, Depression, Acute Pancreatitis, and Anemia. Despite having physician orders for medications such as Lidocaine Patch, Eliquis, and Gabapentin, the facility did not create a baseline care plan that included these orders or any other necessary healthcare information to properly care for the resident. The only care plan in place for the resident addressed an ADL self-care performance deficit, which was initiated eight days after admission. This delay in developing a comprehensive person-centered care plan was confirmed by the Unit Manager, Employee E3, during an interview. The lack of a timely baseline care plan and comprehensive care plan for Resident R149 represents a failure to meet the regulatory requirements for comprehensive person-centered care planning.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R149 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a baseline care plan was developed and implemented and that a written summary of the baseline care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a baseline care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Develop Comprehensive Care Plan for Weight Changes
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R33, who experienced significant weight changes. The facility's policy requires that a comprehensive person-centered care plan be developed and implemented for each resident, including measurable objectives and timeframes to meet their physical, psychological, and functional needs. However, upon review of Resident R33's clinical record, it was found that there was no documented evidence of a care plan addressing the resident's weight loss. Resident R33 was admitted to the facility with diagnoses including pleural effusion, dysphagia, and cognitive communication deficit. The resident's weight records showed a significant decrease from 180 lbs at admission to 150.4 lbs over a period of approximately two months, indicating a weight loss of 16.4%. Despite this notable weight change, the facility did not develop a care plan to address the resident's nutritional needs, which is a requirement under the facility's policy and federal regulations.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R33 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a comprehensive care plan was developed and implemented and that a written summary of the comprehensive care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a comprehensive care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Provide Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents who required assistance with activities of daily living. Resident R243, admitted with conditions including chondrocalcinosis, lack of coordination, and severe cognitive impairment, was observed with an inadequately groomed beard. Interviews with the resident and a family member revealed that the facility had not provided grooming assistance since the resident's admission, necessitating family intervention for shaving. A licensed nurse confirmed the absence of documentation or evidence of grooming assistance for this resident. Similarly, Resident R244, who had diagnoses including cirrhosis of the liver, muscle weakness, and intact cognition, was observed with an overgrown beard and hair over the upper lip. The resident reported inadequate grooming since admission, which affected his ability to eat properly. The Director of Nursing confirmed the resident's need for grooming assistance and the overgrown state of his beard. These findings indicate a failure by the facility to maintain adequate grooming for residents requiring assistance.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R243 and R244 facial hair were trimmed by licensed staff. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents was conducted by the DON/Designee to ensure that facial hair is groomed based on residents' wishes. Any additional concerns identified during the audit will be corrected immediately. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: DON/Designee will re-educate facility clinical staff on the components of this regulation with an emphasis on ensuring that residents receive appropriate grooming of hair/facial hair and footcare/nail care. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: DON/Designee to conduct random visual audits of 10 residents 1x a week for 4 weeks, 2x a month for 3 months, then monthly for 2 months to ensure that residents are being groomed appropriately and that facial hair is trimmed. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly for 6 months.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for a resident, as required by professional standards of practice. The resident, admitted with a fracture and muscle weakness, was dependent on staff for mobility and at risk for developing pressure ulcers. Despite this, the facility did not implement a turning and positioning program to prevent pressure ulcers, as confirmed by the absence of documented evidence in the resident's clinical record. The resident, who was at risk for skin breakdown due to immobility and bowel incontinence, developed deep tissue pressure injuries on the sacrum, left heel, and right heel, as well as a Stage 1 pressure injury on the right great toe while under the facility's care. The lack of a documented turning and positioning program was confirmed by the Unit Manager, indicating a failure to adhere to the necessary preventive measures for pressure ulcer development.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Treatment was provided to Residents R1 to address the pressure ulcer and prevent new ulcer from developing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for all Residents at risk for pressure ulcers to ensure proper treatment is being provided. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that treatment to prevent pressure ulcers is being provided and physician orders are followed. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Obtain and Document Weekly Weights
