A list of the most recent deficiencies for The Villas at Bryn Mawr LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-26 | 2024-03-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-07 | 2023-05-23 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-03-09 | 2023-05-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-09 | 2023-05-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-09 | 2023-05-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-09 | 2023-05-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-09 | 2023-05-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-09 | 2023-05-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-09 | 2023-05-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-09 | 2023-05-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-05-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-09 | 2023-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-05-03 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-03-09 | 2023-05-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-03-09 | 2023-05-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-09 | 2023-05-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-09 | 2023-05-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-09 | 2023-05-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-09 | 2023-05-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-09 | 2023-05-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-09 | 2023-05-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-07 | 2023-05-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-07 | 2023-05-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-07 | 2023-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-07 | 2023-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-07 | 2023-05-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-25 | 2022-08-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-25 | 2022-08-09 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2022-07-25 | 2022-08-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-09 | 2022-06-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-13 | 2022-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-13 | 2022-06-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-05 | 2022-02-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-14 | 2022-02-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-14 | 2022-02-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-14 | 2022-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-11 | 2022-02-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-01 | 2021-12-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-01 | 2021-12-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-01 | 2021-12-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-01 | 2021-12-28 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-12-01 | 2021-12-28 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-11-18 | 2021-12-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-12-27 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-15 | 2021-11-09 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-09-17 | 2021-10-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-17 | 2021-10-25 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-09-17 | 2021-10-25 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-09-17 | 2021-10-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-09-17 | 2021-10-25 | N |
| Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. | Health | 2021-09-17 | 2021-10-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-17 | 2021-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-15 | 2021-10-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-15 | 2021-10-25 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-27 | 2021-09-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-22 | 2021-07-02 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-28 | 2021-06-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-11 | 2019-11-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-11 | 2019-11-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-11 | 2019-11-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-13 | 2019-11-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-09-13 | 2019-11-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-13 | 2019-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-13 | 2019-11-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-13 | 2019-11-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-09-13 | 2019-11-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-13 | 2019-11-04 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-09-13 | 2019-11-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-13 | 2019-11-04 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-13 | 2019-11-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-13 | 2019-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-13 | 2019-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-13 | 2019-11-04 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-09-13 | 2019-11-04 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-13 | 2019-11-04 | N |
| Post nurse staffing information every day. | Health | 2019-09-13 | 2019-11-04 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-13 | 2019-11-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-13 | 2019-11-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-13 | 2019-11-04 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-09-13 | 2019-11-04 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-13 | 2019-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-13 | 2019-11-04 | N |
| Keep all essential equipment working safely. | Health | 2019-09-13 | 2019-11-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-13 | 2019-11-04 | N |
