Inspection visit

Health inspectionFebruary 1, 2024

Q: What happened during the February 1, 2024 survey of BRYN MAWR EXTENDED CARE CENTER?

This was a inspection survey of BRYN MAWR EXTENDED CARE CENTER on February 1, 2024. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at BRYN MAWR EXTENDED CARE CENTER on February 1, 2024?

Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

BRYN MAWR EXTENDED CARE CENTERCMS #39531123 citations on this visit

23 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 23 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with facility staff and review of facility policy and procedure, it was determined that the facility failed to provide care and services to enhance residents' dignity related to serving meals on disposable paperware, not serving all residents at the same time at a table and a catheter dignity bag for 14 of 32 Residents reviewed, (104, R42, R77, R120, R72, R122, R23, R74, R126, R112, R2, R57, R58, and R110). Findings include: A review of the facility policy and procedure, titled, Resident Rights and Facility Responsibilities, revised September 3, 2020, states that it is the facility's policy to comply with all Residents Rights. Clinical record review for Resident R110 revealed that resident was admitted to the facility on [DATE]. Observations during the initial tour of the facility on January 29, 2023, at 10:30 a.m. in Resident R110's room revealed that resident had an indwelling foley catheter (a tube that has been inserted into the bladder to drain urine) in place. The urine collection bag attached to the catheter was not covered with a dignity bag exposing a clear plastic bag with a yellow fluid inside of it. Interview with the Director of Nursing (DON) in Resident R110's room on January 30, 2023, at 9:45 a.m. confirmed that Resident R100's catheter bag, which was hanging on the side of her bed, was visible from the doorway and was not covered. During further interview with the DON she stated that the urine collection bag should be in a dignity bag. Observations of the dining room service on the C wing and D wing during the noon meals on January 30, 2024 and January 31, 2024 revealed that residents in this dining room were seated together at a large table inside the dining room were not served their noon meals at the same time. Residents sat and watched other residents eat for 30 minutes before they receive their foods and beverages. Nursing staff, Employees E25 and E7confirmed the lack provisions for a dignified dining experience for all the residents. Observations on Janaury 30 and January 31, 2024, throughout the facility, during the noon meal service on the A wing, B wing, C wing and D wing nursing units revealed that paper products were being used for bowls and cups for the residents. Interview with the registered dietitian, Employee E20, at 2:30 p.m., confirmed that the facility did not have enough regular dish ware for all of the residents during meals. Page 1 of 33 395311 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0550 28 Pa. Code: 201.18(b)(1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.29(a) Resident rights Residents Affected - Some 395311 Page 2 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with residents and staff, it was determined that the facility failed to ensure a resident received reasonable accommodations for rest and sleep related to the size of his bed size for one of 32 residents reviewed. (Resident 129) Residents Affected - Few Findings included Resident R129 was admitted to the facility on [DATE] with diagnoses of infection and inflammatory reactions due to an internal right hip prosthesis, bacteremia, anemia, and abnormal gait, mobility and weakness. Interview with Resident R129 on January 30, 2024, at 11:41 a.m. stated My bed is too small for me! I am 6'3 and 190 pounds. My neighbor (roommate) is 6'1 and they put an extension on his bed and got a new mattress. It's hard sleeping at night. They tell me they are going to change it, but they never do. My wife has said something too. On January 30, 2023, at 1:00 p.m. the Director of Nursing confirmed the facility failed to accomadate the resident with an appropiate sized bed. 28 Pa. Code 211.12(d)(5) Nursing services 395311 Page 3 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview with residents and staff, it was determined that the facility did not ensure that most recent survey results were accessible to residents on two of two nursing floors observed. (First and Second Floor) Residents Affected - Few Findings include: Group interview conducted on January 30, 2024, at 10:30 a.m., with alert and oriented Residents R126, R51, R116, R12, R66, R48, R108, R91 and R44 revealed that the residents were not sure where the results for the most recent surveys from the State agency were located. Observations during a tour with the Nursing Home Administrator on January 10, 2024, at 11:45 a.m. revealed that the first floor had a binder of survey results which did not contain any survey results since January 2023. Observations on the second floor revealed a binder of survey results which did not contain any survey results since 2022. Interview with the Nursign Home Administrator during this tour confirmed that the facility had not posted the recent surveys results in the binders for over a year. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights 395311 Page 4 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition on one of two nursing floors (First Floor) and a feeding pump was maintain in sanitary condition for on one of two tube feedings pumps observed (Resident R47). Findings include: Observations during the initial tour of the facility on January 29, 2024, revealed the following concerns: Observations on January 29, 2024, at 10:25 a.m., in room [ROOM NUMBER] revealed the chair rail behind bed (window bed) was broken revealing sharp, jagged edges, and the raised commode seat over the toilet was soiled in several places with dark brownish substance, especially on the grey chute in the center. Observations on January 29, 2024, at 10:35 a.m., in the hallway in B wing revealed a tan colored hand rail with several spots that had deep groves and scratches on the surface and a dark brown colored paint on these areas in five or more spots along both sides of the hall. Observations on January 29, 2024, at 10:40 a.m., in room [ROOM NUMBER] revealed white patches on the wall which were rough and did not match the color of the surrounding wall. Interview with Resident R12 on January 29, 2024, at 10:40 a.m., revealed that she thought the place could use a good paint job. Above results were acknowledged by the Nursing Home Administrator on February 1, 20204 at 3:15 p.m. Based on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related with linen transportation in one of two nursing units (1st Floor), and appropriate cleaning techniques for medical equipment, related to Observations on B wing, room [ROOM NUMBER]W revealed Resident R47's feeding pump was covered with a light brown substance that had dripped and dried on the surface of the feeding pump. Interview with, Employee E28, the regular LPN on B wing, on January 31, 2024, at 2:05 p.m. revealed that Resident E28 was under her care, and that the feeding pump should have been cleaned before the feeding was started and as needed during the shift as she would check on feeding pumps to make sure they are running properly. 28 Pa Code 201.18(e)(2.1) Management 395311 Page 5 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

