Bryn Mawr Extended Care Center

In the surveyor’s words

From the most serious findings on record at Bryn Mawr Extended Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF812Feb 1, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF678Feb 29, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Jan 25, 2023

  Based on the review of clinical records, facility reported incident, facility policies, interviews with staff and facility documentation, it was determined that the facility failed to provide appropriate supervision for one of five residents reviewed, which resulted in Resident R1 eloping from the facility and remaining out of the facility for 12 hours. This failure placed Resident R1 at risk for harm. This deficiency was identified as Immediate Jeopardy past non-compliance. (Resident R1) Findings include: Review of facility policy Elopement/Unauthorized Absence Policy dated March 18, 2022, revealed that The facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. […]

• Actual harm, isolatedF689Mar 12, 2026

  Based 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: Review of Resident R3's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 9, 2026, revealed Resident R3's diagnoses included Hemiplegia (total paralysis of one side of the body) and Hemiparesis (weakness or partial loss of muscle movement on one… […]

• Actual harm, isolatedF697Nov 1, 2024

  Based 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). Findings include: Review of the facility's policy for Emergency Medication Supplies (Emergency kit) revised December 2023 stated the pharmacy may provide the facility with Emergency Medication. […]