Villas at Bryn Mawr LLC

Inspectors wroteBased on interview and document review, the facility failed to immediately report incidents of potential resident-to-resident abuse to the state agency (SA) within two hours, as required for 2 of 2 residents (R64, R116) reviewed for abuse. In addition, the facility failed to ensure allegations of potential abuse were reported to the state agency (SA), within 2 hours, for an injury of unknown cause resulting in a fracture for 1 of 1 residents (R80) whose allegations were reviewed. Further, the facility failed to ensure timely reporting of self-neglect for a missing resident for 1 of 1 resident (R7) reviewed who left the building and did not return and whose whereabouts were unknown.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the resident room in a safe, clean, and comfortable condition for 2 of 2 residents (R30, R64) by failing to repair or otherwise seal a broken resident room window, leaving an opening to the outside environment that allowed pests to enter the facility. In addition, the facility failed to ensure condition of wall corner trim pieces and baseboards on the second-floor hallways were in a safe condition. Also, the facility further failed to ensure 2 of 2 residents (R10, R100) rooms were maintained in good repair by failing to address missing drawer fronts, missing mirrors, broken wallboard, hanging curtains off their hooks.

Inspectors wroteBased on observation and interview, the facility failed to ensure handrails on the second floor were securely attached to the wall. This had the potential to affect all residents, staff, and visitors who had access to the handrails.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a dignified dining experience for 3 of 3 residents (R11, R40, R53 ) who were seated at the dining room table with other residents who were served meals without being served meals themselves resulting in them waiting for their meals while tablemates dined.

Inspectors wroteBased on interview and document review, the facility failed to ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to 1 of 3 residents (R39) reviewed for beneficiary notices.

Inspectors wroteDuring observation, interview and record review, the facility failed to ensure protection of resident property for 2 of 2 residents (R10, R15) reviewed for missing items.

Inspectors wroteBased on interview and document review, the facility failed to ensure ongoing, adequate monitoring for side effects with psychotropic medication use to promote continuity of care for 1 of 5 residents (R15) reviewed for unnecessary medication use. In addition, the facility failed to ensure psychotropic medication had identified target behaviors/symptoms, and therefore failed to monitor for target behavior/symptoms for 1 of 5 residents (R15) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to provide a written bed hold (BH) for 3 of 3 residents (R9, R15, R100) reviewed for hospitalization. Findings Include: R15 R15's admissions MDS dated [DATE] identified R15 with inability to determine cognition, adequate vision with no corrective lenses, impaired function of one side of upper extremity, utilized a wheelchair for mobility, required substantial assistance with dressing and personal hygiene. In addition, R15 had diagnoses of Encephalopathy (malfunction in the brain causing mental status changes), blood clots, ischemic colitis requiring colostomy (bag outside body to collect stool), kidney disease, anxiety, depression, and rhabdomyolysis (breakdown of muscle causing kidney damage). [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect vision status for 1 of 1 residents (R15) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure timeliness of person-centered care conferences for 1 of 1 residents (R100) and to include periodic review and revision by an interdisciplinary team along with the resident in adjusting their care plan and making decisions about their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to consistently and comprehensively assess a non-pressure skin condition to ensure skin condition changes could be adequately monitored and acted upon promptly to promote healing and reduce the risk of complications (i.e., infection, worsening) for 1 of 2 residents (R22) reviewed who had skin impairments. In addition the facility failed to ensure services were coordinated with the hospice agency of 1 of 1 residents (R10) reviewed who received hospice services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to failed to ensure medications were stored in a secure manner when staff left a medication cart unattended and unlocked, resulting in unauthorized individuals having potential access to medications, including controlled substances. This had the potential to affect medications accessible in that cart by allowing unauthorized access and creating the potential for medication diversion or resident harm.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow infection control standards of practice for cleaning a urinal for 1 of 1 resident (R2) reviewed for infection control.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the emergency call system remained accessible and functional for 4 of 4 residents (R9, R30, R52, and R64) who used the shared bathroom by failing to ensure the bathroom emergency call light pull cord was long enough to be reached by a resident from the floor creating the potential for delayed staff response during an emergency.