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. Based on clinical record review, observations of care and services and interviews with staff, it was determined that the facility failed to develop and implement a care plan for one of five residents reviewed for activites of daily living. (Resident R98) Findings include: Clinical record review for Resident R98 revealed that this resident was dependant on staff for activities of daily living (transfer, mobility, dressing, toileting, bathing, grooming, oral care). The occupational therapy department documented on July 26, 2023 that the nursing staff were educated about passive range of motion exercises, chair and bed positioning and how to use orthotic devices for Resident R98. Review of the resident's current care plan revealed that there was no care plan developed for transfers out of bed. Resident R98 was observed spending time in bed during the days of the survey Janaury 29, 2024 through February 1, 2024. Continued review of the resident's care plan revealed that there was no care plan developed for PROM (passive range of motion) stretching for upper and lower extremities as tolerated by Resident R23. Interview with nursing staff, Employee E24, at 12:30 a.m., on January 31, 2024 revealed that Resident R23 could tolerate gentle PROM to the upper and lower extremities daily. The nursing staff member also reported that she requested the therapy department to evaluate the residents for transfers. Interview with the Director of Nursing, Employee E2 at 3:35 p.m., on February 1, 2024 confirmed the lack of development and implementation of a care plan for activities of daily living for Resident R23. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395311 Page 6 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interview, it was determined that the facility failed to ensure that a resident was transferred out of bed as ordered by the physician for one of 32 residents reviewed. (Resident R110) Residents Affected - Few Findings include: Review of clinical record review for Resident R110 revealed that the resident was admitted to the facility on [DATE], with diagnosis of acute hematogenous osteomyelitis (one of the most common forms of bone infection (osteomyelitis) where the bacteria travel in the bloodstream from another infected site and get lodged into the bone.) Further review of Resident R110's physician's orders revealed an order dated July 21, 2023, for the use of a hoyer lift (mechanical device use to transfer a person from one surface to another) for functional transfers. Review of Resident R110's care plan revealed an intervention initiated on January 26, 2023, for Hoyer lift for transfers. Interview with Resident R110 on January 29, 2023, at 10:30 a.m. revealed that she had been waiting for two weeks to get out of bed into her chair, and when she asked she was told that they could not find the Hoyer pad (fabric sling that goes under resident and attaches to the mechanical Hoyer lift). The resident stated that she had asked the nurse aide who said that it was sent to the laundry. The nurse aide told the resident that she called the laundry and that they could not locate it. She called therapy and was told it was the nurse's job to locate the Hoyer pad. Interview with Employee E12, Registered Nurse, on January 29, 2024, at 1:15 p.m. revealed that she did not know where Hoyer pad was, and that she would check with therapy. Interview with the DON on January 30, 2024, at 12:57 p.m. revealed that she did not know where the Hoyer pad was, and that she would look into it. Interview with Licensed nurse, Employee E28, on January 31, 2024, at 2:09 p.m. revealed that the resident was not out of bed yet, but that she had found the Hoyer pad in Resident R110's closet on the floor in the back of the closet, and that she would make sure the resident was out of bed the next morning. 28 Pa. Code 211.12(d)(5) Nursing services 395311 Page 7 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations and staff interview, it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two out of 32 residents reviewed (Resident R26 and R129). Residents Affected - Few Findings include: Review of clinical records of Resident R26 indicated that R26 was admitted to the facility on [DATE], with diagnoses including Paranoid Schizophrenia (positive symptoms of schizophrenia, including delusions and hallucinations; these debilitating symptoms blur the line between what is real and what is not, making it difficult for the person to lead a typical life), and Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During an interview on January 29, 2024, at 9:59 a.m., Resident R26 stated that the resident did not get a bath on January 29, 2024. Review of physician order indicated that Resident R26 was to receive bathing/shower every Tuesday and Friday 7-3. Review of the task sheet for bathing /shower of Resident R26, revealed no documented evidence on Tuesday, January 9, 2024, to indicate that Resident R26 was provided with bath/shower. On January 31, 2024, at 12:07 p.m., interview with a Licensed Nurse, the Unit Manager, Employee E22, confirmed the findings. Review of Resident R129's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of infection and inflammatory reactions due to an internal right hip prosthesis, subsequent encounter, bacteremia, anemia, and abnormal gait, mobility and weakness. Interview with Resident R129 on January 30, 2024, at 11:41 a.m. stated I have been asking for a haircut and a shave ever since I got here, over three weeks ago. My wife even tried to call them too. The resident stated he likes to keep it short and buzzes his hair and face when he is at home The resident's hair was approximately three inches past his collar and his beard was approximately the same. The resident stated he was not comfortable with his long hair and beard. Review of Resident R129's care plan revealed an ADL (activity of daily living)/self-care deficit related to decreased mobility impaired balance and weakness dated December 23, 2023, interventions included needs will be met with staff assistance. Interview with the Director of Nursing on January 30, 2023, at 1:00 p.m. could not reveal documented evidence that Resident R129 grooming needs were addressed. 28 Pa. Code 201.29(d) Resident's Rights 395311 Page 8 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0677 28 Pa Code 211.12(c) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12(d)(3) Nursing services Residents Affected - Few 395311 Page 9 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation review of clinical records and interviews with resident and staff, it was determined that the facility failed to obtain and clarify orders for wound treatment and failed to follow orders for dermatitis for one of 32 residents reviewed (Resident R129). Residents Affected - Few Findings include Review of Resident R129's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of infection and inflammatory reactions due to an internal right hip prosthesis, bacteremia, anemia, and abnormal gait, mobility and weakness. Review of physician note date December 27, 2023, noted Resident R129 with a past medical history of a right prosthetic hip joint replacement secondary to two prior hip surgeries due to MRSA (Methicillin-resistant Staphylococcus aureus is a bacterial infection that is difficult to treat in humans). A Wound V.A.C. (vacuum assisted closure of a wound using negative pressure wound therapy (NPWT) that optimizes wound healing) was placed to assist in healing and was noted to be managed by the wound care team. Interview with Resident R129 on January 30, 2024, at 11:41 a.m. stated I am ordered triamcinolone cream for my body, but the nurses don't give it to me. My wound vac wasn't working for almost a day. They left the wound dressing on, but the machine wasn't working. They said someone was going to fix it but that didn't happen. Review of Resident R129's physician notes revealed on January 23, 2024, the resident told the physician that in the morning his