Health inspection·May 10, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to follow the physician orders related to weekly weights for one of 13 residents reviewed (Residents R37). Residents Affected - Few Findings include: Review of facility policy titled, Weight Assessment and Intervention, revised September 2008, revealed that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Nursing will measure resident weights weekly for two weeks on admission. Review of physician orders for Resident R37 revealed an order dated, April 27, 2024, for weekly weights x 4 weeks; in the morning every Friday. Review of Resident R37's clinical records revealed the last registered weight of 170.5 pounds on April 26, 2024. Interview with the Registered Dietitian, Employee E6, on May 7, 2024, at 2:07 p.m. confirmed that there were no further documented weights for Resident R37. Further interview revealed that after immediately reweighing Resident R37 on May 7, 2024, his weight registered 157 pounds. Employee E6 confirmed that the resident experienced a significant weight loss of 8% in eleven days (13.5 pounds). 28 Pa Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 2 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, review of clinical records, observations and resident, resident representative and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 13 residents reviewed (Resident R38). Residents Affected - Few Findings include: Review of care plan for Resident R38 dated April 3, 2024, revealed that the resident required assistance for Activities of Daily Living functions. Observation of Resident R38 on May 3, 2024 at 10:33 a.m., revealed that the resident had long and thick toenails on both feet. Resident R38's representative statedat the time of the observation that he asked staff to consult a podiatrist at least five times but no response was received. Interview with Director of Nursing (DON) on May 7, 2024 at 12:00 p.m. confirmed that resident's toe nails were long and a podiatrist should have consulted. He also confirmed that there was no appointment made for Resident R38. DON also stated facility had a podiatry service physician that comes into the building as needed and for emergency. Review of progress note for Resident R38 dated May 7 2024, revealed that Resident observed with grossly long toe nails. Request sent to podiatrist for podiatry services. No injury or skin break down observed. 28 Pa Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 3 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policies and staff interviews, it was determined that the facility failed to provide nutritional interventions, failed to complete timely nutritional assessments by a qualified nutrition professional, failed to notify physician of weight loss, failed to ensure residents with vegetarian diet received appropriate diet with nutritional value and failed to complete weight assessment to promote acceptable parameters of nutritional status which resulted in Resident R20 experiencing unplanned significant weight loss four times from November 24, 2023 to April 24, 2024, (lost 33.03% (43 pounds) of body weights) and continued to place Resident R20 at risk for further nutritional decline. This failure placed Resident R20 in Immediate Jeopardy situation, for one of three residents reviewed for nutritional risk. (Resident R20) Residents Affected - Few Findings include: Review of facility policy Weight Assessment and Intervention dated September 2008, revealed that Weight Assessment The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. Any weight changes of 5% or more since the last weight assessment will be retaken the next day for any weight change of 5% or more confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) (usual weight) x 100): 1 month -5% weight loss is significant; greater than 5% is severe a. 3 months =7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe. If the weight change is desirable this will be documented and no change in the care plan will be necessary. Analysis Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 4 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; Level of Harm - Immediate jeopardy to resident health or safety c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated Residents Affected - Few The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. Cognitive or functional decline; b. Chewing or swallowing abnormalities; c. Pain; d. Medication-related adverse consequences; e. Environmental factors (such as noise or distractions related to dining); f. Increased need for calories and/or protein; g Poor digestion or absorption; h. Fluid and nutrient loss; and/or i. Inadequate availability of food or fluids. 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; d. Environmental factors that may inhibit appetite or desire to participate in meals: e, Chewing and swallowing abnormalities and the need for diet modifications: f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives. Review of an undated facility policy Vegetarian Diet revealed that, The Vegetarian Diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 5 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 accommodates the food preference of the individuals avoiding certain animal food in their diet. Level of Harm - Immediate jeopardy to resident health or safety Upon admission, the nursing staff will submit a Tray Card Slip to the dietary department denoting the physician's order for vegetarian diet. The patient will be placed on a vegetarian diet. Review of facility documentation revealed that the facility had a vegetarian extension of the cycle menu. Residents Affected - Few Review of clinical record revealed that Resident