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered by the physician for two residents. Resident R1 was admitted with diagnoses including a fracture of the lower end of the left femur and muscle weakness. A physician's order dated February 12, 2025, required weekly weights for four weeks, then monthly. However, there was no documented evidence that Resident R1 was weighed weekly as ordered, nor was there any indication of refusal to be weighed. An interview with the Unit Manager confirmed the absence of documentation regarding attempts to obtain weights or any refusal by the resident. Similarly, Resident R33, admitted with conditions such as pleural effusion and dysphagia, had a physician's order for weekly weights. After being discharged to the hospital and readmitted, there was no documented evidence of a weight being taken at readmission. The resident's weight records showed gaps greater than seven days between weighings, contrary to the physician's orders. The Unit Manager confirmed the lack of documentation for attempts to weigh the resident or any refusal. These deficiencies indicate a failure to adhere to physician orders and maintain proper documentation.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Resident immediately weighed per physicians' orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current will be conducted to ensure physician orders for obtaining weights are followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that physician orders for weights are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Follow Nutritional Recommendations for Enteral Feeding
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident receiving enteral nutrition, as evidenced by a lack of adherence to the recommendations provided by the Registered Dietitian. Resident R33, who was admitted with conditions including pleural effusion, muscle weakness, dysphagia, and cognitive communication deficit, required tube feeding due to difficulty swallowing. The care plan indicated that the Registered Dietitian was to evaluate the resident's nutritional needs quarterly and as needed, making recommendations for changes to the tube feeding regimen. Despite the Registered Dietitian's recommendation on January 2, 2025, for the tube feed to run at 65 ml/hour over 22 hours for a total volume of 1430 ml daily, the facility did not follow this guidance promptly. The clinical record showed a series of physician orders adjusting the tube feed rate, but there was no documented rationale from the physician for the delay in meeting the resident's caloric needs as recommended. This oversight resulted in the facility's failure to ensure the resident received the appropriate treatment and services to maintain nutritional parameters.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 tube feeding orders were reviewed with physician to updated to reflect current needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all tube feeding orders are current and are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that tube feeding orders updated and are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care services for two residents, R146 and R149, as observed during a survey. Resident R146, who was admitted with diagnoses including Acute Respiratory Failure and COPD, had a physician's order for oxygen at 2 liters per minute via nasal cannula. However, during an observation, it was found that the oxygen flow meter was set at 5 liters per minute, contrary to the physician's order. This discrepancy was confirmed by the Director of Nursing, Employee E3, during a follow-up observation. Resident R149, admitted with diagnoses including COPD and Generalized Anxiety Disorder, was observed receiving oxygen therapy without a physician's order. The oxygen concentrator's flow meter was also set at 5 liters per minute, and the oxygen tubing and humidification bottle lacked proper labeling. The resident reported informing the staff about the issue, but no action was taken. The Director of Nursing and Unit Manager confirmed the absence of a physician's order for oxygen therapy for Resident R149.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R146 and R149 were provided with respiratory care and supplemental oxygen as ordered by the physician. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents on oxygen will be audited to ensure they are MD orders are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident R148, consistent with professional standards of practice. The resident, who was admitted with diagnoses including spinal stenosis, low back pain, and chronic pain syndrome, had documented severe pain levels of 10 and 8 on March 3 and March 4, 2025, respectively. Despite having physician orders for Oxycodone and Tramadol for severe and moderate pain, the resident did not receive the prescribed Oxycodone on these dates. Additionally, there was no documented rationale for not administering the medication, nor was there evidence that the physician was informed of the non-administration or that non-pharmacological pain management techniques were implemented. The facility's policy on pain management emphasizes the importance of assessing and addressing pain based on professional standards and the resident's care plan. However, the review of Resident R148's clinical records revealed a lack of adherence to these guidelines. The resident's allergies to several opioids, including Oxycodone, were noted, yet there was no documentation explaining the decision not to administer the prescribed medication or any alternative strategies employed. This oversight in pain management was further highlighted by the absence of documentation regarding the effectiveness of interventions or modifications to the care plan, as required by the facility's policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148's pain medication were delivered and she has been receiving it as per Physician orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted of residents that have an order for pain medications to ensure that they are being given per physician order. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for two months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Manage Resident's Opioid Allergies