wound vac fell off in the bathroom. The resident stated he had an appointment with the orthopedic surgeon the next day to check on it. The same note indicated the physician called the surgeons office and was told the dressing needed to be replaced. New orders were received that day, on January 23, 2024, to replace the wound vac dressing on the resident's right lower extremity. Review of Resident R129's physician orders revealed an order dated January 2, 2024, for triamcinolone cream; given topically three times a day for dermatitis, at 9:00 a.m., 1:00 p.m. and 5:00 p.m. Further review revealed the triamcinolone cream was not administered on January 27, and 28, 2024. Review of Resident R129 initial physician orders dated December 26, 2023, instructed to place wound vac on right hip incision one time a day every Tuesday, Thursdays, and Saturdays for the incision to the right hip with sutures. Further review of the physician orders failed to obtain written instructions detailing the appropriate dressing material, negative pressure setting (from -20 to -200 mmHg) therapy setting (continuous intermittent or variable) and instructions in case of the machine malfunction or loss of suction. On January 30, 2023, at 1:00 p.m. the Director of Nursing (DON) confirmed the facility failed to obtain and clarify Resident R129's wound orders using negative pressure wound therapy. The DON also confirmed the triamcinolone cream was ordered but not given on January 27, and 28, 2024. 28 Pa Code 201.29(d) Resident's Rights 395311 Page 10 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0684 28 Pa Code 211.12(c) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12(d)(3) Nursing services Residents Affected - Few 395311 Page 11 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations of care and services, review of personnel files, review of the facility assessment and logs of in-service training and competencies for nursing staff, it was determined that the facility failed to ensure that all nursing staff possess the competencies and skills sets necessary to providing nursing and related services to meet each resident's needs for four of four personnel files. (Employees E6, E12, E7 and E24) Findings include: A review of the facility assessment revealed that residents at this facility had diagnoses of dementia, mental health disorders, bowel and bladder incontinence, cerebral vascular disease, neuropathy, paraplegia, prostate cancer, obstuctive uropathy, skin and soft tissue infections, respiratory infections, multi-drug resistant organisms, septicemia, clostridium difficile, COVID 19, tracheostomy care and terminal illnesses. Observations of care and services throughout the days of the survey January 29, 30, 31, and February 1, 2024 confirmed the residents at this facility had diagnoses of the following: dementia, mental health disorders, bowel and bladder incontinence, cerebral vascular disease, neuropathy, paraplegia, prostate cancer, obstuctive uropathy, skin and soft tissue infections, respiratory infections, multi-drug resistant organisms, septicemia, clostridium difficile, COVID 19, tracheostomy care and terminal illnesses. A review of the logs for the regular in-service training and competencies for Employee E24, a licensed practical nurse hired on June 1, 2009 revealed that there was no training and competencies for intravenous therapy and care for fluids and antibiotics. A review of the logs for the regular in-service training and competencies for Employee E7, a licensed practical nurse hired on may 11, 2023 revealed that there was no training and competencies for intravenous therapy and care for fluids and antibiotics and tracheostomy care. A review of the logs for the regular in-service training and competencies for Employee E12, a registered nurse hired on December 18, 2023 revealed that there was no training and competencies for intravenous therapy and care for fluids and antibiotics, tracheostomy care and urinary catheter care. A review of the logs for the regular in-service training and competencies for Employee E6, a registered nurse hired on February 18, 2023 revealed that there was no training and competencies for intravenous therapy for fluids and antibiotics and urinary catheter care. Interview with the Director of Nursing, Employee E2, and Nursing Home Administrator, Employee E1 at 3:15 p.m., on February 1, 2024 confirmed the lack of routine and required training and skills set competencies for nursing staff Employees E6, E12, E7 and E24. 28 PA. Code 201.19(1)(2)(3)(5)(6)(7)(10) Personnel policies and procedures 28 PA. Code 201.18(b)(1)(3)(1) Management 28 PA. Code 211.12(c)(d)(4)(5) Nursing services 395311 Page 12 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one out of five residents sampled. (Resident R30). Residents Affected - Few Findings include: Resident R30 was admitted to facility on June 29, 2022, with diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment; Symptoms include forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), and Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of the physician order revealed that Resident 30 had an order dated, June 7, 2023, for Nystatin External Powder 100000 Unit/GM (Nystatin Topical), apply to under right breast topically every day and evening shift for redness. Review of pharmacist's evaluation dated August 3, 2023, indicated that R30 has received topical anti-infective , Nystatin Powder for greater than eight weeks without a documented stop date; Please document a stop date. Rationale for recommendation: Prolonged use may increase the risk of adverse consequences, including the development of drug-resistant organisms. Further review of Pharmacist Consultation Report sheet revealed that the physician did not noted the pharmacist's recommendations until November 16, 2023, and the order for Nystatin External Powder 100000 Unit/GM (Nystatin Topical), apply to under right breast topically every day and evening shift for redness was not discontinued until November 16, 2023. During an interview conducted on February 1, 2024, at 1:27 p.m., the Nursing Supervisor, a Licensed Nurse, Employee E 29, confirmed these findings. 28 Pa Code 211.2(a) Physician services 28 Pa Code 211.5(f)(g)(h) Clinical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services 395311 Page 13 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record and policy and procedure review and staff intierview, it was determined that the facility failed to ensure that residents did not receive unnecessary medications for two of 32 residents reviewed (Resident R62 and R23). Findings Include: A review of the policy titled psychoactive medications dated May 26, 2021 it was revealed that the diagnosis supporting the use of the psychoactive medication would be documented in the medical record. The policy also said that all residents receiving psychoactive medication will have their behaviors, effectiveness of interventions pharmacological and non-pharmacological monitored and documented. Review of Resident R62's clinical record revealed that resident was admitted on [DATE], with diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Further review of Resident 62's clinical record revealed a January 4, 2024, recommendation to consider discontinuing Lexapro and starting Fluoxetine 20 milligrams (mg) daily for depression, that Fluoxetine is more stimulating than Lexapro and can help with motivation. Interview with Nursing Home Administrator on February 1, 2024, at 3:45 p.m. confirmed that the facilities had no documentation to review that would indicate the recommendation was acted upon. Review of Resident R23's clinical record revealed that this resident was admitted on Janaury 9, 2024 with diagnoses of metabolic encephalopathy and dementia. Further review of the medication administration records for Janaury, 2024 and the physician's orders for Janaury, 2024 revealed that Resident R23 was ordered Trazodone on January 9, 2024, 50 mg tablet twice a day for yelling out. The medication administration record indicated that the resident was administered this medication as ordered Janaury 9 through Janaury 31, 2024. There was no documentation to indicate that the physician considered the use of non-pharmacological approaches unless contraindicated to minimize the need to the psychotropic medication Trazodone. Interview with the Director of Nursing, Employee E2, at 3:50 p.m., on February 1, 2024 confirmed the lack of medical record documentation to indicate that the use of the medication Trazodone was necessary for the behavior of yelling for Resident R23. Interview with the Director of Nursing, Employee E2, at 3:50 p.m., on February 1, 2024 confirmed the lack of use of non-pharmacological approaches for the care of Resident R23 for treatment and care of the behavior of yelling. 