Health inspection·September 24, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that she will have to ask the social worker. Interview with Licensed Nurse Employee E3 conducted on September 24, 2025, at 12:02 PM revealed that last week either Monday (September 15, 2025) or Tuesday (September 16, 2025), Resident R1 asked her to write his complaints against a night shift nurse's aide who was rough with him during care. Further Employee E3 revealed that she wrote Resident R1's complaints in a grievance form and dropped it into the grievance box located in the unit.Interview with the Social Worker Employee E4 revealed that she regularly checks the grievance box and that did not see any grievance forms in the grievance boxes.Further interview with Employee E4 also revealed that she does not have Resident R1's grievance and that she has not done any investigation related ton Resident R1's complaints because she never got any grievances.Interview with Director Employee E2 confirmed that there was not aware of any grievances submitted by Resident R1.Further interview with Employee E2 confirmed that the facility did not conduct an investigation related to Resident R1's complaints that the night shift nurse's aide was rough with him during care. Pa. 28 Code: 201.29(i) Resident Rights. Event ID: Facility ID: 395095 If continuation sheet Page 2 of 4 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 09/24/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, review of facility documents and interview with staff and residents, it was determined that the facility failed to investigate an allegation of verbal abuse by two of four residents reviewed. (Resident R1 and Resident R2)Findings include: Review facility policy entitled Abuse Prevention Program dated January 1 2022 and reviewed on November 30 2022, revealed that under section Policy Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation this includes but is not limited to freedom from corporal punishment, and voluntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraints not required to treat the resident symptoms. Under section Policy Implementation #6. Identify and assess all possible incidents of abuse. # 7. Investigate and report any allegation of abuse within time frames as required by federal and state requirement. #8. Protect residents during abuse investigation.Review of policy for Abuse investigation and Reporting dated January 1, 2022, and reviewed on November 30 2022, Reveal that under section Policy All reports of resident abuse neglect exploitation misappropriation of resident property mistreatment and or injuries of an own source shall be promptly reported to local state and federal agencies as defined by current regulations and thoroughly investigated by facility management findings of abuse investigation will also be reported. Under Policy Implementation # D the administrator will suspend immediately an employee who has been accused of resident abuse pending the outcome of the investigation #16 The individual conducting the investigation will as a minimum a review the completed documentation forms #c. Interview the person reporting the incident #d. Interview any witnesses to the incident #e. interview the resident as medically appropriate #g. Interview staff members on all shifts who have had contact with a resident during the period of the alleged incident #h. Interview the resident's roommate family members and visitors #j. Review all events leading up to the alleged incident.Review of Resident R1's clinical record Reveal that resident R1 was admitted to the facility on [DATE], with the diagnosis of but not limited to Severe Protein Calorie Malnutrition.Review of Resident R1S MDS (minimum data set-a federally required resident assessment completed at a specific interval), dated September 10, 2025, revealed that under Section C - Cognitive Patterns,0500. BIMS Summary Score (brief interview for mental status) revealed that Resident R1 was coded 15, suggesting that Resident R1 was cognitively intact.Review of the facility grievance log revealed no grievances from Resident R1. Interview with Resident R1 conducted on September 24, 2025, at 9:42AM revealed that Resident R1 complained that the nurse's aide that works during the night shift was so rough with him during care and that she yells at him.Further Interview with Resident R1 revealed that he wrote a complaint about the nurse's aide twice already. Further Resident R1 also revealed that last week, the medication nurse wrote his complaint for him. Further, Resident R1 revealed that nothing has been done to address his complaints. Interview with DON (director of nursing) Employee E2 conducted on September 24, 2025, at 11:59AM revealed that when asked if she did an investigation on Resident R1's grievance, Employee E2 revealed that she will have to ask the social worker. Interview with Licensed Nurse Employee E3 conducted on September 24, 2025, at 12:02 PM revealed that last week either Monday (September 15, 2025) or Tuesday (September 16, 