Health inspection·March 6, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Further review of Resident R26's clinical record revealed no documented evidence that advanced directives or his choices related to his Advanced Directive was discussed with Resident R26. Interview with Unit Manager Employee E3 conducted on March 4, 2025 at 12:40 p.m. confirmed that there was no Advanced Directives in place for Resident R26 Residents Affected - Few Review of Resident R26's physician order revealed that there was no physician's order for Advanced Directives. 28 Pa Code 211.12(d)(3) Nursing services 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 17 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 03/06/2025 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to identify the placement of beds against the wall as a restraint three one of 13 residents reviewed. (Residents R247, R248, R249). Residents Affected - Few Findings Include: Review of facility policy titled, Use of Restraints, revised 2017, revealed physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrics freedom of movement or restricts normal access to one's body. Further review of policy Use of Restraints revealed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restrics his/her typical ability to change postion or place, that device is considered a restraint. Clinical record review revealed Resident R247 was admitted to the facility February 23, 2025 with a diagnoses of Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior), cognitive communication deficit, and lack of coordination. Observation on March 03, 2025 at 07:05 a.m. revealed Resident R247's asleep in bed and the bed (left side) against the wall. Review of Resident R247's care plan, dated February 24, 2025, revealed Resident 247 was at high risk for falls related to deconditioning, gait, and balance problems. No care plan or assessment was included in Resident R247's clinical record for safety or preference with a bed against the wall. Clinical record review revealed Resident R248 was admitted to the facility February 23, 2025 with a diagnosese of respiratory failure with hypoxia (low level of oxygen in the body tissue), muscle weakness, and repeated falls. Review of Resident R248's MDS, dated [DATE], revealed the resident had a BIMS score of 13 indicating intact cognition. Observation on March 03, 2025 at 7:10 a.m. revealed Resident R248 asleep in bed and the bed (left side) against the wall. Review of Resident R248's care plan, dated February 24, 2025, revealed Resident 248 was at high risk for falls related to deconditioning, gait, and balance problems. No care plan or assessment was included in Resident R248's clinical record for safety or preference with a bed against the wall. Clinical record review revealed Resident R249 was admitted to the facility February 23, 2025 with a diagnoses of hypertensive urgency (dangerously high blood pressure), muscle weakness, and abnormalities of gait and mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 3 of 17 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 03/06/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Review of Resident R249's MDS assessment, dated March 02, 2025, revealed the resident had a BIMS score of 15 indicating intact cognition. Observation on March 03, 2025 at 7:12 a.m. revealed Resident R249 asleep in bed and the bed (right side) against the wall. Residents Affected - Few Interview on March 03, 2025 at 7:52 a.m. with Licensed Practical Nurse, Employee E4, confirmed Residents R247, R248, and R249's beds were against the wall. Observation on March 04, 2025 at 11:38 a.m. revealed Resident R249 sitting on bed and bed (right side) against wall. Interview on March 04, 2025 at 11:40 a.m. with Resident R249 revealed upon admission to the facility the bed was already against the wall. Resident R249 stated it is not Resident R249's preference for the bed to be against the wall. Observation on March 05, 2025 at 09:40 a.m. - 09:45 p.m. revealed Residents R247, R248, and R249's beds against the wall. Interview on March 05, 2025 at 09:50 a.m. with Director of Nursing, Employee E2, confirmed Resident R247, R248, and R249's beds were against the wall. 28 Pa. Code 211.8(e)(f) Use of Restraints. 28 Pa. Code:211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 4 of 17 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 03/06/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of facility policy, it was determined that the faciltiy failed to ensure that a baseline care plan was developed for one of 13 residents reviewed. (Resident R149) Findings include: Review of facility policy on care plan, Comprehensive-Person Centered revealed that. Under Section Policy Statement, a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychological and functional needs is developed and implemented for each resident. Under section Policy Interpretation and Implementation. Revealed that. #1 The interdisciplinary team, in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. #7. The