Villas at Bryn Mawr LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689Aug 12, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF684Mar 13, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600Sep 29, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF578Sep 11, 2025

  Based 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]. […]

• Immediate jeopardy, isolatedF689Jun 24, 2025

  Based 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. […]