R20 was admitted to the facility with the diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hemiparesis (weakness on one side of the body, including the arms, legs, hands, and face), cognitive communication deficit and dysphagia (difficulty swallowing). Review of Resident R20's Minimum Data Set (MDS- assessment of resident care needs) dated April 7, 2024, revealed that the resident lost more than 5 % the last month and 10% or more in last 6 months and the resident was not on a prescribed weight loss regimen. Review of an admission nutritional assessment dated [DATE], revealed that the resident was on a vegetarian and on a cardiac diet. Resident weighed 132 pounds with a BMI of 20.7, with an estimated calorie need of 2000-2200 kcal 63-83 grams of protein. Review of weight assessment for Resident R20 dated November 1, 2023, revealed that the resident weighed 132 .6 pounds. Review of weight assessment for Resident R20 dated November 28, 2023, revealed that the resident weighed 119.0 pounds which was 10.25 % weight loss in a month (severe weight loss). Review of a re-weight assessment for Resident R20 dated December 1, 2023, revealed that the resident weighed 115.0 pounds which was 13.27 % weight loss in a month (severe weight loss). Review of weight assessment for Resident R20 dated January 2, 2024, revealed that the resident weighed 107.0 pounds which was 6.95 % weight loss in a month and 18.9 % in three months (severe weight loss). There were no monthly weights available for review for the month of February 2024. Review of weight assessment for Resident R20 dated March 29, 2024, revealed that the resident weighed 91 pounds which was 13.33 % weight loss from the last weight of January 5, 2024 of 105 pounds and 31.5 % in six months (severe weight loss). Review of weight assessment for Resident R20 dated April 24, 2024, revealed that the resident weighed 88.8 pounds which was 2.41 % weight loss from the last weight of March 29, 2024. and 33.03 % in six months (severe weight loss). Review of the Registered Dietician's weight change note dated November 30, 2023 in response to a weight on November 28, 2023, revealed that a reweight was requested. No other nutritional interventions were recommended. Review of Registered Dietician's weight change note dated December 4, 2023 in response to a weight on December 1, 2023, revealed that a re-weight was requested. No other nutritional interventions were recommended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 6 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Registered Dietician's weight change note dated December 12, 2023 revealed that the dietician requested another re-weight again. Review of Registered Dietician's weight change note dated December 14, 2023, revealed that the dietician requested a re-weight again due to discrepancy in weight and wound management. Recommended to add vitamin C x 14 days. No other nutritional interventions were initiated or recommended related to the resident's weight loss. Review of Resident R20's December 2023 Medication Administration Record revealed that the nutritional recommendation of Vitamin C was not implemented. Resident did not receive the medication as recommended by the Registered Dietician. Review of the weight assessment for Resident R20 revealed that there was no re-weight obtained after December 1, 2023, as requested by the Registered Dietician. Review of Registered Dietician's weight change note dated January 3, 2024, in response to a weight on January 2, 2024, revealed that a re-weight was requested. Review of the Registered Dietician's weight change note dated January 5, 2024, in response to a weight on January 5, 2024 , revealed that the weight loss was confirmed. Resident on cardiac diet, vegetarian. Dietician recommended to liberalize the diet and discontinue cardiac diet. Recommended to start house shake (protein supplement) once daily, magic cup (protein supplement) once daily and weekly weights for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for the month of January 2024 revealed that the supplements were not initiated and given as recommended. No weekly weights were completed. Physician was not notified. There were no monthly weighs available for the month of February 2024. Review of dietician progress note dated January 29, 2024, revealed that the dietician recommended to add Vitamin C 500 mg twice daily, start multivitamin with minerals and zinc. Review of clinical record revealed that the above recommendations were not initiated or provided to the resident. There was no nutritional assessment from January 29, 2024 to April 1, 2024. Review of clinical record for January 2024 and February 2024 revealed no evidence that the above recommendations were implemented. Review of physician order dated March 2024, revealed that it was not until March 2024 that an order was obtained for the nutritional supplement Mighty shake (products with extra calories and protein in a tasty drink that is rich and creamy like a milkshake). Review of the Registered Dietician's weight change note dated April 1, 2024, revealed that the dietician requested a re-weight again. Review of the Registered Dietician's weight change note dated April 3, 204, revealed that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 7 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Immediate jeopardy to resident health or safety dietician documented diet not liberalized as recommended. Intake >50 % for most meals, given that he follows vegetarian lifestyle, liberalizing diet would offer more option. Current BMI (body mass index) 14.3under weight. To also recommend weekly weights to follow. Review of clinical record for Resident R20 for month