CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Villas at Bryn Mawr LLC
View the most recent health deficiencies and inspection results for Villas at Bryn Mawr LLC. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Villas at Bryn Mawr LLC. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide enough food/fluids to maintain a resident's health. | Health | 2026-03-13 | 2026-04-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-03-13 | 2026-04-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-09-29 | 2025-10-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-06-24 | 2025-07-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-06-24 | 2025-07-18 | Y |
| 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 | 2025-06-24 | 2025-07-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-06-24 | 2025-07-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-24 | 2025-06-10 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2025-03-27 | 2025-04-29 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2025-03-27 | 2025-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2025-03-27 | 2025-04-29 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2025-03-27 | 2025-04-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-03-27 | 2025-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-03-27 | 2025-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-27 | 2025-04-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2025-03-27 | 2025-04-29 | N |
| Provide appropriate foot care. | Health | 2025-03-27 | 2025-04-29 | 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 | 2025-03-27 | 2025-04-29 | 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 | 2025-03-27 | 2025-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-27 | 2025-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-27 | 2025-04-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-03-27 | 2025-04-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2025-03-27 | 2025-04-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-04-15 | 2025-04-29 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2025-03-27 | 2025-04-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-01-23 | 2025-02-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-01-14 | 2025-02-03 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2024-08-12 | 2024-09-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-12 | 2024-09-04 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-08-12 | 2024-09-04 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-08-12 | 2024-09-04 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-08-12 | 2024-09-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-02 | 2024-06-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-05-02 | 2024-06-14 | 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 | 2024-05-02 | 2024-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-02 | 2024-06-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-02 | 2024-06-14 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-02 | 2024-06-14 | N |
| Post nurse staffing information every day. | Health | 2024-05-02 | 2024-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-02 | 2024-06-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-05-02 | 2024-06-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-02 | 2024-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-02 | 2024-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-02 | 2024-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-02 | 2024-06-14 | 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 | 2024-05-02 | 2024-06-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-05-02 | 2024-06-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-02 | 2024-06-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-02 | 2024-06-14 | N |
| 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 | 2023-03-09 | 2023-05-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| 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 |
| 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 |
| 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 |
| PASARR screening for Mental disorders or Intellectual Disabilities | 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 |
| 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 |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-09 | 2023-05-03 | 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 |
| 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 | 2023-03-09 | 2023-05-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-09 | 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 | 2023-03-09 | 2023-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-09 | 2023-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-09 | 2023-05-03 | 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 | 2025-09-11 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-02-27 | Not Fixed | Y |