A list of the most recent deficiencies for Bryn Mawr Extended Care Center. 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? |
|---|---|---|---|---|
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Establish methods for sharing information. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Meet other general requirements. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-12 | 2024-03-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-01 | 2024-03-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-01 | 2024-03-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-01 | 2024-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-01 | 2024-03-11 | 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 | 2024-02-01 | 2024-03-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-01 | 2024-03-11 | 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 | 2024-02-01 | 2024-03-11 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-02-01 | 2024-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-01 | 2024-03-11 | N |
| Keep all essential equipment working safely. | Health | 2024-02-01 | 2024-03-11 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2024-02-01 | 2024-03-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-01 | 2024-03-11 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-01 | 2024-03-11 | 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 | 2024-02-01 | 2024-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-01 | 2024-03-11 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-01 | 2024-03-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-01 | 2024-03-11 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-01 | 2024-03-11 | Y |
| 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 | 2024-02-01 | 2024-03-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-01 | 2024-03-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-03-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-01 | 2024-03-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-01 | 2024-03-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-01 | 2023-11-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-01 | 2023-11-30 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-21 | 2023-09-13 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-02 | 2023-05-19 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-23 | 2023-05-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-23 | 2023-05-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-23 | 2023-04-24 | 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 | 2023-03-23 | 2023-04-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-23 | 2023-04-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-13 | 2023-04-11 | 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 | 2023-03-13 | 2023-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-13 | 2023-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-13 | 2023-04-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-13 | 2023-04-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-13 | 2023-04-11 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-03-13 | 2023-04-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-03-13 | 2023-04-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-13 | 2023-04-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-13 | 2023-04-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-25 | 2023-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-25 | 2023-01-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-22 | 2022-12-12 | Y |
| 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 | 2022-11-22 | 2022-12-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-22 | 2022-12-12 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-09 | 2022-12-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-09 | 2022-12-12 | Y |
| Meet other general requirements. | Fire Safety | 2022-04-25 | 2022-06-07 | 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 | 2022-04-25 | 2022-06-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-25 | 2022-06-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-06 | 2022-04-27 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-06 | 2022-04-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-06 | 2022-04-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-06 | 2022-04-27 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-11-14 | Not Fixed | Y |