Penalty
Summary
The facility failed to ensure the safe and effective use of medications for a resident, identified as R148, who had documented allergies to several opioids. The resident was admitted with multiple diagnoses, including spinal stenosis and chronic pain syndrome, and had a known allergy to opioids such as fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, and codeine. Despite these documented allergies, a physician's order included oxycodone, which the resident was allergic to, and tramadol, which the resident suspected might cause a milder allergic reaction. Interviews with the resident and facility staff confirmed the presence of documented opioid allergies in the resident's clinical records. The physician, identified as Employee E5, acknowledged the oversight and stated that oxycodone had been discontinued, leaving the resident on tramadol. Additionally, the facility administrator, identified as Employee E1, admitted that the facility lacked a policy addressing allergies, which contributed to the oversight in medication management for the resident.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 medications were reviewed with physician to identify any allergies and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all medication allergies are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that medication allergy orders are followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Consistent Staffing Deficiencies Across All Shifts
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios across all shifts for 21 consecutive days. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short of the necessary staffing levels based on the resident census. For instance, on February 20, 2025, with a census of 45 residents, only 24 NA hours were scheduled when 36 hours were required. Similar shortfalls were observed on other days, indicating a pattern of understaffing during the day shift. The evening and overnight shifts also experienced significant staffing deficiencies. The evening shift required one NA per 11 residents, yet the facility consistently scheduled fewer hours than needed, with shortfalls ranging from 2.18 to 13.09 hours. On February 23, 2025, for example, 32 NA hours were scheduled for a census of 62 residents, while 45.09 hours were required. The overnight shift, which required one NA per 15 residents, also fell short, with discrepancies ranging from 3.2 to 9.53 hours. These consistent staffing inadequacies were confirmed by the facility's administrator, indicating a systemic issue in meeting the mandated staffing ratios.
Plan Of Correction
Nursing schedules were reviewed to ensure the proper Nurse's Aide ratio on the morning, evening, and overnight shifts. NHA/designee will reeducate the scheduler and Director of Nursing on the correct Nurse's Aide ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure Nurse Aids are being staffed at the proper ratio. Results will be shared at QA.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during both day and evening shifts over a period of 9 out of 21 days reviewed. Specifically, the regulation mandates a minimum of one LPN per 25 residents during the day shift and one LPN per 30 residents during the evening shift. However, the facility's staffing records revealed that on several occasions, the number of LPN hours provided was insufficient to meet these requirements. For instance, on February 14, 2025, the day shift had only 8 LPN hours for a census of 37 residents, whereas 11.84 hours were required. Similarly, on February 23, 2025, the evening shift had 8.50 LPN hours for a census of 62 residents, requiring 16.53 hours. The deficiency was confirmed through a review of nursing staff care hours and an interview with the facility's administrator, who acknowledged the shortfall in meeting the LPN-to-resident ratios. This issue was consistent across multiple days, indicating a pattern of inadequate staffing levels that did not comply with the regulatory requirements. The administrator's confirmation further substantiates the facility's failure to adhere to the mandated staffing ratios, impacting the quality of care provided to the residents.
Plan Of Correction
Nursing schedules were reviewed to ensure the proper LPN ratios on the day and evening shifts. NHA/designee will reeducate the scheduler Director of Nursing on the correct LPN ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure LPN's are being staffed at the proper ratio. Results will be shared at QA.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of the facility's nursing staffing sheets for the weeks spanning February 13, 2025, to March 5, 2025. On 12 out of 21 days reviewed, the facility's staffing hours fell below the required threshold. Specific days with insufficient staffing hours included February 13, 14, 15, 18, 19, 20, 21, 23, 25, 27, 28, and March 2, 2025, with the lowest recorded at 2.93 hours on February 20, 2025. The deficiency was confirmed by the facility's administrator, Employee E1, on March 6, 2025.
