Bryn Mawr Extended Care Center

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not report an allegation of resident-to-resident abuse the State Survey Agency as required for one of eight records reviewed (Resident R1).

Inspectors wroteBased on observations, review of facility documentation and clinical records, and staff and resident interviews, it was determined the facility failed to ensure Resident R3, was adequately secured during transportation in the facility's contracted transportation service van. This failure resulted in actual harm to Resident R3 who sustained a fracture of right tibial plateau, for which the treatment involved surgical procedure for one of two residents reviewed (Resident R3) Findings Include: [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure a resident was provided the self-determination in regard to a room change for one of 33 residents reviewed (Resident 157). Findings Include: Review of facility policy Resident Rights and Facility Responsibilities Policy reviewed October 7, 2025, revealed it is the facility's policy to comply with all Resident Rights, and to communicate these rights to residents and their designated representatives in a language that they can understand. Review of Resident Rights Room Assignments & Changes revised July 2011, revealed during the course of a residents stay, room changes may be necessary for the welfare of each resident. [...]

Inspectors wroteBased on review of facility records and interview with staff, it was determined that the facility failed to transmit the required initial comprehensive MDS assessment for one of 29 residents reviewed (Resident R153)

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and interviews with staff and residents it was determined that the facility failed to review and revise resident care plans in accordance with resident needs for one of 33 residents reviewed (Resident R134). Findings Include: Review of Resident R134's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 13, 2026, revealed the resident had severe cognitive impairment and a diagnosis of aphasia (communication deficit). Review of Resident R134's comprehensive care plan dated August 27, 2025, revealed the resident had potential for falling related to limited mobility and impaired balance. Intervention dated August 10, 2025, specified scoop mattress in place. Observations and interview on March 12, 2026, at 11:00 a.m. [...]

Inspectors wroteBased on observation, review of clinical documentation and interviews with staff, it was determined that the facility did not ensure physician orders were followed related to wound treatment for one of 29 residents reviewed (Resident R12).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete dialysis records related to dialysis communication for two of two Dialysis-Residents reviewed (Residents R3 and R16).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and interviews with staff, residents, and resident representatives it was determined that the facility failed to have available a thermometer to heat of food brought from home by a family member for one of 33 residents reviewed (Resident R162). Findings Include: Review of facility policy Food Brought in From Outside the Facility reviewed November 2024, revealed staff outside the dietary department will store and handle food in accordance with food safety standards when residents or their friends/family bring food into the facility. Further review of facility policy revealed if food needs to be reheated, reheat food in microwave so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate infection control practices were maintained during wound care for one of 29 residents reviewed (Resident R12).

Inspectors wroteBased on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that a call bell system was functioning for one of 33 residents reviewed. (Resident R2)

Inspectors wroteBased on review of clinical record, and review of facility policy, it was determined that facility did not ensure that residents received treatment in accordance with professional standards of practice related to medication administration for one of one residents reviewed (Resident R16)

Inspectors wroteBased on observations, review of facility policies, clinical record reviews, and interviews with residents and staff, it was determined that the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests and physical, mental and psychosocial well-being on two of two nursing units. (1st and 2nd Floor)

Inspectors wroteBased on interviews, review of clinical records, and the review of facility documentation and policy, it was determined that the facility did not ensure residents were free from verbal abuse for one of 28 resident records reviewed (Resident R46).

Inspectors wroteBased on observations, interviews with resident and staff and review of clinical records and facility policy, it was determined the facility did not ensure a baseline care plan was developed with interventions to prevent pressure injury or trauma for one resident diagnosed with diabetes of 28 residents reviewed. (Resident R86)

Inspectors wroteBased on review of facility policies and documentation, clinical record review, interview with staff, and observations, it was determined that the facility failed to ensure that a licensed nurse maintained professional standards of quality of care for one of four residents reviewed. This failure resulted in delay of medical treatment relating to one resident not receiving medications timely. (Resident R 41)

Inspectors wroteBased on review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to timely provide assistance with incontinence care for one of 35 residents reviewed (Resident R9). Findings Include: Review of Resident R9's clinical record revealed a quarterly Minimum Data Set Assessment (MDS - federally mandated resident assessment and care screening) dated February 28, 2025, that indicated the resident was able to make her needs known, cognitively intact, and had diagnoses of anxiety, depression, and muscle weakness. [...]

Inspectors wroteBased on observation, interviews with resident and staff, review of clinical records, and facility documentation, it was determined the facility failed to implement interventions to prevent the development of diabetic wound. This failure placed Resident R86 at risk for developing a diabetic wound to the right heel, requiring debridement and antibiotic therapy for one of 28 clinical records reviewed (Resident R86).

Inspectors wroteBased on review of facility policy, review of clinical records, resident and staff interview and observation, it was determined that the facility failed to provide an environment that is free from accident and hazards relating to adequate supervision and smoking safety.

Inspectors wroteBased on review of clinical records, facility policy and interviews with staff, it was determined that the facility failed to ensure that a follow- up appointment was scheduled with an urologist for a resident with an an indwelling urinary catheter for one of 28 resident records reviewed (Resident R121).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure the identified pharmacy review irregularities were implemented for one of five residents reviewed (Resident R63). Findings Include: Review of facility policy on Medication Regimen Review (MRR) Section Procedure, #9 revealed that the facility should encourage the physician/provider or other responsible parties receiving the MRR (Medical Record) and the Director of Nursing to act upon the recommendations contained within the MRR. #9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MMR and provide an explanation as to why the recommendation was rejected. [...]