comprehensive person-centered care plan: #a. includes measurable objectives and time frames. #b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, or psychosocial well-being, #c. includes the resident's stated goals upon admission and desired outcomes. #d. builds on the resident's strengths and #e. reflects current recognized standards of practice for problem areas and conditions. Review of Resident R149's clinical record revealed that Resident R149 was admitted to the facility on [DATE], with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), Centrilobular Emphysema, Generalized Anxiety Disorder, Alcohol Dependence, Depression, Acute Pancreatitis, Anemia (low red blood count). Review of Resident R149's physician order revealed orders for but not limited to Lidocaine External Patch 4 %, apply to left shoulder daily topically one time a day for pain-dated 2/24/25; Eliquis Oral Tablet 5 milligrams (mg) give 1 tablet by mouth two times a day for DVT (Deep Vein Thrombosis- a condition in which a clot develops in the deep vein) prevention-dated 2/23/25, Gabapentin Oral Tablet 600 mg give 1 tablet by mouth three times a day for Neuropathy-dated 2/23/25. Further review of Resident R149's care plans revealed only one care plan in place which addressed ADL (activities of daily living) self-care performance deficit. Further, the ADL care plan was initiated on March 3, 2025. Further, there was no other comprehensive care plans in place for Resident R149. Interview with Unit Manager Employee E3 conducted on March 3, 2025 on at 09:55 AM confirmed that there was no baseline care plan and no comprehensive resident centered care plan developed for Resident R149 until March 3, 2025, eight days after Resident R149 was admitted to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 5 of 17 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 03/06/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to develop comprehensive care plan for one of thirteen residents reviewed related to weight changes(Resident R33). Findings Include: Review of facility policy on care plan, Comprehensive-Person Centered revealed that. Under Section Policy Statement, a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychological and functional needs is developed and implemented for each resident. Under section Policy Interpretation and Implementation. Revealed that. #1 The interdisciplinary team, in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. #7. The comprehensive person-centered care plan: #a. includes measurable objectives and time frames. #b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, or psychosocial well-being, #c. includes the resident's stated goals upon admission and desired outcomes. #d. builds on the resident's strengths and #e. reflects current recognized standards of practice for problem areas and conditions. Review of Resident R33's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to Pleural effusion (build up of fluid in lungs), dysphagia (difficulty swallowing) and cognitive communication deficit. Review of Resident R33's weight record revealed the following weight values: December 6, 2024 -180 lbs (admission weight) January 2, 2025 -147 lbs (-18.3%, -33 lbs) January 15, 2025 -148lbs (-17.8%, -32 lbs) January 27, 2025 -150 lbs (-16.7%, -30 lbs) February 22, 2025 -150.4 lbs (-16.4%, -29.6 lbs) Further review of Resident R33's clinical record revealed no documented evidence that a comprehensive care plan was developed to address the resident's weight. 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 6 of 17 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 03/06/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, resident and staff interviews, it was determined that the facility failed to provide services to maintain adequate grooming of residents that required staff assistance with activities of daily living for two of 13 residents reviewed (Resident R243, R244). Residents Affected - Few Findings include: Clinical record review revealed Resident R243 was admitted to the facility February 15, 2025 with a diagnosis that included but not limited to chondrocalcinosis (form of arthritis that causes sudden episodes of pain and swelling in joints), lack of coordination, and cognitive communication deficit. Review of Resident R243's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated February 27, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Observation on March 04, 2025 at 12:05 p.m. revealed Resident R243's beard was not adequately groomed. Interview on March 04, 12:07 p.m. with Resident R243 and Resident R243's family member revealed resident has not been adequately groomed by facility since admission. Resident R243's family member revealed resident's family member came to facility with razor to shave resident since no assistance was being provided by facility. On March 04, 2025 at 12:15 p.m. interview with Licensed Nurse, Employee E4, confirmed there was no documentation or evidence that staff