Plan Of Correction
Nursing schedules were reviewed to ensure the total hours of general nursing care for each 24-hour period meets the requirement. NHA/designee will reeducate the scheduler and the Director of Nursing on the total hours of general nursing care for each 24-hour period. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure total hours of general nursing care for each 24-hour period are met. Results will be shared at QA.
Failure to Implement Nutritional Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional interventions and timely assessments for Resident R20, who experienced significant unplanned weight loss over several months. The resident, who was on a vegetarian and cardiac diet, lost 33.03% of their body weight from November 2023 to April 2024. Despite the resident's severe weight loss, the facility did not implement necessary dietary recommendations or notify the physician of the resident's condition. The Registered Dietician made multiple recommendations to address the resident's weight loss, including liberalizing the diet, adding nutritional supplements, and conducting weekly weight monitoring. However, these recommendations were not implemented, and the physician was not notified of the resident's significant weight loss. Additionally, the facility failed to follow the approved vegetarian menu, and meal intake was not properly monitored or documented. Interviews with facility staff revealed a lack of communication and follow-through on dietary recommendations. The Food Service Director was unaware of the approved vegetarian menu, and the Registered Dietician, who worked only two days a week, could not track the resident's weight loss effectively. The physician confirmed they were not informed of the resident's weight loss, and there was no evidence of a physician assessment in response to the resident's condition.
Removal Plan
- The facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that the residents in the facility with concerns regarding weight loss were addressed by the physician/dietician and that recommendations were implemented if applicable; resident food preferences were being honored, to ensure that meal consumption amounts are being properly monitored and documented and to ensure that current policies were reviewed with changes made as indicated.
- Resident 20 was reweighed, and the dietician and physician were notified to implement interventions as needed.
- The resident was reassessed by the physician.
- The resident was re-interviewed by the dietary manager to update preferences related to preferred vegetarian diet.
- Current facility residents were re-weighed. The physician and dietician were notified of any significant changes with interventions implemented if applicable.
- Currently facility residents were interviewed by the Certified Dietary Manager to ensure their diet preferences were up-to-date and to ensure their preferences were being honored. An additional audit of the meal tracker system was completed by the Certified Dietary Manager to ensure that orders accurately reflected residents' current preference.
- Dietary recommendations for the last 30 days were reviewed to ensure that any recommendations made were implemented.
- Facility Licensed Nurses received education from the Director of Nursing regarding the procedures for obtaining resident weights and notifying the physician and dietician of any significant changes, along with implementing dietary recommendations in a timely manner.
- Facility clinical staff received education from Director of Nursing on ensuring that resident meal intake is appropriately monitored and documented.
- Facility Dietary Staff will receive education from the CDM on ensuring that residents are receiving the appropriate diet based on their preferences.
- An Ad Hoc QAPI Meeting was held to discuss the events surrounding the resident's weight loss, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding obtaining weights, communication with the IDT team when significant changes occur, implementing physician/dietician recommendations in a timely manner and ensuring that resident meal preferences are honored.
- Any staff member that did not receive education related to the above mentioned was notified by the staffing coordinator verbally via phone indicating they may not return to work until the education is received.
- Newly hired staff will receive education in orientation.
- Education for respective facility staff as stated above, weekly weight meetings with the members of the interdisciplinary team to ensure that weights are being obtained and any significant changes are addressed immediately with the appropriate team members to include the physician, verbally while in the facility and via phone call when not present; the dietician will be present in the weekly weight meetings and will provide a paper copy of recommendations made; an additional copy of recommendations will be provided to the facility in the form of an electronic copy via email to the NHA, DON, and CDM; care plans are active and reflect appropriate interventions related to the residents' current nutrition and weight status.