of April 2024 revealed that there were no weekly weights completed as ordered. Residents Affected - Few Review of the Registered Dietician's weight change note dated April 28, 2024, in response to a weight on April 24, 2024, revealed that resident lost significant weight and weighed 88.8 pounds. Weight loss continued, recommended to add the nutritional supplement Boost breeze, requested to add percentage consumed for the supplements for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for May 2024 revealed that the boost breeze was not started, mighty shake percentage consumed was not documented, weekly weights were not initiated, and the physician was not notified as recommendations by the dietician as of May 3, 2024. Observation of Resident R20's meal intake dated May 7, 2024, at 12:30 p.m. revealed that the resident was observed taking couple bites of a vegetable burger, a nursing assistant asked the resident how the food was. He replied horrible. The nursing assistant walked away from the resident without offering alternatives. Interview with Food Service Director, Employee E13, on May 7, 2024, at 3:11 p.m. stated he was aware that the resident was on a vegetarian diet. He stated kitchen made vegetarian dishes like salads, vegetable burgers as available in the kitchen. He stated she was not aware of a vegetarian menu extension which has been approved by a dietician based on appropriate nutritional needs. Employee E13 stated he was not sure how much calorie intake the resident had or had no documentation of what kind of food the resident received for the past 4 months. Employee E13 confirmed that the facility did not follow the approved vegetarian menu. Interview with Registered Dietician, Employee E6, on May 7, 2024, at 2:46 p.m. stated that Resident R20 had lost significant weight over the last 6 months. She stated she made recommendations in response to weight loss multiple times, but the interventions were not implemented as recommended. She stated she only worked 2 days a week and it was not possible to track weight loss with limited time available. Registered Dietician, Employee E6 also confirmed that the weekly weights were not started, and no interventions were in place after residents last weight of 88.8 which was a significant weight loss. Registered Dietician, Employee E6 stated she did not notify the physician; it was supposed to be the nursing department who notified the physician. Interview with Regional Food Service Staff, Employee E14, on May 8, 2024, at 12:00 p.m. stated facility had approved vegetarian menu extension. Employee E13 did not know how to find it as a result it was not followed. Interview with physician for Resident R20, on May 7, 2024, at 2:00 p.m. stated she was not aware of Resident R20's weight loss. She stated she always approved dietary recommendation unless it created too many medications for residents. Physician stated Resident R20 is severely contracted, so it was possible to identify weight loss from observation and weight was required. Physician confirmed that the resident did not have any diagnosis or disease condition which created an unexplained weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 8 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A request for meal intake consumption record for Resident R20 for last 4 months was requested to the facility administrator on May 7, 2024, May 8, 2024, and May 10, 2024. However, facility did not submit meal intake documentation. Review of available meal intake consumption record form April 9, 2024, to May 9, 2024, it was revealed that facility did not document any meal consumption for April 12, May 2, May 4, May 5, 2024. Facility only documented on meal intake on April 9, 10, 16, 20, 24, 26, 27, 2024; May 1, 3, 6, and 7, 2024 missed two meal intake documentation for these dates. Facility documented only two meal intake documentation on April 13, 15, 17, 18, 21, 28, 2024 and missed one meal documentation for these dates. Review of clinical record for Resident R20 on May 7, 2024 revealed that there was no weekly, weights implemented, no dietary recommendation from April 28, 2024 implemented, no physician notification and evaluation completed for Resident R20 in response to weight loss, facility did not follow approved vegetarian diet with appropriate nutritional value and did not monitor meals intake appropriately. An Immediate Jeopardy situation was identified to the Nursing Home Administrator, on May 9, 2024, at 1:30 p.m. for the facility's failure to implement dietary recommendation as ordered by the Registered Dietician and failed to follow the facility approved vegetarian diet for Resident R20, who was assessed as nutritionally at risk and preferred a vegetarian diet. The facility failed to monitor meal intake, to notify the physician and to complete a physician assessment in response to a significant weight loss. This failure resulted in the resident experiencing a significant weight loss on December 1, 2023, had a further significant weight loss on, January 5, 2024, March 29, 2024, and on April 24, 2024. This continued failure placed Resident R20 in harm at risk for further weight loss and further harm without appropriate interventions. An immediate jeopardy template (a document which included information necessary to establish each of the key components of the immediate jeopardy) was provided to the Nursing Home Administrator on May 9, 2024, at 1:30 p.m. The facility submitted a written plan of action on May 9, 2024, at 5:00 p.m. and implemented the plan of action which included: -On 5/8/2024 the facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that the residents in the facility with concerns regarding weight