Bryn Mawr Village

In the surveyor’s words

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

• Immediate jeopardy, isolatedF692May 10, 2024

  Based on clinical record review, review of facility policies and staff interviews, it was determined that the facility failed to provide nutritional interventions, failed to complete timely nutritional assessments by a qualified nutrition professional, failed to notify physician of weight loss, failed to ensure residents with vegetarian diet received appropriate diet with nutritional value and failed to complete weight assessment to promote acceptable parameters of nutritional status which resulted in Resident R20 experiencing unplanned significant weight loss four times from November 24, 2023 to April 24, 2024, (lost 33.03% (43 pounds) of body weights) and continued to place Resident R20 at risk for further nutritional decline. […]

• Actual harm, isolatedF689Feb 13, 2026

  Based on review of facility policy, facility documentation, clinical records, and staff interview it was determined the facility failed to ensure the resident environment remained free of accident hazards for one of 12 residents reviewed (Resident R47). This failure resulted in actual harm to Resident R47 who spilled a hot liquid on his/her thigh resulting in a burn. This deficiency was identified as past non-compliance.Findings Include: Review of facility policy Assisting the Resident with In-Room Meals revised December 2013 revealed staff should check that hot foods are hot (but not scalding temperature). […]

• No harm, potential for more than minimal, widespreadF812May 10, 2024

  Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings include: Review of facility undated dating and labeling procedure guide revealed that all items in the refrigerator must be dated and labeled with a date, use by date, initials, and item name. An initial tour of the main kitchen was conducted on May 3, 2034, at 8:56 a.m. with the facility Administrator, Employee E1, and Kitchen Supervisor, Employee E3. Observations revealed that the main cook was not wearing a hair net while cooking in the main kitchen area. […]

• No harm, potential for more than minimal, patternF552Feb 13, 2026

  Based on clinical record review and staff interviews, it was determined that the facility failed to discuss the risks/benefits in advance for newly admitted resident for two of five resident records reviewed (Residents R1, and R23).Findings include:A review of the clinical record for Resident R1 revealed an admission date of July 21, 2025, with diagnosis of acute respiratory failure with hypoxia, parkinsonism, shortness of breath, heart failure, type 2 diabetes mellitus, depression, hypoxemia and acute kidney failure. […]

• No harm, potential for more than minimal, patternF655Feb 13, 2026

  Based on review of facility policy and review of clinical records, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan for two of three newly admitted residents reviewed (Resident R38, and R45).Findings:A review of the facility policy titled Care Plans-Baseline, last revised in March 2022, revealed that, a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forth-eight (48) hours of admission. […]