Inspectors wroteBased on interview and document review the facility failed to assess, develop, implement interventions and provide supervision for 1 of resident (R1) reviewed for tube feeding. The facility was aware R1 had food seeking behaviors and was on a NPO (nothing by mouth) diet restriction. This resulted in R1 being sent to the emergency department. Once in the emergency department, R1 required intubation and resuscitation by cardio pulmonary resuscitation (CPR) due to cardiac arrest. The immediate jeopardy began on 3/08/26, when the facility failed to assess, develop, implement interventions and provide supervision to R1 when R1 was known to have food seeking behaviors and was on a NPO diet restriction. [...]

Inspectors wroteBased on interview and document review the facility failed to assess and develop a plan to ensure tube feeding needs were met for 1 of 1 resident (R1) reviewed who had a behavior of disconnecting her feeding and sustained over 13 pounds (lbs.) of weight loss in less than 30 days as a result.

Inspectors wroteBased on interview and document review, the facility failed to ensure newly developed areas of skin breakdown were promptly assessed to determine interventions needed to promote healing, ensure recommendations and orders for pressure ulcer care were acted upon timely to facilitate healing and reduce the risk of continued worsening for 1 of 4 residents (R4) reviewed. R4 developed skin breakdown on 12/6/25, that was not addressed until several days later and when R4 was seen by a wound care provider for the developed pressure injuries then the recommendations for care were not implemented until weeks later causing harm to R4 when he developed more pressure ulcers and his existing ones worsened. The facility took corrective action prior to the onsite survey, and these

Inspectors wroteBased on interview and document review, the facility neglected to provide care and services to a resident with mental health needs who refused assessments and interventions since admission on [DATE], R1 was not transferred to a higher level of care despite facility and provider awareness for 1 of 3 residents (R1) who were reviewed for neglect of care when R1 contacted emergency medical services (EMS) because she felt dizzy, was vomiting, and could not move her lower extremities. When EMS arrived R1 was adhered to her mattress and covered in urine and feces. R1 admitted to the hospital malnourished, with maggots around her groin, bra hook embedded down to the muscle layer, reddened folds to right flank, pressure ulcers from stage one to stage four covered her entire back, open areas to coccyx, and bilateral gluteus, and skin tears along her posterior thighs. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow R1's Physician Orders for Life-Sustaining Treatment (POLST) do not attempt resuscitation (DNR), do not intubate (DNI), and to allow natural death for one of three residents (R1) reviewed for cardiopulmonary resuscitation (CPR). R1 was found unconscious in his room in his wheelchair and registered nurse (RN)-A and licensed practical nurse (LPN)-B initiated CPR when R1 requested DNR/DNI, allowing for natural death, potentially complicating R1's rights by unnecessary life-saving measures. The past noncompliance immediate jeopardy began on [DATE] when RN-A and LPN-B initiated CPR on R1, who's wishes were DNR/DNI. RN-G and Administrator-A were notified of the immediate jeopardy at 9:44 a.m. on [DATE]. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to provide adequate levels of supervision to prevent elopement for 1 of 1 residents (R1) who required 24/7 supervision, resided on a locked unit and left the facility without their knowledge. This resulted in an Immediate Jeopardy (IJ) situation for R1. The IJ began on 6/10/25, when R1 was not provided with adequate supervision during an outside activity which resulted in R1 leaving the facility at approximately 1:23 p.m., he was found by police at approximately 1:46 p.m. on a busy street about a half mile away from the facility. The administrator, director of nursing and regional nurse consultant (RNC)-A were notified of the immediate jeopardy on 6/24/25, at 11:42 a.m. The facility implemented immediate corrective action on 6/10/25 to prevent recurrence, so the IJ was issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to report the reasonable suspicion of a crime to law enforcement for 1 of 1 resident (R4) reviewed who made an allegation of sexual abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to revise the care plan for an elopement-safety related intervention for 1 of 1 resident (R1) reviewed for resident safety.