loss were addressed by the physician/dietician and that recommendations were implemented if applicable; resident food preferences were being honored, to ensure that meal consumption amounts are being properly monitored and documented and to ensure that current policies were reviewed with changes made as indicated. -Resident 20 was reweighed, and the dietician and physician were notified to implement interventions as needed on 5/8/2024. -The resident was reassessed by the physician on 5/9/2024. -The resident was re-interviewed by the dietary manager 5/9/2024 to update preferences related to preferred vegetarian diet. -Current facility residents were re-weighed on 5/8/2024 and 5/9/2024. The physician and dietician were notified of any significant changes with interventions implemented if applicable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 9 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few -Currently facility residents were interviewed by the Certified Dietary Manager on 5/9/2024 to ensure their diet preferences were up-to-date and to ensure their preferences were being honored. An additional audit of the meal tracker system was completed by the Certified Dietary Manager to ensure that orders accurately reflected residents' current preference. -Dietary recommendations for the last 30 days were reviewed on 5/9/2024 to ensure that any recommendations made were implemented. -Facility Licensed Nurses received education on starting on 5/8/2024 and will be completed on 5/9/2024 from the Director of Nursing regarding the procedures for obtaining resident weights and notifying the physician and dietician of any significant changes, along with implementing dietary recommendations in a timely manner. -Facility clinical staff received education starting on 5/9/2024 and will be completed on 5/9/2024 from Director of Nursing on ensuring that resident meal intake is appropriately monitored and documented. -Facility Dietary Staff will receive education from the CDM starting on 5/9/2024 and will be completed on 5/9/2024 on ensuring that residents are receiving the appropriate diet based on their preferences. -An Ad Hoc QAPI Meeting was held on 5/9/2024 to discuss the events surrounding the resident's weight loss, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding obtaining weights, communication with the IDT team when significant changes occur, implementing physician/dietician recommendations in a timely manner and ensuring that resident meal preferences are honored. -Any staff member that did not receive education related to the above mentioned was notified by the staffing coordinator verbally via phone indicating they may not return to work until the education is received. -Newly hired staff will receive education in orientation -Education for respective facility staff as stated above, weekly weight meetings with the members of the interdisciplinary team to ensure that weights are being obtained and any significant changes are addressed immediately with the appropriate team members to include the physician, verbally while in the facility and via phone call when not present; the dietician will be present in the weekly weight meetings and will provide a paper copy of recommendations made; an additional copy of recommendations will be provided to the facility in the form of an electronic copy via email to the NHA, DON, and CDM; care plans are active and reflect appropriate interventions related to the residents' current nutrition and weight status. -Audits will be conducted as follows: bi-monthly resident interviews by the CDM to ensure that resident food and diet preferences remain up to date; random audits of 5 residents weekly to ensure that food intake is being appropriately monitored and documented. -Actions to be completed on 5/9/2024 -The Quality Improvement Performance Committee will continue to hold weekly meetings to review and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 10 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Immediate jeopardy to resident health or safety discuss the results of the ongoing quality monitoring. The findings of these quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings. On May 10, 2024, the action plan was reviewed, clinical records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed. Residents Affected - Few Following the verification of the immediate action plan the Immediate Jeopardy was lifted on May 10, 2024, at 3.58 p.m. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 11 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 3 residents with weight loss reviewed (Resident R21). Residents Affected - Few Findings include: Review of facility policy Weight Assessment and Intervention dated September 2008, revealed that Weight Assessment The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) (usual weight) x 100): 1 month -5% weight loss is significant; greater than 5% is severe a. 3 months =7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of weight assessment for Resident R20 dated November 1, 2023, revealed that the resident weighed 132 .6 pounds. Review of weight assessment for Resident R20 dated November 28, 2023, revealed that the resident weighed 119.0 pounds which was 10.25 % weight loss in a month (severe weight loss) Review of a reweight assessment for Resident R20 dated December 1, 2023, revealed that the resident weighed 115.0 pounds which was 13.27 % weight loss in a month (severe weight loss) Review of weight assessment for Resident R20 dated January 2, 2024, revealed that the resident weighed 107.0 pounds which was 6.95 % weight loss in a month and 18.9 % in three months (severe weight loss) There were no monthly weighs available for