provided Resident R243 with grooming assistance. Clinical record review revealed that Resident R244 had a diagnosis that included but not limited to cirrhosis of liver (disease of liver resulting in scarring and liver failure), muscle weakness, and cognitive communication deficit. Review of Resident R244's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated March 3, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. Observation on March 04, 2025 at 10:45 a.m. revealed Resident R244's beard overgrown and hair growing over resident's upper lip. Interview on March 04, 2025 at 10:47 a.m. revealed Resident R244 has not received adequate grooming since resident's admission to facility. Resident R244 further stated that his beard is hanging over upper lip causing him to not eat properly and comfortably. Interview with Director of Nursing, Employee E2, confirmed Resident R244's beard is overgrown and resident required assistance with grooming. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 7 of 17 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 03/06/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to promote healing of pressure ulcers and prevent development of pressure ulcers for one of 13 residents reviewed for pressure ulcer. (Resident R1) Residents Affected - Few Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of lower end of left femur (break in the thigh bone), closed fracture with routine healing, and muscle weakness. Review of Resident R1's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 10, 2025, revealed in section GG00130 Resident R1 was dependent for ability to roll from lying on back to left and right side, and return to lying on back on the bed. Further review revealed in section M0150, Resident R1 at risk of developing pressure ulcers/ injuries. Continued review revealed in section M0100, Resident R1 does not have a pressure ulcer/injury, a scar over bony prominence, or a non-removeable dressing/device (as of February 10, 2025). Review of Resident R1's care plan February 8, 2025, revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. Further review of Resident R1's care plan, initiated February 3, 2025, revealed resident has bowel incontinence and resident at risk for skin breakdown related to immobility. Review of Resident R1's wound note dated February 12, 2025, revealed the resident acquired DTPIs (Deep Tissue Pressure Injury) on sacrum, left heel and right heel while under care of facility. Review of Resident R1's wound note dated February 19, 2025, revealed the resident acquired Stage 1 pressure injury to right great toe- medial while under care of facility. Review of Resident R1's entire clinical record revealed no documented evidence that a turning and positioning program was implemented to prevent the development of pressure ulcers. Interview with Unit Manager Employee E3 conducted on March 5, 2025 at 11:02 am confirmed that there was no documented evidence for turning and positioning to prevent development of pressure ulcer. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 8 of 17 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 03/06/2025 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based staff interviews and review of clinical records, it was determined that the facility failed to ensure that weekly weights were obtained as ordered by physician for 2 out of 13 residents reviewed (Resident R1, Resident R33). Residents Affected - Few Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of lower end of left femur (break in the thigh bone), closed fracture with routine healing, and muscle weakness. Review of Resident R1's clinical record revealed a physician's order dated February 12, 2025 for resident to be weighed weekly x 4 weeks, then monthly. Review of Resident R1's weight record revealed the the resident was weighted at the time admission on [DATE]- 129.0 pounds. Continued review of weight record revealed no documented evidence that the resident was weighted weekly as ordered by the physician. Review of Resident R1's clinical record revealed no documented evidence that Resident R1 had refused to be weighed. Interview with Unit Manager Employee E3 conducted on March 4, 2025 at 2:00 pm confirmed that if weight is not obtained for a resident or resident refuses, it should be noted in the progress note and care plan should be created. Further interview with Employee E3, confirmed Resident R1's clinical record revealed no documented evidence of an attempt to obtain weights or refusal by resident. Review of Resident R33's clinical record revealed that Resident R33 was admitted to the facility on [DATE] with diagnoses that included but not limited to Pleural effusion (build up of fluid in lungs), muscle weakness, dysphagia (difficulty swallowing) and cognitive communication deficit. Review of Resident R33's clinical record revealed a physician's order on December 11, 2024 for resident to be weighed weekly x 4 weeks, then monthly. Continued review of the resident's clinical record