28 Pa Code 201.14(a) Responsibility of licensee 395311 Page 14 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0758 28 Pa Code 201.18(b)(1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa code 211.12 (d) (1) Nursing Services Residents Affected - Few 395311 Page 15 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater. Residents Affected - Few Findings include: On January 30, 2024, at 10:01 a.m., observed that Employee E12, a Licensed Nurse, administered Mucinex DM 600 mg- 30 mg-extended release 12 hr, to Resident R100. Review of physician order for R100 indicated an order for Mucinex Oral Tablet Extended Release 12 Hour (Guaifenesin), Give 600 mg by mouth two times a day for cough. Further review of Physician order for R100 indicated an order, dated August 14, 2023, to administer Insulin Lispro Injection Solution 100 Unit/ML (Insulin Lispro), Inject as per sliding scale If 60-150+)U, Call MD if <60; 151-200= 2U: 201-250=4U; 251-300=6U; 301-350=8U;351-400=10U; Over 400 call MD; Subcutaneously before meals for DM2 (Diabetes Mellitus). Review of Medication Administration Record on January 30, 2024, at 10:11 a.m., revealed that the insulin was not administered to R100, as ordered on January 30, 2024, at 8 a.m., or at the time of breakfast. At the time of the observation, interviewed with Employee E12, and confirmed the findings. The facility incurred a medication error rate of 7.41 %. Pa Code:211.12(d)(1)(2)(5) Nursing Services. 395311 Page 16 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on reviews of the established meal delivery schedule, observations of the meal service on the nursing units and interviews with staff, it was determined that the facility did not employ sufficient support personnel to carry out the functions of the food and nutrition services department. Findings include: A review of the established scheduled times for meals (breakfast, lunch and dinner), revealed that the noon meals were scheduled for delivery from the main kitchen to the C wing nursing unit at 12:15 p.m., and the delivery time for the noon meals from the main kitchen to the B wing nursing unit was 12:45 p.m. daily. Observations of the noon meal service on Janaury 30, 2024 revealed that the food and nutrition department did not deliver the meal cart for the B wing nursing unit until 1:30 p.m., that were scheduled to arrive from the main kitchen at 12:45 p.m. Observations of the noon meal service on January 30, 2024 revealed that the food and nutrition department did not deliver the meal cart for the C wing nursing unit until 12:50 p.m., when the scheduled time for delivery from the main kitchen to the nursing unit was 12:15 p.m., The observations of the late meal tray delivery from the main kitchen were confirmed by the licensed nurse, Employee E12, that was working on the B wing nursing unit on January 30, 2024. Employee E12 stated that she was waiting for the meal cart delivery; because she was supposed to administer insulin timely to residents that were diabetic on the B wing nursing unit so that the insulin would work effectively for the noon meal. The registered dietitian, Employee E 20 confirmed the late delivery of the noon meals from the main kitchen to the residents on the C wing nursing on January 30, 2024. The registered dietitian reported that there were insufficient staff to prepare and serve meals in a timely manner. 28 PA. Code 201.18(b)(1)(3)(e)(1)(6) Management 28 PA. Code 211.10(a)(c)(d) Resident care policies 395311 Page 17 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on reviews of facility menus, meal tray tickets and interviews with residents and staff, it was determined that menus were not prepared in advance to meet the nutritional needs of each resident and followed for seven of ten residents reviewed with specific food adversions. The facility failed to ensure that food was availble for the facility emergency menu as planned. (Residents R78, R119, R99, R17, R22, R97, R28 and R68) Findings include: A review of the facility's menus for October 2023 through Janaury, 2024 with the registered dietitian, Employee E5, at 1:15 p.m., on January 30, 2024 revealed that the facility had breakfast meats planned periodically for service to the residents. The menus only offered pork sausage and bacon or pork gravy for the planned breakfast meats throughout October, 2023 to January 2024. There were no substitutes of turkey, chicken or beef for the breakfast meats. Interview with the registered dietitian, Employee 5 and the dietary cook Employee E13 at 1:30 on January 30, 2024 revealed that the facility purchases pork products only for breakfast meats for the residents. A review of the meal tray cards for Residents (R78, R119, R99, R17, R22, R97, R28 and R68) revealed that these residents disliked pork and pork products either for religious reasons or disfavor of the taste. Interview with alert and oriented Resident R68, revealed that the resident had been asking for months to have other breakfast meat alternates added to the facility menus. Futher interview with Resident R68 revealed that the resident leaves the facility for hemodialysis treatments three times a week. Resident R68 reported that his family has brought foods for him to take to dialysis to eat for breakfast; since the facility had not planned a menu or breakfast meal for the resident on the days he leaves the facility at 5:30 a.m., on Tuesday, Thursday and Saturday for dialysis care. Interview with the nursing staff, licensed nurse, Employee E24 and licensed nurse, Employee E7 on Janaury 29 at 1:00 p.m., and January 30, 2024 at 9:30 a.m., confirmed that the food and nutrition department failed to menu plan breakfast meals or foods and deliver them to the C wing nursing unit on the days Resident R68 was routinely leaving the facility for dialysis care at 5:30 a.m. on Tuesday, Thursdays and Saturdays. Interview with the resident's family member on January 30, 2024 at 10:45 a.m., confirmed the lack of menu planning and provision of breakfast meals for Resident R68 as he leaves the facility for hemodialysis treatments three times a week. Interview with the registered dietitian, Employee E26, at 9:35 a.m., on February 1, 2024 confirmed that on January 31, 2024 the food and nutrition department failed to prepare and deliver a breakfast meal for Resident R68 and place it in the refrigerator on the C wing nursing unit at 3:00 p.m., on January 31, 2024. The registered dietitian, Employee E26 also confirmed that Resident R68 left the facility for dialysis treatment at 5:30 a.m., on February 1, 2024 without eating foods or fluids 395311 Page 18 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prepared by the food and nutrition department prior to departure. Resident R68 failed to receive a packed breakfast on the go foods and fluids to meet his nutritional needs; from the food and nutrition department. Observations of the food and nutrition services department on January 29 and 30, 2024 revealed that the facility had no emergency foods or fluids supplies on hand. Interview with the administrator, Employee E1, at 3:00 p.m., on January 30, 2024 confirmed that the facility had no emergency foods or fluid supplies in the building. A review of the facility's preplannned menus revealed a three day emergency menu plan for all therapeutic diets was devised by the registered dietitian for all the residents. Storage of the three day supply of foods and fluids, in accordance with professional standards for food service safety was the responsibility of the food and nutrition services department at the facility. Interview with the registered dietitian, Employee E20, at 3:10 p.m., on January 30, 2024 confirmed that none of foods or fluids that were planned in case of an emergency ( assorted juices, dry cereals, breakfast bars, nutritional supplements, canned tuna, canned vegetables, shelf stable milk, bread, crackers, canned fruits, puddings, cookies, canned ham, chicken, beef chili, ravioli, peanutbutter, pulled chicken, soups, refried beans and tortilla ) were readily available and on hand, in the dry storage supply area of the facility. 