- Audits will be conducted as follows: bi-monthly resident interviews by the CDM to ensure that resident food and diet preferences remain up to date; random audits of 5 residents weekly to ensure that food intake is being appropriately monitored and documented.
- The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of these quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety. During an initial tour of the main kitchen, it was observed that the main cook was not wearing a hair net while cooking. In the main refrigerator, all items were dated with a single date, March 28, 2024, which included defrosted pork loins, cheddar cheese, mozzarella cheese, and yogurt. The kitchen supervisor confirmed that this date indicated the open date. Additionally, pulled ham was dated May 25, 2024, and cheese was dated April 1, 2024, with the assistant supervisor indicating these dates as the use-by dates. Interviews with the kitchen supervisor and the Administrator confirmed that the food items were not labeled according to professional standards and facility procedures.
Failure to Provide Required Annual Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that five nursing assistants received the required minimum of 12 hours of annual training to maintain their competence. This deficiency was identified during a review of facility documentation, personnel files, and staff interviews. On May 8, 2024, a request was made to the Nursing Home Administrator and Director of Nursing for the annual training records of five nursing assistants, identified as Employees E15, E16, E17, E18, and E19. The facility was unable to provide these records. An interview with the facility Administrator on the same day confirmed that the facility did not track or complete the annual in-service training as mandated by the training requirements for nursing assistants. This lack of compliance with the training requirements was in violation of 28 Pa. Code 201.18(b)(1)(3) Management and 28 Pa. 211.12(c) Nursing services.
Confidentiality Breach and Privacy Violation
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records and provide privacy during incontinence care for two residents. An interview with the Power of Attorney (POA) for a resident revealed that she had requested her mother's medical records and received them with another resident's medical information included. This breach was confirmed by the Medical Records Staff, who admitted that the records were not reviewed properly before being released. Additionally, an observation on the nursing unit showed that a staff member provided incontinence care to a resident with the room door fully open, exposing the resident. This was immediately confirmed by the Director of Nursing.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the monitoring of a resident's weight. According to the facility's policy, weights should be measured weekly for two weeks upon admission to prevent and monitor undesirable weight loss. A physician's order for a resident, dated April 27, 2024, specified weekly weights for four weeks, to be taken every Friday morning. However, the clinical records showed that the last recorded weight for the resident was 170.5 pounds on April 26, 2024, and no subsequent weights were documented. An interview with the Registered Dietitian confirmed the absence of further documented weights. Upon reweighing the resident on May 7, 2024, the resident's weight was found to be 157 pounds, indicating a significant weight loss of 8% (13.5 pounds) over eleven days. This deficiency was identified under 28 Pa Code 211.12(d)(5) Nursing services.
Failure to Provide Timely Foot Care
Penalty
Summary
The facility failed to provide timely foot care for a resident, identified as Resident R38, who required assistance with Activities of Daily Living. On May 3, 2024, an observation revealed that the resident had long and thick toenails on both feet. The resident's representative reported having requested a podiatrist consultation at least five times without receiving a response. The Director of Nursing confirmed on May 7, 2024, that the resident's toenails were indeed long and that no appointment had been made with a podiatrist, despite the facility having a podiatry service available for emergencies. A progress note from the same day indicated that a request was finally sent to the podiatrist, and no injury or skin breakdown was observed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bryn Mawr
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bryn Mawr Extended Care Center | 0.3 mi | ★★★★★ | 30 | 0 |
| Rosemont Center | 1.1 mi | ★★★★★ | 13 | 0 |
| Quadrangle | 1.2 mi | ★★★★★ | 1 | 0 |
| Beaumont At Bryn Mawr | 1.9 mi | ★★★★★ | 0 | 0 |
| Westgate Hills Rehabilitation And Nursing Ctr | 2.6 mi | ★★★★★ | 17 | 0 |
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