revealed that the resident was discharged to the hospital on December 12, 2024. Review of Resident R33's clinical record revealed that Resident R33 was readmitted to the facility on [DATE]. Review of Resident R33's weight record revealed that the resident weighted 180 pounds at admission on [DATE]. The next available weight was on January 2, 2025 -147 lbs. There was no documented evidence that the resident was weighted at the time of readmission on [DATE]. Review of Resident R33's clinical record revealed the resident was weighted on, January 2, 2025 and the next available weight was not until January 15, 2025 which is greater than 7 days. Review of Resident R33's clinical record revealed that the next weight from January 15, 2025 was on January 27, 2025 which is greater than 7 days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 9 of 17 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 03/06/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R33's clinical record revealed no documented evidence that Resident R33 had refused to be weighed. Interview with Unit Manager Employee E3 conducted on March 4, 2025 at 2:00 pm confirmed that if weight is not obtained for a resident or resident refuses, it should be noted in the progress note and care plan should be created. Further interview with Employee E3, confirmed R33's clinical record revealed no documented evidence of an attempt to weight or refusal by resident. 28 Pa. Code 211.5(ix) Clinical findings 28 Pa. Code 211.12(d)(1)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 10 of 17 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 03/06/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to follow recommendations to maintain acceptable parameters of nutrition for a resident receiving enteral nutrition for one of two residents reviewed. (Resident R33) Findings include: Review of Resident R33's clinical record revealed that Resident R33 was admitted to the facility on [DATE] with diagnoses that included but not limited to Pleural effusion (build up of fluid in lungs), muscle weakness, dysphagia (difficulty swallowing) and cognitive communication deficit. Review of Resident R33's care plan revealed that resident requires tube feeding related to dysphagia (difficulty swallowing) and intervention initiated for Registered Dietitian to evaluate quarterly and as needed, monitor caloric intake, estimate needs and make recommendations for changes to tube feeding as needed. Review of Resident R33's clinical record revealed a physician order dated December 30, 2024 for one time a day Jevity 1.5 (tube feed) at 20 ml/hour up at 7pm. No total volume listed in physician order. Review of Resident R33's clinical record revealed a physician order dated January 2, 2025 one time a day Jevity 1.5 (tube feed) at 30 ml/hour up at 7pm. No total volume listed in physician order. Review of Resident R33's clinical record revealed a physician order dated January 8, 2025, increase tube feed by 10 ml every 8 hours until goal of 65ml/hour is reached. Review of Resident R33's clinical record revealed a physician order dated January 11, 2025 for two times a day for Nutrition Jevity 1.5 (tube feed) 65ml/ hour for 22 hours TV (total volume) 1430 ml. Review of Resident R33's nutritional assessment review dated January 2, 2025 revealed recommendation from Registered Dietitian for tube feed to run at 65ml/hour over 22 hours for TV (total volume) of 1430ml daily. Further review of Resident R33's clinical record revealed no documented rationale from physician for delay in meeting resident's caloric needs as recommended by the Registered Dietician. 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 11 of 17 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 03/06/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's and administering oxygen as ordered by the physician for two of thirteen residents reviewed. (Residents R146 and R149). Residents Affected - Few Findings Include: A review of the facility policy titled Oxygen Administration The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident R146's clinical record revealed that Resident R146 was admitted to the facility February 23, 2025, with diagnoses of but not limited to Acute Respiratory Failure, COPD (Chronic Obstructive Pulmonary Disease), and Anemia (low blood count) Review of Resident R146's physician orders revealed an order for O2 (Oxygen) at 2L (liters)/min via NC (nasal Cannula), continuously every shift for SOB (shortness of breath). Observation conducted on March 3, 2025, at 09:17 a.m. during tour of the facility revealed that Resident R146 was in bed awake on oxygen concentrator via nasal cannula. Further observation revealed that the resident's tubing with a label w 2.20 written on it. Further observation revealed that the oxygen flow meter on the oxygen concentrator was at 5 liters/minute. Interview with the Director of Nursing Employee E3 conducted during a follow up observation together with Employee E2 on March 3, 2025, at 09:31 