the month of February 2024. Review of weight assessment for Resident R20 dated March 29, 2024, revealed that the resident weighed 91 pounds which was 13.33 % weight loss from the last weight of January 5, 2024. and 31.5 % in six months (severe weight loss) Review of weight assessment for Resident R20 dated April 24, 2024, revealed that the resident weighed 88.8 pounds which was 2.41 % weight loss from the last weight of March 29, 2024. and 33.03 % in six months (severe weight loss). Review of dietician weight change note dated January53, 2024, in response to a weight on January 5, 2024, revealed that the weight loss was confirmed. Resident on cardiac diet, vegetarian. Dietician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 12 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few recommended to liberalize the diet and discontinue cardiac diet. Recommended to start house shake (protein supplement) once daily, magic cup (protein supplement) once daily and weekly weights for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for the month of January 2023 revealed that the physician was not notified and an assessment was not completed. Review of dietician weight change note dated April 28, 2024, in response to a weight on April 24, 2024, revealed that resident lost significant weight and weighed 88.8 pounds. Weight loss continued, recommended to add boost breeze, requested to add percentage consumed for the supplements for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for May 2024 revealed that the physician was not notified as recommended by the dietician as of May 3, 2024. Interview with Physician for Resident R20, on May 7, 2024, at 2:00 p.m. stated she was not aware of Resident R20's weight loss. She also confirmed that there was no assessment was completed for Resident R21 in response to weight losses. 28 Pa. Code:211.12(d)(5) Nursing services. 28 Pa. Code:211.2(a) Physician services. 28 Pa. Code 211.5(f) Clinical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 13 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on the review of facility documentation, review of personnel files and interview with staff, it was determined that the facility did not ensure that a nurse aide had a minimum of 12-hour annual training to ensure continuing competence as required for five of five employees reviewed. (Employee E15, E16, E17, E18 and E19) Residents Affected - Some Finding include: A request was made to the facility Nursing Home Administrator and Director of Nursing for annual training records for five nursing assistants, Employees E15, E16, E17, E18 and E19 on May 8, 2024, at 10:15 a.m. Facility did not submit training records for Employees E15, E16, E17, E18 and E19. Interview with the facility Administrator on May 8, 2024, at 1:30 p.m. confirmed that the facility did not track, and complete annual in-service as required by the training requirements for nursing assistants. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. 211.12(c) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 14 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of one medication storage rooms observed (first floor cart A and second floor medication storage room). Findings include: Observation of the facility east medication storage room on May 6, 2024, at 10:14 a.m., revealed that the storage room was open. The door had a lock, but it was left unlocked. Observation inside the medication storage room revealed that there was a medication refrigerator with medications. The refrigerator had metal hooks for locks, but the lock was missing. Interview with Employee E11, Licensed Practical Nurse, on May 6, 2024, at 10:14 a.m. confirmed that the medication storage room and the refrigerator was unlocked. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code. 211.12(c) Nursing services 28 Pa. Code 211.12 (d)(1) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 15 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility's planned written menus, menu extensions, and facility policy, and staff interviews, it was determined that the facility failed to follow approved vegetarian diet to ensure nutritional adequacy for one of 13 residents reviewed. (Resident R21) Findings included: Review of an undated facility policy Vegetarian Diet revealed that, The vegetarian Diet accommodates the food preference of the individuals avoiding certain animal food in their diet. Upon admission, the nursing will submit a Tray Card Slip to the dietary department denoting the physician's order for vegetarian diet. The patient will be placed on a vegetarian diet. Review of facility documentation revealed that the facility had a vegetarian extension of the cycle menu. Review of an admission nutritional assessment dated [DATE], revealed that the resident was on a vegetarian and on a cardiac diet. Resident weighed 132 pounds with a BMI of 20.7, with an estimated calorie need of 2000-2200 kcal 63-83 g of protein. Interview with Food Service Director, Employee E13, on May 7, 2024, at 3:11 p.m. stated he was aware that the resident was on a vegetarian diet. He stated kitchen made vegetarian dishes like salads, vegetable burgers as available in the kitchen. He stated she was not aware of a vegetarian menu extension which has been approved by a dietician based on appropriate nutritional needs. Employee E13 stated he was not sure how much calorie intake the resident had or had no documentation of what kind of food the resident received for the past 4 months. Employee E13 confirmed that the facility did not follow the approved vegetarian menu. Interview with Regional Food Service Staff, Employee E14, on May 8, 2024, at 12:00 p.m. stated facility had approved vegetarian menu extension. The Food Service Director, Employee E13 indicated during interview that she did not know how to assess the vegetarian extension electronically and as a result the vegetarian menu extension was not followed. 