Inspectors wroteBased on interview and document review, the facility failed to assess a resident to determine the need for additional treatments and services for mental and psychosocial well-being for 1 of 1 resident (R4) reviewed who made an allegation of sexual assault and had a history of post-traumatic stress disorder (PTSD) and psychosocial adjustment difficulty.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available for administration per physician order for 1 of 1 resident (R1) reviewed for resident safety.

Inspectors wroteBased on interview and document review, the facility failed to implement admission physician's orders of daily weight checks for 1 of 1 resident (R1) who had a diagnosis of malnutrition and was alleged to have a significant weight loss.

Inspectors wroteBased on observation, interview, and documentation, the facility failed to ensure opened food items were wrapped, labeled, dated, and disposed of by use by dates. The facility failed to ensure personal staff items were not stored next to resident food items. Further, the facility failed to ensure facial hair restraints were worn during meal service and hair nets were worn in the kitchen. In addition, the facility failed to ensure the kitchen's dish machine reached adequate temperature and pans and utensils were completely dry before storage to prevent bacterial growth. This had potential to affect all 98 residents who resided in the facility, staff, and visitors who consumed food from the main production kitchen, and specifically residents on station two who consumed food from the steam table.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess and care plan for a resident's social and emotional well-being for 1 of 1 resident (R20) who wished to help in the dining area. Additionally, did not adequately assess for food preferences or find ways to encourage resident to adhere to dietary recommendations, and neglected to follow up with an order for a video swallow study for 1 of 1 residents (R23) reviewed who frequently refused a modified diet and requested regular-textured foods. Additionally, the facility failed to assess, care plan, and implement interventions for 1 of 1 resident (R90) reviewed for skin assessment. The facility also failed to coordinate care for a resident who was consistently out of the building for scheduled appointments and not receiving treatments/medications as ordered for 1 of 1 resident (R52) reviewed for dialysis.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the first-floor shower room was maintained in a clean, sanitary manner when the shower ceiling was observed with brown staining. This had the potential to affect 26 residents (including R28, R73, and R304) who resided on the first floor and utilized the shower room on a routine basis.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure there was reasonable access to private phone use for 1 of 1 residents (R303) reviewed who utilized the facility phone.

Inspectors wroteBased on interview and document review, the facility failed to ensure the quarterly Minimum Data Set (MDS) was completed in a thorough manner to ensure areas of cognition and depressive symptoms were evaluated for 2 of 4 residents (R3, R19) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 1 of 1 residents (R17) reviewed for PAS.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance and/or equipment to complete personal hygiene cares (i.e., nail care) for 1 of 5 residents (R59) reviewed who needed set-up assistance with nail care.

Inspectors wroteBased on observation, interview and document the facility failed to provide activities of daily living (ADLs) including nail care and routine bathing to 2 of 3 residents (R19, R31) reviewed for ADLs who were observed to be disheveled with long, dirty fingernails and greasy appearing hair.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure cataract surgery was coordinated with an appointed guardian to facilitate attendance and successful surgery for 1 of 1 resident (R3) reviewed who complained about their poor vision. In addition, the facility failed to act on reports of missing hearing devices and/or seek a replacement for 1 of 1 residents (R28) reviewed who was reported to have had lost their hearing aids.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure long, hard toenails (i.e., dystrophic) were appropriately referred to the onsite contracted podiatry service in a timely manner for 1 of 1 resident (R3) reviewed who needed professional management of their nails due to a medical condition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide routine range of motion (ROM) for 1 of 1 resident (R63) reviewed for ROM who was dependent on staff for all activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and implement behavioral interventions for 1 of 1 resident (R46) reviewed for behavior of throwing dining ware.

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate and accurate psychotropic medication side effect monitoring was completed and recorded to reduce the risk of complication (i.e., orthostasis) and promote continuity of care for 1 of 5 residents (R59) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was used for 1 of 1 resident (R63) who received cares and was on enhanced barrier precautions.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure private and confidential resident information was secure and not visible to residents and visitors when resident care sheets were left out in public view. This had the ability to affect 48 residents on second floor.

Inspectors wroteBased on interview and document review, the facility failed to ensure a pain medication was re-ordered timely to prevent pain for 1 of 3 residents (R1) reviewed for pharmacy services.