28 Pa. Code: 211.6(a) Dietary services 28 Pa. Code: 201.18(b)(1)(3) Management 395311 Page 19 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, reviews of policies and procedures and clinical records, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at satisfying temperatures for six of 32 residents reviewed (Residents R125, R63, R5, R68, R17 and R131). Residents Affected - Some Findings include: A review of the policy titled Food and nutrition: food production and food safety dated June 10, 2022 it was indicated that the dietary staff were responsible for serving hot foods to the residents at a temperature range of 130 to 155 degrees Fahrenheit. This policy also indicated that cold foods were to be served to the residents at a temperature of 41 degrees Fahrenheit. The goal of the dietary services were for hot food and beverages and cold foods and fluids to be palatable at point of delivery to the residents. A review of Test Tray Form, revealed that the standard temperature for hot foods, including entrée and starch, on tray line was 135 degrees Fahrenheit and cold food, including milk and juice, was 41 degrees Fahreheit. Interview with Resident R125 on January 29, 2024, at 11:00 a.m. revealed that the food is terrible, it is cold, and they forget things like salad dressing, how can you eat salad without dressing? Interview with Resident R63 on January 29, 2024, at 11:10 a.m. revealed that the food is really bad, it's not hot, and it runs right through me, the water is bad too, so my family has to bring in bottled water for me. Interview with Resident R5 on January 29, 2024, at 11:25 a.m. revealed that the food does not taste good, and it is not always hot. Interview with Resident R17 at 11:30 a.m., on Janaury 30, 2024 revealed that this resident was unhappy with the menu planning at the facility. The resident said that she was not getting foods that she preferred to eat. The resident said she frequently has to send her foods back to the kitchen and ask for substitute foods. She likes vegetables like cabbage, spinach and collard greens but rarely gets them. She said she does not like too much bread because she was diabetic. Clinical record review revealed a comprehensive quarterly assessment (MDS-an assessment of care needs) dated January 29, 2024 indicated that Resident R17 was cognitively intact. This interview with Resident R17 was confirmed with the dietitian, Employee E26 at 9:30 a.m., on February 1, 2024. Interview with Resident R131 at 11:45 a.m., on January 30, 2024 revealed that this resident did not like the foods and fluids planned on the menus. The resident said that the foods were terrible and the foods planned on the menus do not reflect foods and beverages that he was used to eating. The resident said cheese steak hoagies were a favorite. The resident also reported that he had to order double portions; so that he could get enough to eat, because the portion sizes served were small and unsatisfying. Clinical record review revealed a comprehensive quarterly assessment (MDS) dated [DATE] that indicate Resident R131 had modified cognition skills. Interview with the registered dietitian, Employee E26 at 9:45 a.m., on February 1, 2024 confirmed the physician's order for double portions for Resident R131. 395311 Page 20 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Resident R68 at 10:00 a.m., on January 31, 2024 revealed that this resident said the menu planning was not considerate of residents' food preferences. This resident explained that for several months he had been asking the dietary department to add breakfast meats to the menu. The resident specifically told the kitchen staff that he disliked pork products. The clinical record indicated a quarterly comprehensive assessment (MDS-an assessment of care needs) dated December 6, 2023 that indicated resident R68 was cognitively intact. A review of the facility menus for october, 2023 through january 2024 with the dietitian, Employee E26, at 10:a.m., on February 1, 2024 confirmed that the facility menus had not substituted beef or turkey breakfast foods for residents who disliked pork bacon or sausage. During a group meeting with alert and oriented resident who regularly attend resident council meetings, all nine residents R126, R51, R116, R12, R66, R48, R108, R91 and R44 indicated that the food is not very good, is often cold, and that they often run out of things or send the wrong food item and overall this is the biggest problem on a daily basis. A temperature test tray evaluation was done on the C wing nursing unit during the noon meal service. The observations of the regular diet were confirmed with the registered dietitian, Employee E20, on Janaury 30, 2024. The menu called for apple juice, fried chicken, garlic mashed potatoes, spinach, corn bread, margarine, fruit cobbler and hot beverage. The test tray evaluation at point of service for the residents revealed a warm apple juice at 59 degrees Fahrenheit, cool and unfamiliar peach cobbler, as a white cake with canned diced peaches in a small bowl. The tempeature of the peach cobbler was 90 degrees Fahrenheit. The dietary recipe indicated that the peaches were to be baked with brown sugar and butter and placed on top of a warm biscuit. There was no corn bread prepared as planned on the menu. The test tray did not contain corn bread. The regular diet contained four teaspoons of salt packets and six teaspoons of sugar substitute packets. The menu called for one teaspoon of salt and one tespoon of pepper in packets for flavor. A hot beverage was not provided. Creamer for the hot beverage was also not provided as planned. A temperature test tray completed on the B wing nursing unit was done during the noon meal service. The observations of the pureed diet were made with the registered dietitian, Employee E20, on January 30, 2024. The menu called for pureed chicken, pureed garlic mashed potatoes, pureed spinach, pureed corn bread, margarine, pureed fruit cobbler and hot beverage. The pureed meat was cold at 110 degrees Fahrenheit. There was no dessert provided as planned. There was no pureed corn bread as planned. A hot beverage was provided without creamer. Six packets of sugar substitute was on the test tray; no cane was offered. Margarine or butter was not provided as planned. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services 28 PA. Code 211.12(d)(3)(5) Nursing services 28 PA. Code 211.10(a)(c)(d) Resident care policies 395311 Page 21 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the operations of the Food and Nutrition Department, reviews of policies and procedures, interviews with staff and reviews of chemical manufacturer's specifications, it was determined that the facility failed to ensure that the dish machine dispensed the proper level of sanitizing solution to sanitizing food service equipment. The facility failed to ensure that there was proper water pressure to maintain water in the three compartment sink, to sanitizing the food service equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays). This failure resulted in an Immediate Jeopardy situation for one of one kitchens serving 128 residents. (Kitchen) Findings include: A review of the facility policy titled dish machine use and three compartment sink use dated April 1, 2013, for the Food and Nutrition Services Department indicated that dietary employees were responsible for following standards of practice to ensure that all food service equipment, utensils and dishes are washed and sanitized. The policy indicated that prior to use of the dish machine and three compartment sink (manual washing and sanitizing) the employees were to verify the temperature of the water and chemical concentration. The policy said that the employees were to follow the specifics provided by the dish machine manufacturer and chemical supplier specifications for proper use of the chemicals(hypochlorite and quaternary solution). The dietary employees were to monitor the temperature gauge and chemical concentration of the sanitizers frequently and if requirements were not met they were to immediately discontinue use of the dish machine and three step process to manually wash , rinse and sanitize dishware. Observations of the operation of the dish machine with the Director of Dietary Services, Employee E4, on January 29, 2024 at 9:16 a.m. revealed that the chemical that was dispensing into the dish machine was not registering when tested with the litmus test directed by the chemical manufacturer. The Director of Dietary Services, Employee E4 reported that the chemical being used during the operation of the low temperature dish machine was [NAME] Sani Quat (a quaternary ammonia product). Observations of the dish machine manufacturer's operation procedures that were permanently affixed to the dish machine revealed that the proper chemical to use when operation this machine was chlorine or hypochorite at 50 ppm (parts per million). The instructions also indicated that the optimal temperature of the water for wash and final rinse was a minimum of 120 degrees Fahrenheit to 140 degrees Fahrenheit. Observations were confirmed with the Director of Dietary services, Employee E4, and the Nursing Home Administrator, Employee E1 January 29, 2024 at 10:00 a.m. Observations of the three compartment sink revealed that there was no sanitizing system in place to clean and sanitize the dietary equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays). The Director of Dietary services, Employee E4 reported that the three compartment sink had not been used since January 3, 2024. The piping underneath the sink was leaking water onto the floor and the plumbing and water pressure was not fully operating at the faucet. The Director of Dietary, Employee E4 also reported that with out the proper water pressure and ability to maintain water in the sink, the chemical for sanitizing the food service equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays) was ineffective. The chemical sanitizer was not dispensing or 395311 Page 22 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some manually added to the three compartment sinks. The process used to manually wash, rinse and sanitize dishware was standard of practice procedure for ensuring food safety. Observations were confirmed with the Director of Dietary Services, Employee E4 and the administrator, Employee E1, on January 29, 2024, at 10:30 a.m. Interview with the Director of Dietary Service, Employee E4, on January 29, 2024 at 11:00 a.m. revealed that the food and nutrition department was not keeping a log of temperatures or chemical concentration testing during the operation of the dish machine or the manual use of the three compartment sink. Based on these findings, and jeopardy related to the unsafe and unprofessional practices of the dietary staff inside the main kitchen of the Food and Nutrition Services Department. The nursing home administrator was notified of the immediate jeopardy situation on January 29, 2024 at 4:16 p.m., at which time an immediate action plan was requested from the administrator, by the survey team. The immediate jeopardy template was provided to the nursing home administrator on January 29, 2024 at 4:16 p.m. On January 29, 2024 at 7:13 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following: 1. The facility initiated paper products for the lunch meal on Janaury 29, 2024. 2. [Chemical manufacture company] was notified that there were issues with the sanitation for the dish machine and the three compartment sink. State Chemical Solutions technician evaluated for correct sanitation process around 1530 on Janaury 29, 2024. 3. The current director of dietary services was no longer employed with [NAME] Mawr Extended Care Center. 4. The facility immediately cleaned and sanitized the dish ware, pots and pans to prevent food borne illness. 5. [Nurse consultant] completed a seventy two hour progress note to review and identify any signs of food borne illness. One resident was identified with loose stools. The resident was assessed [the nursing supervisor]. The registered nurse indicated that the resident denied any complaints. 6. Certified Dietary Manager completed education with current dietary staff in the building on proper use of the sanitizer for the dish machine and three compartment sink, this includes how to test sanitizer solution. A cleaning and sanitizing competency and education was planned for each dietary employee. 7. On January 30, 2024 Registered Dietitian was responsible for education of the dietary staff on all shifts to ensure that all dietary staff understands about the required sanitation process for the dish machine and three compartment sink. 8. All off duty staff were to receive education about the required sanitation process for the dish machine and three compartment sink upon return to work. 9. Dish machine will be checked for proper sanitation prior to doing the dishes, after each meal 395311 Page 23 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and documented on the sanitation log. At some point during washing of the dishes another sanitation check will occur and be documented. If the sanitation check does not fall within parameters, stop washing and notify the supervisor immediately. The supervisor will notify the administrator; who would be responsible to notify State Chemical, the manufacturer. 10. The three compartment sink will be checked for sanitation prior to each use and three times a day after each meal and documented on the sanitation log. At some point during washing of the dishes another sanitation check will occur and be documented. If sanitation check does not fall within parameters, stop washing and notify the supervisor immediately. The supervisor will notify the administrator: who would be responsible to notify State Chemical, the manufacturer. The administrator /assigned designee will observe dish machine sanitation and three compartment sink sanitation three times a day for two weeks and daily thereafter. 11. Results will be presented to QAPI for review and revision as needed. Interviews were conducted with dietary staff on January 30, 2024, from 9:00 a.m. until 3:00 p.m. to verify the implementation of the plan of action. Dietary staff interviewed were able to confirm that they were trained and demonstrate that training was effective related to proper chemical sanitizer, proper chemical sanitizer concentration to use and proper temperature of the water to effectively use the chemicals in the dish machine and manually in the three compartment sink. Observations were done with dietary staff on January 30, 2024, following the breakfast and noon meals to verify the method of chemical sanitizer testing, water temperature and concentration of chemical solution being used to sanitize with in the low temperature dish machine and the three compartment sink. Following verification of the immediate action plan, the Immediate Jeopardy was lifted on January 30, 2024 at 4:09 p.m. 28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 Pa. Code 204.19 Plumbing, heating ventilation and air conditioning and electrical 28 Pa. Code 211.10(d) Resident care policies 395311 Page 24 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