2025), Resident R1 asked her to write his complaints against a night shift nurse's aide who was rough with him during care. Further Employee E3 revealed that she wrote Resident R1's complaints in a grievance form and dropped it into the grievance box located in the unit.Interview with the Social Worker Employee E4 revealed that she regularly checks the grievance box and that did not see any grievance forms in the grievance boxes.Further interview with Employee E4 also revealed that she does not have Resident R1's grievance and that she has not done Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395095 If continuation sheet Page 3 of 4 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 09/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete any investigation related ton Resident R1's complaints because she never got any grievances.Interview with Director Employee E2 confirmed that there was not aware of any grievances submitted by Resident R1.Further interview with Employee E2 confirmed that the facility did not conduct an investigation related to Resident R1's complaints that the night shift nurse's aide was rough with him during care.Review of Resident R2's clinical record Reveal that Resident R2 was admitted to the facility on [DATE], was discharged on August 28, 2025, and was readmitted on [DATE], with the diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Morbid Obesity.Review of Resident R2's MDS (minimum data set-a federally required resident assessment completed at a specific interval), dated September 10, 2025, revealed that under Section C - Cognitive Patterns,0500. BIMS Summary Score (brief interview for mental status) revealed that Resident R1 was coded 14, suggesting that Resident R1 was cognitively intact.Interview with Resident R2 conducted on September 24, 2025, at 9:28AM revealed that revealed that the nurse's aides were rough during care and that they yelled at her. Further, Resident R1 revealed that one time, she pushed the call bells 3 times, the staff came in 3 times, and she turned it off telling her I'm busy, I can't do you right now and when she came back, she was rough with me.Further interview with Resident R2 revealed that the nurse's aide that was rough with her during care works on the evening shift. Further Resident R2 revealed that last night during the night shift, an African nurse's aide yelled at her. Further interview with Resident R2 revealed that resident R2 has reported the above complaints to the Director of Nursing and to the Administrator.Review of Resident Concern Report completed by Social Worker Employee E4 dated August 15, 2025, revealed that a voice message from Resident R2's husband was left on August 14, 2025, and was received on August 15, 2025, complaining about being left in bed for hours in feces before someone care in to help her. Further, the Resident Concern Report also revealed that Resident R2's husband complained that his wife was being manhandled. Further, the Resident Concern Report section: Document steps taken to investigate and outcome revealed a statement from Resident R2 stating she push the call bell three times nurse's aide came in three times and turned it off, I'm busy I can't do you right now and when she came back, she was rough with me.Further review of Resident Concern Report revealed no documented evidence that a complete investigation was conducted. There was no statements from staff, there was no findings or conclusion, there was documented action by the facility to address the issues, no staff disciplinary action, there was no staff education.Further review of the report indicated that it was investigated by Employee E2 and Employee E4 on August 15, 2025.Further the facility administrator signed the report on August 18, 2025.Interview with Social Worker Employee E4 conducted on September 24, 2025, at 12:41PM revealed that she identified the nurse's aide involved in Resident R2's complaint and interviewed her. Employee E4 revealed that the nurse's aide told her that Resident R2 had pressed the call bell at least 50 time in 2 hours and that the nurse's aide said that she can't do Resident R2 alone, and that it's hard not be rough because she is such a big lady, there is no gentle want do it Further interview with Employee E4 confirmed that she did not write her interview with the nurse's aide and her statement was not on file.Interview with DON (director of nursing) Employee E2 conducted on September 24, 2025, at 11:59AM revealed that when asked if she did an investigation on Resident R2's complaints, Employee E2 revealed that she did not know because the facility administrator who was no longer working at the facility took care of that investigation.The facility was not able to provide upon request, documented evidence that an investigation was conducted on Resident R1 and Resident R2's allegations of verbal and physical abuse. 28 Pa. Code:201.18(a)(1)(3) Management28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Event ID: Facility ID: 395095 If continuation sheet Page 4 of 4