Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 245203

The Villas At Bryn Mawr Llc

58 federal citations on record , including 4 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $35,260.

Abuse Icon Special Focus Status 4 Immediate Jeopardy

Record summary

Federal record · Q1 2026
58
Total citations
40
Last 3 years
4
Actual harm+
1
Federal penalties
$35,260
Total fines
1
Overall ★ rating

Most common violation categories here

Quality of Care21 Resident Rights8 Care Planning7 Medication & Pharmacy7 Abuse & Neglect3

Most common F-tags at this facility

F6893 F7553 F6773 F6843 F6092

Citation history

58 on record
SurveyF-TagViolationSeveritySource
Sep 29, 2025F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.JComplaint
Sep 11, 2025F578Honor 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.JComplaint
Jun 24, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Jun 24, 2025F742Provide 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.DComplaint
Jun 24, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.JComplaint
Jun 24, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DComplaint
Jun 24, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Apr 15, 2025F692Provide enough food/fluids to maintain a resident's health.DComplaint
Mar 27, 2025F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.DComplaint
Mar 27, 2025F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EStandard
Mar 27, 2025F880Provide and implement an infection prevention and control program.DStandard
Mar 27, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Mar 27, 2025F758Implement 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.DStandard
Mar 27, 2025F688Provide 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.DStandard
Mar 27, 2025F687Provide appropriate foot care.DStandard
Mar 27, 2025F685Assist a resident in gaining access to vision and hearing services.DStandard
Mar 27, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard
Mar 27, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Mar 27, 2025F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.DStandard
Mar 27, 2025F645PASARR screening for Mental disorders or Intellectual DisabilitiesDStandard
Mar 27, 2025F638Assure that each resident’s assessment is updated at least once every 3 months.DStandard
Mar 27, 2025F583Keep residents' personal and medical records private and confidential.BStandard
Mar 27, 2025F576Ensure residents have reasonable access to and privacy in their use of communication methods.DStandard
Jan 23, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Jan 14, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Aug 12, 2024F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.DComplaint
Aug 12, 2024F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.BComplaint
Aug 12, 2024F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.BComplaint
Aug 12, 2024F914Provide bedrooms that don't allow residents to see each other when privacy is needed.DComplaint
Aug 12, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.LComplaint
May 2, 2024F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
May 2, 2024F880Provide and implement an infection prevention and control program.EStandard
May 2, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
May 2, 2024F732Post nurse staffing information every day.CStandard
May 2, 2024F699Provide care or services that was trauma informed and/or culturally competent.DStandard
May 2, 2024F693Ensure 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.DStandard
May 2, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
May 2, 2024F584Honor 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.DStandard
May 2, 2024F554Allow residents to self-administer drugs if determined clinically appropriate.DStandard
Feb 26, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DComplaint
Mar 9, 2023F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.FStandard
Mar 9, 2023F759Ensure medication error rates are not 5 percent or greater.DStandard
Mar 9, 2023F758Implement 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.DStandard
Mar 9, 2023F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Mar 9, 2023F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DStandard
Mar 9, 2023F742Provide 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.DStandard
Mar 9, 2023F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.DStandard
Mar 9, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DStandard
Mar 9, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Mar 9, 2023F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Mar 9, 2023F658Ensure services provided by the nursing facility meet professional standards of quality.DStandard
Mar 9, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Mar 9, 2023F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedDStandard
Mar 9, 2023F645PASARR screening for Mental disorders or Intellectual DisabilitiesEStandard
Mar 9, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DStandard
Mar 9, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DStandard
Mar 9, 2023F558Reasonably accommodate the needs and preferences of each resident.DStandard
Mar 9, 2023F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.DStandard

Federal enforcement history

Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $35,260 .

DateTypeFinePayment denial
Aug 12, 2024Fine$35,260—
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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