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 Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related Residents Affected - Many to ensuring that the dish machine dispensed the proper level of sanitizing solution to sanitizing food service equipment. The facility failed to ensure that there was proper water pressure to maintain water in the three compartment sink, to sanitizing the food service equipment which resulted in an Immediate Jeopardy situation for one of one kitchens serving 128 residents. Findings include: Review of the job description for the Nursing Home Administrator revealed that the Nursing Home Administrator is to lead and direct the overall operations of the nursing faciltiy in accordance with the community policies procedures, customer and resident needs and both Sate and Federal guidelines. To maintain excellent care for the residents/ patients and achieve the faciltiy's business objective. As the Administrator, you are delegated to administrative authority, responsibility and accountability necessary for carrying out the assigned duties. You are responsible for carrying out the operational core responsiblities established by the company and facility. You are all responsible for oversight of the resident care policies established by the facility . Monitor each departments's activities, ensuring that each department attains and maintains compliance with State and Federal requirements . Ensure facility grounds are properly maintained and that equipment is clean and well maintained. Observations of the operation of the dish machine with the Director of Dietary Services, Employee E4, on January 29, 2024 at 9:16 a.m. revealed that the chemical that was dispensing into the dish machine was not registering when tested with the litmus test directed by the chemical manufacturer. The Director of Dietary Services, Employee E4 reported that the chemical being used during the operation of the low temperature dish machine was Advance Sani Quat (a quaternary ammonia product). Observations of the three compartment sink revealed that there was no sanitizing system in place to clean and sanitize the dietary equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays). The Director of Dietary services, Employee E4 reported that the three compartment sink had not been used since January 3, 2024. The piping underneath the sink was leaking water onto the floor and the plumbing and water pressure was not fully operating at the faucet. The Director of Dietary, Employee E4 also reported that with out the proper water pressure and ability to maintain water in the sink, the chemical for sanitizing the food service equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays) was ineffective. The chemical sanitizer was not dispensing or manually added to the three compartment sinks. The process used to manually wash, rinse and sanitize dishware was standard of practice procedure for ensuring food safety. Observations were confirmed with the Director of Dietary Services, Employee E4 and the administrator, Employee E1, on January 29, 2024, at 10:30 a.m. Interview with the Director of Dietary Service, Employee E4, on January 29, 2024 at 11:00 a.m. revealed that the food and nutrition department was not keeping a log of temperatures or chemical concentration testing during the operation of the dish machine or the manual use of the three compartment sink. 395311 Page 25 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0835 Based on the deficiencies identified in this report, the Nursing Home Administrator failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate jeopardy situation. Level of Harm - Minimal harm or potential for actual harm Refer F812 Residents Affected - Many 28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 Pa. Code 204.19 Plumbing, heating ventilation and air conditioning and electrical 28 Pa. Code 211.10(d) Resident care policies 395311 Page 26 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record and policy and procedure reviews and interviews with staff, it was determined that the facility failed to ensure that clinical records were accurate for one of 32 residents reviewed. (Resident R121) Findings include: Review of Resident R121's clinical record revealed that the resident was admitted to the facility on [DATE] wit the diagnoses of high blood pressure, heart failure altered mental status, Type Two Diabetes, morbidly obese, unspecified psychosis and chronic pulmonary disease. Review of the psychiatry note dated January 30, 2024, revealed an order for Risperdal solution for bipolar disorder. Review of Resident R121 clinical record revealed no documentation to indicate that the resident had a diagnosis of bipolar disorder. 28 Pa. Code 211.5(f) Clinical records 395311 Page 27 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related with linen transportation in one of two nursing units. (2nd Floor) Residents Affected - Some Findings include: Observation at the D wing of the facility, on February 1, 2024, at 10:01 a.m., revealed that the linen cart located very near to the nurses' station of D wing was not covered at the front side of the cart to prevent contamination. At the time of the finding interviewed the Unit Manager, a Licensed nurse, Employee E30 and confirmed that the linen cart should have been covered to prevent contamination and to maintain infection control. Observation at the D wing of the facility, on February 1, 2024, at 10:20 a.m., revealed that a Nurse Aide, Employee E31, was transporting clean linen for the use of residents by holding the linens letting it to touch the Nurse Aide's uniform. At the time of the finding interviewed Employee E31, and confirmed that the linen should have been transported without letting it touch the employee's clothing to prevent contamination and to maintain infection control. Observation at the D wing of the facility, on February 1, 2024, at 10:33 a.m., revealed that a Nurse Aide, Employee E32, was transporting clean linen for the use of residents by holding the linens letting it to touch the Nurse Aide's uniform. At the time of the finding interviewed E32, and confirmed that the linen should have been transported without letting it touch the employee's clothing to prevent contamination and to maintain infection control. 28 Pa Code 211.12 (d)(1)(5) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee 395311 Page 28 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations of the operations within the Food and Nutrition Department, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that all mechanical and resident care equipment was maintained in safe operating condition. Residents Affected - Few Findings include: A review of the facilitites policies and procedures for the dish machine and three compartment sink use dated April 1, 2013 revealed that the dietary staff were responsible for monitoring the operations of the two essential and mechanical pieces of industrial-sized equipment inside the main kitchen. Dietary staff were also required to report mechanical and operational problems to the dietary director; who was to report functional problems to the administrator and maintenance department. The administrator was responsible for contacting the chemical supply company to adjust chemical consentrations, accordance with manufacturer's specifications. Observations of the main kitchen within the food and nutrition department between 9:16 a.m and 11:00 a.m., January 29, 2024 revealed that the dietary staff were not operating the dish machine properly. The chemical was not dispensing according to manufacturer's directions into the dish machine. The temperature of the final rinse water was 150 to 160 degrees Fahrenheit. Observations of the main kitchen of the food and nutrition department between 9:16 a.m and 11:00 a.m., on January 29, 2024 revealed that the manual cleaning station with the three compartment sink was leaking water onto the floor as dietary staff were attempting to fill the sinks with water. The water pressure was low as the dietary staff tried to add a chemical to the sink. The readings for the chemical sanitizer were above the recommended range to sanitize the dish ware, pots and pans. A high concentration of chemical sanitizer was potentially hazardous for contamination of foods. Interview with the director of dietary services, Employee E4, revealed that the food and nutrition department was not using the three compartment sinks since January 3, 2024 due to that fact that they were not fully functioning. A review of the work order request for the maintenance department, made by the director of dietary services, Employee E4, on January 3, 2024 revealed that the dish machine and three compartment sink were requiring mechanical and plumbing repairs. The request indicated that the sanitizer was not dispensing into the dish machine. The request also indicated that the hot water was not working efficiently with lack of water pressure. The work order also requested that the maintenance staff repair the pipes underneath the pot and pan sink (three compartment sinks) because of water leakage onto the floor and not enough water to chemical concentrations held in the sinks for washing rinsing and sanitizing food service equipment, dish ware, pots and pans. Two temperature test trays were conducted with the registered dietitian, Employee E20, during the noon meal services on the C wing nursing unit and the B wing nursing unit on January 30, 2024. It was confirmed at that time, the failed to operate the food service with a complete thermal (pellet) system. This thermal system was used to transport foods plated on the trayline assembly area to the nursing units throughout the facility. Dietary staff, Employees E23 and E13, that were interviewed at 1:30 p.m., on Janaury 30, 2024 reported that the facility did not have enough essential dietary service equipment for serving meals to the residents every day. The dietary staff said that since they didn't have enough metal pellets and 395311 Page 29 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0908 Level of Harm - Minimal harm or potential for actual harm thermal pellet holders for all of the residents, it was decided that they would not using any thermal meal service equipment. The dietary staff also reported that they did not have enough every day china for all of the residents to use during breakfast, lunch and dinner meals. The dietary staff reported that they were using paper products for pureed foods, desserts, cereal, juices and salads due to the fact that the essential everyday resident care equipment for the food service department was not available for use. Residents Affected - Few 28 Pa. Code: 201.18(b)(1)(3)(e)(1)(2)(2.1) Management 395311 Page 30 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0922 Have enough backup water supply for essential areas of the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on observations of the facility's emergency water supplies, reviews of policies and procedures and interviews with staff, it was determined that facility failed to follow established procedures to ensure water availability and storage of potable and non-potable water, for emergency purposes with loss of normal water supplies. Residents Affected - Many Findings include: A review of the facility policy titled food and nutrition services: disaster-emergency planning dated October 6, 2020 revealed that it was the policy of the facility to have a three day supply of water on hand for the operation of the food service department. The policy was for potable and non-potable water. The policy indicated that one half gallon of potable water per resident per day was necessary and that one gallon per resident per day of non-potable water was necessary. Observations of the emergency water storage at the facility revealed that the facility had 60 gallons of water on hand. According to the facility emergency water policy the facility required 414 gallons of non-potable and 207 gallons of potable to be on hand for emergency purposes with a census of 138 residents. The lack of emergency water supplies on hand; which would be, inaccordance with the facility's established policies for ensuring an adequate supply of potable and non-potable water for the food service and entire facility was confirmed during and interview with the Nursing Home Administrator at 1:45 p.m., on February 1, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(d)(e) Management 395311 Page 31 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations of the nursing units, interviews with staff, inspection of the food and nutrition services department and reviews of the pest control operator's reports, it was determined that the facility was not maintaining an effective pest control program. Residents Affected - Some Findings include: Observations of the facility's layout and design revealed the the food and nutrition services department, lobby, administrator's office and the A wing and B wing nursing units were located on the ground floor of the facility. Observations of the two doors leading directly outside the building and located inside the food and nutrition services department or the hallway leading into the main kitchen revealed that these doors were not sealed properly. The thresholds of both doors, upon closing provided an air gap allowing pests and rodents easy access to the interior of the building. Confirmation of the unsealed doors, allowing access to the builing for pests and rodents was confirmed with the maintenance director, Employee E3 at 2:15 p.m., on Janaury 29, 2024. A review of the pest control operator's service reports from October, 2023 through January, 2024 for the interior and exterior of the building revealed that the services of a pest exterminator were documenting treatments for common household pests (mice and roaches) in the main kitchen, lobby and first floor nursing unit and administrator's office. Interview with the Nursing Home Administrator, Employee E1 and the Maintenance Director, Employee E3 at 2:00 p.m., on January 31, 2024 confirmed that the facility has an on-going problem with common house hold pest (mice and roaches). 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 395311 Page 32 of 33 395311 02/01/2024 Bryn Mawr Extended Care Center 956 Railroad Avenue Bryn Mawr, PA 19010

