Facility profile · CCN 395095
Bryn Mawr Village
35 federal citations on record , including 1 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $15,902.
Record summary
Federal record · Q1 202635
Total citations
34
Last 3 years
1
Actual harm+
1
Federal penalties
$15,902
Total fines
3
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
35 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Sep 24, 2025 | F610 | Respond appropriately to all alleged violations. | E | Complaint |
| Sep 24, 2025 | F585 | 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. | D | Complaint |
| Mar 6, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard |
| Mar 6, 2025 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard |
| Mar 6, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Mar 6, 2025 | F693 | 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. | D | Standard |
| Mar 6, 2025 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Mar 6, 2025 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Mar 6, 2025 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Mar 6, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Mar 6, 2025 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Mar 6, 2025 | F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard |
| Mar 6, 2025 | F578 | 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. | D | Standard |
| May 10, 2024 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | D | Standard |
| May 10, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| May 10, 2024 | F808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | D | Standard |
| May 10, 2024 | F806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Standard |
| May 10, 2024 | F803 | 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. | D | Standard |
| May 10, 2024 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard |
| May 10, 2024 | F730 | Observe each nurse aide's job performance and give regular training. | E | Standard |
| May 10, 2024 | F710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | D | Standard |
| May 10, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | J | Standard |
| May 10, 2024 | F687 | Provide appropriate foot care. | D | Standard |
| May 10, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| May 10, 2024 | F583 | Keep residents' personal and medical records private and confidential. | D | Standard |
| Feb 14, 2024 | F622 | 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. | D | Complaint |
| Jul 10, 2023 | F940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | D | Standard |
| Jul 10, 2023 | F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | D | Standard |
| Jul 10, 2023 | F887 | 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. | D | Standard |
| Jul 10, 2023 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Jul 10, 2023 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Jul 10, 2023 | F730 | Observe each nurse aide's job performance and give regular training. | D | Standard |
| Jul 10, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Jul 10, 2023 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Standard |
| Mar 16, 2023 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | D | Complaint |
Federal enforcement history
Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $15,902 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| May 10, 2024 | Fine | $15,902 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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