a.m., confirmed that Resident R146's oxygen flow meter was at 5 liters/minute. Further, Employee E3 confirmed that the physician's order was for O2 (Oxygen) at 2L/min via NC (nasal Cannula) continuously every shift for SOB (shortness of breath). Review of Resident R149's clinical record revealed that Resident R149 was admitted to the facility on [DATE], with diagnoses of but not limited to COPD (Chronic Obstructive Pulmonary Disease), Centrilobular Emphysema, Generalized Anxiety Disorder, and Anemia. Review of Resident R149's physician's orders revealed that there was no order for oxygen therapy. Observation conducted on March 3, 2025, at 09:44a.m. revealed that Resident R149 was in bed, oxygen concentrator via nasal cannula. Further observation revealed that Resident R149's oxygen tubing and the humidification bottle did not have a date affixed to it. Further observation revealed that the oxygen concentrator's flow meter reading was 5 liters/minute. Interview with Resident R149 conducted at the time of the observation revealed that he told the staff about it but they didn't do anything about it. Interview with Director of Nursing, Employee E2 conducted on March 3, 2025, at 09:53 a.m. during a follow up observation Unit Manager, Employee E3 confirmed that Resident R149's oxygen flow meter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 12 of 17 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 03/06/2025 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 0695 reading was 5 liters/minute. Level of Harm - Minimal harm or potential for actual harm Interview with Unit Manger Employee E3, conducted on March 3, 2024, at 09:55 a.m. confirmed that there was no physician's order in place for oxygen for Resident R149. Residents Affected - Few 28 Pa. Code 211.12(d)(1) Nursing services 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 13 of 17 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 03/06/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to ensure that appropriate pain management was provided to a resident consistent with standards of professional practice for one of thirteen residents reviewed (Resident R148). Residents Affected - Few Findings include: Review of thefacility policy entitled Pain assessment and management revealed that under section Purpose: The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under Section General Guidelines: #1 The pain management program is based on facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident's choices related to pain management. #2. Pain management is defined as the process of alleviating the residents pain based on his or her critical condition and established treatment goals. #3. pain management is a multidisciplinary care process that includes the following #a. assessing the potential for pain. #b. recognizing the presence of pain. #c. identifying the characteristics of pain. #d. Addressing the underlying causes of pain, developing and implementing approaches to pain management. #f. Identifying and using specific strategies for different levels and sources of pain. #g. Monitoring for the effectiveness of interventions and #h. modifying approaches as necessary. #5. Acute pain or significant worsening of chronic pain should be assessed every 30 to 60 minutes after the onset and reassess as indicated and to relief is obtained. #6. For stable chronic pain, the resident pains and consequences of pain are assessed at least weekly. Under section Implementing Pain Management Strategies: #2. Pharmacological interventions may be prescribed to manage pain; however, they do not usually address the cause of pain and can have adverse effects on the residents. Under section Documentation: #1. Document the residents reported level of pain with adequate detail as necessary and in accordance with the pain management program. #2 Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Review of Resident R148's clinical record revealed that Resident R148 was admitted to the facility on [DATE], with diagnoses of but not limited to: Spinal Stenosis, Low Back Pain, Pain in Leg, Chronic Pain Syndrome, Allergy. Review of Physician's orders revealed the following orders: Oxycodone HCl Oral (opioid) Tablet 5 MG (milligrams) give 1 tablet by mouth every 6 hours as needed for severe pain-date ordered 3/2/25 Tramadol HCl Oral (opioid) Tablet 50 MG give 1 tablet by mouth every 6 hours as needed for severe pain-date ordered 3.1.25 with date discharged order of 3/2/25 Tramadol HCl Oral (opioid) Tablet 50 MG Give 1 tablet by mouth every 8 hours as needed for moderate pain-date ordered 3/2/25 Tylenol tablets 325 mg give 2 tablet by mouth every 4 hours as needed for pain do not exceed 3 gm/ day-date ordered: 2/28/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 14 of 17 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 03/06/2025 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review or Resident R148's MAR (medication administration record) for March 3, 2025, revealed that during the day