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on a reviews of one of two personnel files for nursing assistants employed by the facility, reviews of the facility assessment, documentation of annual performance evaluations and logs of regular in-service training and competencies for nurse aides, it was determined that the facility failed to ensure regular performance reviews and consistent in-service training and competencies were completed as required for oneof two personnel files. (Employee E9) Findings include: Interview with the Nursing Home Administrator, Employee E1, at 11;15 a.m., on February 1, 2024 confirmed that the facility had no documentation to indicate the date employment began for Employee E9, a nursing assistant providing care to the residents at the facility. Employee E9 was employed by the facility from an agency. Further interview with the Nursing Home Administrator revealed that there was no documentation of any in-service training for Employee E9, based on the documented care needs of the residents identified in the facility assessment. A review of the facility assessment revealed that the residents of this facility had diagnoses of impaired cognition, mental disorders, depression, bipolar disorder, anxiety disorder, congestive heart failure, deep vein thrombosis, parkinson's disease, traumatic brain injury, cerebral palsey, visual loss, fractures, cancer, diabetes, obesity, renal failure, anemia, bowel and bladder incontinence, skin ulcers, infections total knee replacements and terminal diagnoses. Further interview with the Nursing Home Administrator revealed that there was no documentation of a performance evalution for Employee E9, a nursing assistant providing care and service to the residents at the facility. 28 Pa. Code 211.12(c)(d)(4)(5) Nursing services 395311 Page 33 of 33

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Citations

23 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0577GeneralS&S Dpotential for harm
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0726GeneralS&S Epotential for harm
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0802GeneralS&S Dpotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
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.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812SeriousS&S Kimmediate jeopardy
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0835GeneralS&S Fpotential for harm
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0922GeneralS&S Fpotential for harm
F922 - Establish procedures to ensure that water is available to essential areas
Have enough backup water supply for essential areas of the nursing home.
0925GeneralS&S Epotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
0947GeneralS&S Epotential for harm
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0908GeneralS&S Dpotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.

FAQ · About this visit

Common questions about this visit

What happened during the February 1, 2024 survey of BRYN MAWR EXTENDED CARE CENTER?

This was a inspection survey of BRYN MAWR EXTENDED CARE CENTER on February 1, 2024. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BRYN MAWR EXTENDED CARE CENTER on February 1, 2024?

Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 29, 2026. If you believe any information is inaccurate, report it here.

Health inspection·February 1, 2024