28 Pa. Code 211.6 (a) Dietary services. 28 Pa. Code 201.18 (e)(2)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 16 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, observations, and staff interviews, it was determined that the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for one of 13 residents reviewed. (Resident R37) Findings Include: Review of Resident R37's admission nutrition assessment dated [DATE], revealed that the resident had a lactose allergy and intolerance to lactose. Review of physician orders dated April 18, 2024, revealed an order for lactose intolerance, no milk. Further review of resident's nutrition assessment dated [DATE], revealed that Resident R37 had a lactose allergy and intolerance. Further review revealed an order dated May 2, 2024, for fortified foods one time a day for nutritional supplement Super Cereal. Interview with Resident R37 and his wife, on May 3, 2024, at 2:07 p.m. revealed that Resident R37 cannot tolerate a single dairy product. Further interview revealed that the resident had requested a nutritional supplement, Boost Breeze (fruit flavored clear nutritional supplement) to avoid dairy. Interview with the Registered Dietitian, Employee E6, conducted on May 7, 2024, at 2:07 p.m. revealed the fortified cereal contains oatmeal, dry milk, whole milk, butter, brown sugar, water, and salt. Interview with Resident R37 on May 7, 2024, at 2:30 p.m. confirmed that the resident has been receiving and consuming the fortified cereal each morning. 28 Pa. Code: 211.6(a)(c) Dietary service 28 Pa. Code 201.29(j) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 17 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for two of 10 residents observed during dining (Resident R25, R14). Findings Include: Review of facility policy, Therapeutic Diets, undated, revealed that 'therapeutic diets are prepared and served as ordered by the attending physician. Review of physician orders for Resident R25 confirmed an order dated, October 14, 2022, for health shake three times a day and double portions dated August 24, 2024. Observations during dining, on May 6, 2024, at 12:57 p.m. revealed Resident R25's meal ticket indicated that the resident was ordered to receive double portions and a mighty shake supplement. Observations revealed resident was not served a double portion lunch meal which consisted of ham, and a mighty shake supplement. Review of physician orders for Resident 14 confirmed an order dated October 14, 2022, for a Health Shake. Observation of dining, on May 6, 2024, at 12:57 p.m. revealed that Resident R14's meal ticket indicated, magic cup which was not provided on her meal tray. Interview with Licensed Practical Nurse, Employee E11, on May 6, 2024, at 1:15 p.m. confirmed the above-mentioned findings. Follow-up dining observations on May 7, 2024, at approximately 12:30 p.m. revealed that Resident R25 and Resident R14 did not receive a mighty shake according to their meal ticket and physician diet order. Interview with Licensed practical Nurse, Employee E11, and Unit Manager, Employee E12, at 12:45 p.m. confirmed this finding. 28 Pa. Code 211.6 (a) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 18 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings include: Review of facility undated dating and labeling procedure guide revealed that all items in the refrigerator must be dated and labeled with a date, use by date, initials, and item name. An initial tour of the main kitchen was conducted on May 3, 2034, at 8:56 a.m. with the facility Administrator, Employee E1, and Kitchen Supervisor, Employee E3. Observations revealed that the main cook was not wearing a hair net while cooking in the main kitchen area. Observations in the main refrigerator revealed all items were dated with one date, March 28, 2024, including defrosted pork loins, cheddar cheese, mozzarella cheese, and yogurt. Interview with the kitchen supervisor, Employee E3 revealed that the day, March 28, 2024, indicated the open date. Further observations revealed that pulled ham was dated May 25, 2024, and the cheese was dated April 1, 2024. Interview with the assistant supervisor revealed that the dated ham and cheese must be used by the indicated date. Interview with the kitchen supervisor, Employee E3, and Administrator at approximately 10:15 a.m. confirmed that the food items stored in the refrigerator were not labeled in accordance with professional standards for food service safety and facility foodservice procedures. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 19 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to failing to ensure that one of three residents reviewed (Resident R20) was provided with nutritional interventions, timely nutritional assessments, notification to the resident's physican of the resident's weight loss, and that the resident was provided an appropriate vegetarian diet. This failure resulted in Resident R20 experiencing unplanned significant weight loss of 43 pounds in 5 months and in an Immediate Jeopardy situation. (Resident R20) Residents Affected - Few Findings include: Review of the job description for the Nursing Home Administrator revealed, The The Administrator establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents needs in compliance with federal, state and local requirements; establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state and local regulations. Establish systems to enforce the facility policies and procedures