A list of the most recent deficiencies for Bryn Mawr Village. 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-10 | 2023-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-10 | 2023-08-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-10 | 2023-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-10 | 2023-08-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-10 | 2023-08-15 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-07-10 | 2023-08-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-10 | 2023-08-15 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-07-10 | 2023-08-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-16 | 2023-04-21 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-18 | 2023-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-18 | 2023-02-15 | Y |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-02 | 2023-01-01 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-10-27 | 2022-12-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-27 | 2022-12-20 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-10-27 | 2022-12-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-27 | 2022-12-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-27 | 2022-12-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-27 | 2022-12-20 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-10-27 | 2022-12-20 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-10-27 | 2022-12-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-27 | 2022-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-27 | 2022-12-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-27 | 2022-12-20 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-27 | 2022-12-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-10-27 | 2022-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-27 | 2022-12-20 | N |
| Report COVID19 data to residents and families. | Health | 2022-10-27 | 2022-12-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-27 | 2022-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-12-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-09 | 2022-09-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-09 | 2022-09-09 | Y |
| 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 | 2022-08-09 | 2022-09-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-16 | 2022-08-15 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-06-16 | 2022-08-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-04-06 | 2022-05-30 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-07 | 2022-03-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-07 | 2022-03-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-07 | 2022-03-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-07 | 2022-03-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-07 | 2022-03-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-07 | 2022-03-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-07 | 2022-03-30 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Meet other general requirements. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-28 | 2021-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-15 | 2021-11-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-15 | 2021-11-02 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-09-15 | 2021-11-02 | N |
