Bryn Mawr Extended Care: Medication Delays Found - PA
The resident, identified in inspection records only as Resident R16, was prescribed levothyroxine at 25 micrograms, to be given every morning at 6:00 a.m. The electronic medication administration record showed no indication the drug was given on either October 2 or October 3. Levothyroxine is a synthetic thyroid hormone typically prescribed for hypothyroidism, a condition that requires consistent daily dosing to maintain stable hormone levels.
That wasn't the only missed window. On October 1, Resident R16's 9:00 a.m. medications didn't arrive until 12:35 p.m. or later. Escitalopram oxalate, a 20-milligram antidepressant tablet, was among them. So was Pregabalin, a 100-milligram Schedule V capsule used to treat nerve pain. Ziprasidone HCL, a 20-milligram antipsychotic capsule, was also held until 12:37 that afternoon. Restasis eye drops, a cyclosporine formulation used to treat chronic dry eye, were scheduled for 9:00 a.m. and given at 12:37 p.m. The Biotene oral rinse, prescribed three times daily, was due at 9:00 a.m. and didn't come until 12:35 p.m.
The delays kept going through the evening. Artificial tear drops scheduled for 4:00 p.m. on October 1 were administered at 6:28 p.m. The 8:00 p.m. dose of those same drops didn't come until 9:59 p.m. Restasis was due again at 8:00 p.m. and was also given at 9:59. The pattern repeated the following day: the 4:00 p.m. artificial tears on October 2 were given at 6:56 p.m., and the 8:00 p.m. dose didn't arrive until 10:08 p.m.
Inspectors pulled the facility's own written policy on medication administration, revised as recently as November 15, 2024. The policy states staff must verify, each time a medication is given, that it is the correct medication, the correct dose, the correct route, the correct rate, the correct time, and for the correct resident. The electronic record showed the facility's own staff weren't meeting their own standard on any of those counts where timing was concerned.
CMS rated the deficiency as causing minimal harm or potential for actual harm. The violation fell under F0684, which covers appropriate treatment and care in accordance with professional standards. Pennsylvania state codes cited include those governing resident care policies and nursing services.
What the inspection report doesn't say is who was responsible, whether a nurse was double-assigned, whether the facility was short-staffed that day, or whether anyone at the facility noticed the gaps before an inspector did. The record shows only what the e-MAR showed: scheduled times, actual times, and two days where the thyroid medication column stayed blank.
Resident R16 was the only resident reviewed in this complaint inspection. The report notes that few residents were affected. It does not describe any symptoms the resident experienced, and it does not say whether a physician was notified about the missed levothyroxine doses.
For a resident depending on a morning antidepressant, a nerve pain capsule, an antipsychotic, and thyroid hormone replacement, the difference between 6:00 a.m. and noon, or between noon and never, is not a scheduling footnote. It is the difference between a medication working as prescribed and a medication not working at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bryn Mawr Extended Care Center from 2025-10-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
BRYN MAWR EXTENDED CARE CENTER in BRYN MAWR, PA was cited for violations during a health inspection on October 3, 2025.
The resident, identified in inspection records only as Resident R16, was prescribed levothyroxine at 25 micrograms, to be given every morning at 6:00 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.