Establish operating procedures for physician responsibilities. Act as liaison to the governing body for the medical, nursing and other professional staff and all facility departments. Prepare all reports required by the governing body Supervise all department supervisors and administrative staff. Supervise the recruitment, employment, performance, evaluation, promotion and discharge of all staff. Assume responsibility with department supervisors to implement effective policies to assure adequate staffing to meet facility needs Be responsible for all financial transactions Ensure that all necessary supplies are purchased and available Develop relationships with community agencies providing services of benefit to the facility Develop one-to-one relationship ps with residents and families. Arrange with appropriate state and legal agencies for the guardianship of those residents in need (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 20 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Arbitrate complaints and disputes concerning residents, families or personnel. Level of Harm - Minimal harm or potential for actual harm Act as liaison between the facility and regulatory agencies Assume responsibility for implementation of an effective Quality Assurance program Residents Affected - Few Consistently work cooperatively with residents, residents' representatives, facility staff, physicians, consultants and ancillary service providers Follow facility Residents' Rights policies Adhere to Corporate Compliance Program Code of Conduct and policies and procedures Protect the privacy of resident Protected Health Information. Protect the confidentiality and security of all resident and facility information Come to work in clean, neat attire and consistently present a professional appearance Perform other related duties as directed by the governing body Review of the job description for the Director of Nursing revealed that Provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. Develop and implement policies and procedures for the nursing care of residents Supervise and manage all aspects of the nursing department Cooperate with Administration to assure efficient, cost effective operation of the facility Making daily rounds on unit to supervise, observe, examine, interview residents evaluate staffing needs, monitor regulatory compliance, to achieve the care environment and to evaluate staff interactions and clinical skills competency: Develops and maintains nursing policies and procedures that reflect current standards of nursing practice and facility philosophy of care consistent with state and federal laws and regulations Establishes and implements infection control program designed to provide a safe, sanitary and comfortable environment and to prevent the development of disease and infection. Screen prospective admissions for level of care, anticipated needs and length of stay, presence of mental illness or mental retardation as required by federal regulations Audit clinical records for accuracy and completeness of comprehensive resident assessments, effective documentation reflecting resident responses to interventions and consistent implementation of plans of care by all staff and professionals. on all shifts. Conduct quality assessment and assurance activities, including regulatory compliance rounds, in the nursing department to monitor performance and to continuously improve quality. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 21 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assesses culture reports weekly to determine presence of infections, occurrence of nosocomial infections and community acquired infections. Additional duties as assigned by supervisor Review of clinical record revealed that Resident R20 was admitted to the facility with the diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hemiparesis (weakness on one side of the body, including the arms, legs, hands, and face), cognitive communication deficit and dysphagia (difficulty swallowing). Review of Resident R20's Minimum Data Set (MDS- assessment of resident care needs) dated April 7, 2024, revealed that the resident lost more than 5 % the last month and 10% or more in last 6 months and the resident was not on a prescribed weight loss regimen. Review of an admission nutritional assessment dated [DATE], revealed that the resident was on a vegetarian and on a cardiac diet. Resident weighed 132 pounds with a BMI of 20.7, with an estimated calorie need of 2000-2200 kcal, 63-83 grams of protein. Review of weight assessment for Resident R20 dated November 1, 2023, revealed that the resident weighed 132 .6 pounds. Review of weight assessment for Resident R20 dated November 28, 2023, revealed that the resident weighed 119.0 pounds which was 10.25 % weight loss in a month (severe weight loss). Review of a re-weight assessment for Resident R20 dated December 1, 2023, revealed that the resident weighed 115.0 pounds which was 13.27 % weight loss in a month (severe weight loss). Review of weight assessment for Resident R20 dated January 2, 2024, revealed that the resident weighed 107.0 pounds which was 6.95 % weight loss in a month and 18.9 % in three months (severe weight loss). There were no monthly weights available for review for the month of February 2024. Review of weight assessment for Resident R20 dated March 29, 2024, revealed that the resident weighed 91 pounds which was 13.33 % weight loss from the last weight of January 5, 2024 of 105 pounds and 31.5 % in six months (severe weight loss). Review of weight assessment for Resident R20 dated April 24, 2024, revealed that the resident weighed 88.8 pounds which was 2.41 % weight loss from the last