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served timely for one of 28 residents reviewed (Residents R47)

Inspectors wroteBased on interviews, and review of clinical records, it was determined the facility failed to provide outside services for one of 28 resident records reviewed (Resident R117).

Inspectors wroteBased on interviews with staff, and review of clinical records, it was determined that the facility failed to ensure that hospice documentation was complete for one of 28 residents reviewed. (Resident R54)

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to establish an effective infection control program related to use of personal protective equipment with enhanced barrier precautions for two of four residents reviewed. (Resident R499 and R10)

Inspectors wroteBased on a review of clinical records, review of facility documentation, review of facility policy, review of hospital records and interviews with staff, it was determined that the facility failed to assess resident's pain and timely obtain pain medication for adequate pain management for one of 28 residents reviewed. This failure resulted in actual harm to Resident R381 whose pain to the left foot was not properly relieved and managed and continued to experience uncontrolled pain. (Resident R381).

Inspectors wroteBased on observation, review of facility policy and interview with staff, it was determined that the facility did not ensure personal privacy and confidentiality related to signage for enhanced barrier precautions for 5 of 8 residents on transmission based precautions (Residents R56, R126, R117, R88 and R61).

Inspectors wroteBased on observations, review of facility documentation, and resident interviews, it was determined that the facility failed to ensure menus were followed for 10 of 28 clinical records reviewed (Resident R32, R35, R43, R57, R99, R122 and R440R40, R59 and R109).

Inspectors wroteBased on review of clinical records, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify resident's physician of a fall with injury resulting in hospitalization during a leave of absence from the facility for one of six residents reviewed (Resident R6).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment related to discharge status for one of 27 residents reviewed (Resident R129).

Inspectors wroteBased upon review of clinical records and interviews with family and review of facility documentation, it was determined that the facility did not ensure resident requiring continuous oxygen therapy received such services per the physician orders for one of 28 resident records reviewed (Resident R1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of 28 clinical records reviewed (Resident R107).

Inspectors wroteBased on the review of facility policies, clinical record review and staff interviews, it was determined that the facility failed to ensure that resident's physician was notified about abnormal laboratory test results for one of 28 residents reviewed (Resident R107).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that resident bathrooms were equipped with the appropriate call bell system for one out of 28 residents reviewed (Resident R21)

Inspectors wroteBased on review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least 12 hours of continuing education per year as required for three of five nurse aide personnel files reviewed (Employees E6).

Inspectors wroteBased on observation, a review of facility documentation and resident and staff interviews, it was determined that the facility failed to ensure that a safe and comfortable environment was maintained on one of four nursing care units (B wing).

Inspectors wroteBased on a review of established guidelines for cardiopulmonary resuscitation (CPR), review of facility's policies, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy for one of eleven residents reviewed (Resident 207), creating a situation in which the residents were placed in Immediate Jeopardy related to failure to perform cardiopulmonary resuscitation immediately. (Resident 207)

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to ensuring that Cardio Pulmonary Resuscitation (CPR) was provided in accordance with established facility policy for one of eleven residents reviewed (Resident 207), which resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on observations of the operations of the Food and Nutrition Department, reviews of policies and procedures, interviews with staff and reviews of chemical manufacturer's specifications, it was determined that the facility failed to ensure that the dish machine dispensed the proper level of sanitizing solution to sanitizing food service equipment. The facility failed to ensure that there was proper water pressure to maintain water in the three compartment sink, to sanitizing the food service equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays). This failure resulted in an Immediate Jeopardy situation for one of one kitchens serving 128 residents. (Kitchen)

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to ensuring that the dish machine dispensed the proper level of sanitizing solution to sanitizing food service equipment. The facility failed to ensure that there was proper water pressure to maintain water in the three compartment sink, to sanitizing the food service equipment which resulted in an Immediate Jeopardy situation for one of one kitchens serving 128 residents.

Inspectors wroteBased on reviews of facility menus, meal tray tickets and interviews with residents and staff, it was determined that menus were not prepared in advance to meet the nutritional needs of each resident and followed for seven of ten residents reviewed with specific food adversions. The facility failed to ensure that food was availble for the facility emergency menu as planned. (Residents R78, R119, R99, R17, R22, R97, R28 and R68)

Inspectors wroteBased on observations, reviews of policies and procedures and clinical records, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at satisfying temperatures for six of 32 residents reviewed (Residents R125, R63, R5, R68, R17 and R131).

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition on one of two nursing floors (First Floor) and a feeding pump was maintain in sanitary condition for on one of two tube feedings pumps observed (Resident R47).

Inspectors wroteBased on clinical record review, observations of care and services and interviews with staff, it was determined that the facility failed to develop and implement a care plan for one of five residents reviewed for activites of daily living. (Resident R98)

Inspectors wroteBased on clinical record review, resident and staff interview, it was determined that the facility failed to ensure that a resident was transferred out of bed as ordered by the physician for one of 32 residents reviewed. (Resident R110)

Inspectors wroteBased on clinical record review, observations and staff interview, it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two out of 32 residents reviewed (Resident R26 and R129).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater.

Inspectors wroteBased on clinical record and policy and procedure reviews and interviews with staff, it was determined that the facility failed to ensure that clinical records were accurate for one of 32 residents reviewed. (Resident R121)

Inspectors wroteBased on facility documentation and staff interview, it was determined that the facility failed to provide a safe discharge for one of three clinical records reviewed (Residents R1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to protect one of seven residents reviewed for exploitation of resident's personal funds. (Resident R1)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the resident's physician of the resident who was on a blood thinner medication of bleeding from a skin tears for one of seven residents reviewed. (Resident R2)