shift (unspecified time), Resident R148 had a documented pain at level 10. Further, Tylenol 650 mg was given at 04:20PM and at 10:25PM. Further review of Resident R148's MAR for March 3, 2025, revealed that Oxycodone HCl Oral (opioid) Tablet 5 MG give 1 tablet by mouth every 6 hours as needed for severe pain-date ordered 3.2.25 was not administered to Resident R148. Review or Resident R148's MAR (medication Administration Record) for March 4, 2025, revealed that during the day shift (unspecified time), Resident 148 had a documented pain at level 8. Further, Tylenol 650 mg was given at 5:53AM (night shift) but there was no documented evidence that Resident R148 received any pain medication during the day shift of March 4, 2025, when Resident R148 complained of pain at level 8. Further review of Resident R148's MAR for March 4, 2025, revealed that Oxycodone HCl Oral (opioid) Tablet 5 MG give 1 tablet by mouth every 6 hours as needed for severe pain-date ordered 3/2/25 was not administered to Resident R148. Interview with DON (Director of Nursing) Employee E2 conducted on March 5, 2025, at 01:10 Pp.m. revealed that the facility uses the numeric pain scale with 0 (zero)-for no pain, 1-3 for mild pain, 4-6 for moderate pain and 7 to 10 for severe pain. Review of Resident R148's list of allergies revealed that resident R148 was allergic to the following medications: Fentanyl, Hydrocode, Hydromorphone, Morphine, Oxycodone and Codeine. Further review of resident R148's clinical record revealed no documented rationale for not administering the Oxycodone HCl Oral (opioid) Tablet 5 mg give 1 tablet by mouth every 6 hours as needed for severe pain. Further, there was no documented evidence that the physician was made aware that the Oxycodone HCl Oral (opioid) tablet 5 mg 1 tablet as needed for severe pain was not administered for Resident R148's pain at level 10 on March 3, 2025, and level 8 on March 4, 2025, and there was no documented evidence that non-pharmacological technique for pain management was implimented. 28 Pa. Code 211.9 (a)(1) Pharmacy services. 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 15 of 17 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 03/06/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff it was determined that the facility failed to ensure the safe and effective use of medications in a manner that minimizes medication-related adverse consequences or events related to drug allergies for one of thirteen residents reviewed. (Resident R148) Findings include: Review of Resident R148's clinical record revealed that Resident R148 was admitted to the facility on [DATE] with diagnoses of but not limited to: Spinal Stenosis, Low Back Pain, Pain in Leg, Chronic Pain Syndrome, Allergy Review of Resident R148's list of allergies revealed that resident R148 was allergic to and the allergic reaction the following medications: Allergen: Fentanyl (opioid) Reaction Manifestation: Anaphylaxis, Hives, Shortness of breath, Angio-edema Severity: Severe Allergen: Hydrocodone (opioid) Reaction Manifestation: Hives, Itching Severity: Unknown Allergen: Hydromorphone (opioid) Reaction Manifestation: Anaphylaxis, Hives, SOB (shortness of breath), Angio-edema Severity: Severe Allergen: Morphine (opioid) Reaction Manifestation: none documented Severity: none documented Allergen: Oxycodone (opioid) Reaction Manifestation: none documented Severity: none documented Allergen: Codeine Reaction Manifestation: none documented Severity: none documented Review of Physician's orders revealed the following orders: Oxycodone HCl Oral (opioid) Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for severe pain-date ordered 3.2.25 Tramadol HCl Oral (opioid) Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for severe pain-date ordered 3.1.25 with date DC: 3.2.25 Tramadol HCl Oral (opioid) Tablet50 MG Give 1 tablet by mouth every 8 hours as needed for moderate pain-date ordered 3.2.25 Tramadol HCl Oral (opioid) Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for moderate/Severe pain-dated 3.4.25 Interview with Resident R148 conducted on March 4, 2025, at 10:16 AM revealed that Resident R148 was allergic to Opioids. Further resident revealed that she develops hives, rashes and itching with Oxycodone and Morphine. Resident also revealed that she is possibly allergy to tramadol but not as bad as the morphine and Oxycodone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 16 of 17 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 03/06/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Physician Employee E5 conducted on March 5, 2025, confirmed that there was documented Opioids allergies on Resident R148's clinical records. Further Employee E5 revealed that he had discontinued the Oxycodone and that Resident R148 was only on Tramadol. Interview with Facility Administrator Employee E1 revealed that they did not have a policy addressing allergies. 28 Pa. Code 211.9 (a)(1) Pharmacy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 17 of 17