weight of March 29, 2024. and 33.03 % in six months (severe weight loss). Review of the Registered Dietician's weight change note dated November 30, 2023 in response to a weight on November 28, 2023, revealed that a reweight was requested. No other nutritional interventions were recommended. Review of Registered Dietician's weight change note dated December 4, 2023 in response to a weight on December 1, 2023, revealed that a re-weight was requested. No other nutritional interventions were recommended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 22 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Registered Dietician's weight change note dated December 12, 2023 revealed that the dietician requested another re-weight again. Review of Registered Dietician's weight change note dated December 14, 2023, revealed that the dietician requested a re-weight again due to discrepancy in weight and wound management. Recommended to add vitamin C x 14 days. No other nutritional interventions were initiated or recommended related to the resident's weight loss. Review of Resident R20's December 2023 Medication Administration Record revealed that the nutritional recommendation of Vitamin C was not implemented. Resident did not receive the medication as recommended by the Registered Dietician. Review of the weight assessment for Resident R20 revealed that there was no re-weight obtained after December 1, 2023, as requested by the Registered Dietician. Review of Registered Dietician's weight change note dated January 3, 2024, in response to a weight on January 2, 2024, revealed that a re-weight was requested. Review of the Registered Dietician's weight change note dated January 5, 2024, in response to a weight on January 5, 2024 , revealed that the weight loss was confirmed. Resident on cardiac diet, vegetarian. Dietician recommended to liberalize the diet and discontinue cardiac diet. Recommended to start house shake (protein supplement) once daily, magic cup (protein supplement) once daily and weekly weights for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for the month of January 2024 revealed that the supplements were not initiated and given as recommended. No weekly weights were completed. Physician was not notified. There were no monthly weighs available for the month of February 2024. Review of dietician progress note dated January 29, 2024, revealed that the dietician recommended to add Vitamin C 500 mg twice daily, start multivitamin with minerals and zinc. Review of clinical record revealed that the above recommendations were not initiated or provided to the resident. There was no nutritional assessment from January 29, 2024 to April 1, 2024. Review of clinical record for January 2024 and February 2024 revealed no evidence that the above recommendations were implemented. Review of physician order dated March 2024, revealed that it was not until March 2024 that an order was obtained for the nutritional supplement Mighty shake (products with extra calories and protein in a tasty drink that is rich and creamy like a milkshake). Review of the Registered Dietician's weight change note dated April 1, 2024, revealed that the dietician requested a re-weight again. Review of the Registered Dietician's weight change note dated April 3, 204, revealed that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 23 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dietician documented diet not liberalized as recommended. Intake >50 % for most meals, given that he follows vegetarian lifestyle, liberalizing diet would offer more option. Current BMI (body mass index) 14.3under weight. To also recommend weekly weights to follow. Review of clinical record for Resident R20 for month of April 2024 revealed that there were no weekly weights completed as ordered. Review of the Registered Dietician's weight change note dated April 28, 2024, in response to a weight on April 24, 2024, revealed that resident lost significant weight and weighed 88.8 pounds. Weight loss continued, recommended to add the nutritional supplement Boost breeze, requested to add percentage consumed for the supplements for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for May 2024 revealed that the boost breeze was not started, mighty shake percentage consumed was not documented, weekly weights were not initiated, and the physician was not notified as recommendations by the dietician as of May 3, 2024. A request for meal intake consumption record for Resident R20 for last 4 months was requested to the facility administrator on May 7, 2024, May 8, 2024, and May 10, 2024. However, facility did not submit meal intake documentation. Review of available meal intake consumption record form April 9, 2024, to May 9, 2024, it was revealed that facility did not document any meal consumption for April 12, May 2, May 4, May 5, 2024. Facility only documented on meal intake on April 9, 10, 16, 20, 24, 26, 27, 2024; May 1, 3, 6, and 7, 2024 missed two meal intake documentation for these dates. Facility documented only two meal intake documentation on April 13, 15, 17, 18, 21, 28, 2024 and missed one meal documentation for these dates. Review of clinical record for Resident R20 on May 7, 2024 revealed that there was no weekly, weights implemented, no dietary recommendation from April 28, 2024 implemented, no physician notification and evaluation completed for Resident R20 in response to weight loss, facility did not follow approved vegetarian diet with appropriate nutritional value and did not monitor meals intake appropriately. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate jeopardy situation. Refer to F692 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 24 of 24