Inspectors wroteBased on interview and document review, the facility failed to monitor 2 of 4 residents (R1, R4) following an unwitnessed fall. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had severe cognitive impairment with diagnoses which included stroke. R1's nursing note dated 1/4/25 indicated R1 fell and hit the right side of his forehead causing a bump. The note lacked size and description of the injury, and any indication of treatment. R1's electronic medical record (EMR) lacked documentation of monitoring of the injury and ongoing monitoring following the fall to include neuro checks and vital signs. R4's quarterly MDS dated [DATE] indicated R4 had intact cognition with diagnoses which included type 2 diabetes mellitus. R4's nursing note dated 1/6/25 indicated R4 was found laying on the floor next to his bed during morning rounds. [...]

Inspectors wroteBased on interview and document review, the facility failed to have a system in place to train staff on the process for unlocking the main entrance doors for emergency medical services (EMS) personnel after hours when the doors were locked from 10:00 p.m. to 7:00 a.m R2 had difficulty breathing, 911 was call, and EMS personnel could not gain entrance to the building for ten minutes. This deficient practice placed all 81 residents residing in the facility at risk for serious harm, impairment or death (immediate jeopardy [IJ]) for delayed EMS response. The IJ began on 7/29/24 at 2:29 a.m. when R2 reported difficulty breathing, and staff phoned 911 at approximately 2:09 a.m. on 7/29/24. When EMS arrived at the facility, the doors were locked. A staff member attempted to open the doors and were unable. EMS was unable to enter the building for approximately 10 minutes. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a privacy curtain for 3 or 3 residents (R1,R3, R6) who shared a room and were reviewed for a clean home-like environment.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 staff (nursing assistant [NA]-G, NA-H, NA-I) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills.

Inspectors wroteBased on interview and document review, the facility failed to provide training about communicating with non-English speaking residents who were identified as residents the facility may serve, for 5 of 5 staff (nursing assistant [NA]-G, NA-H, NA-I, registered nurse [RN]-A, licensed practical nurse [LPN]-B) reviewed. The facility identified two residents who were non-English speaking.

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on the facility's Quality Assurance Performance Improvement Program (QAPI) which included the goals and various elements of the program, and how the facility intended to implement the program, staff's role in the facility's QAPI program, and how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program for 5 of 5 staff (nursing assistant [NA]-G, NA-H, NA-I, registered nurse [RN]-A, licensed practical nurse [LPN]-B) reviewed for QAPI training.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of cross-contamination and/or foodborne illness. This had the potential to affect all 88 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure transmission-based precautions (TBP) were assessed for and implemented for 1 of 1 residents (R11) with symptoms of a respiratory illness with the potential to affect 23 residents residing on the unit. In addition, the facility failed to ensure resident education was provided and smoking infection control practices were followed for 2 of 2 residents (R22, R61) assessed for smoking.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow a resident to safely self administer medications for 1 of 1 (R5) resident reviewed who stored medication at their bedside.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure maintenance services were provided in a timely manner to address broken window blinds to help provide a private, homelike living space for 2 of 2 residents (R65, R85) reviewed whose window blinds had broken exposing their room to outside public view.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide nail care for 1 of 1 residents (R28) who required assistance with personal hygiene.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure staff provided cares according to standard of practice for gastrostomy tube (stomach insertion feeding tube) care for 2 of 2 residents (R19, R67) reviewed for tube feedings.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 3 of 3 (R18, R34 and R74) residents reviewed who's diagnoses included post-traumatic stress disorder (PTSD).

Inspectors wroteBased on interview and document review, the facility failed to offer or provide the recommended pneumococcal vaccine to 1 of 5 residents (R74) reviewed for immunizations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure required nurse staffing information was posted on a daily basis including over the weekend. This had potential to affect all 87 residents, staff, and visitors who could wish to review this information.

Inspectors wroteBased on interview and document review, the facility failed to document their weekly skin assessments for 2 of 4 residents (R1 and R3) reviewed for pressure ulcers.