Bryn Mawr Extended Care Center

Based on review of clinical record, and review of facility policy, it was determined that facility did not ensure that residents received treatment in accordance with professional standards of practice related to medication administration for one of one residents reviewed (Resident R16)Findings include:Review of facility policy 'General Dose Preparation and Medication Administration,' revised November 15, 2024, indicates that prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.Review of Resident R16's audit electronic medication administration record (e-MAR), revealed artificial tears drops are scheduled to be administered at 8:00 a.m. and were administered at 12:34 p.m. on October 1, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 4:00 pm but not administered until 6:28 pm on October 1, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 8:00 pm but were not administered until 9:59 pm on October 1, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 4:00 pm but were not administered until 6:56 pm on October 2, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 8:00 pm but were not administered until 10:08 pm on October 2, 2025.Further review of e-MAR indicates Biotene dry mouth oral rinse is to be administered three times a day; Oral rinse was scheduled to be administered at 9:00 am on October 1, 2025 but was not administered until 12:35 pm.Further review of e-MAR indicated Escitalopram oxalate tablet, 20 mg, was scheduled to be administered at 9:00 am but were not administered unitl12:35 pm on October 1, 2025.Further review of e-MAR indicates Levothyroxine, 25 mcg, was to be administered at 6:00 am, with no indication that it was administered on October 2, 2025 and October 3, 2025.

Further review of e-MAR indicates that Pregabalin schedule V capsule, 100 mg, is to be administer at 9:00 am but was administered until 12:37 pm on October 1, 2025.Further review of e-MAR indicates Restasis (cyclosporine) Dropperette; 0.5% - eye drops are to be administered at 9:00 am but were not administered until 12:37 pm on October 1, 2025.Further review of e-MAR indicates Restasis (cyclosporine) Dropperette; 0.5% - eye drops are to be administered at 8:00 pm but were not administered until 9:59 pm on October 1, 2025.Further review of e-MAR, revealed Ziprasidone HCL capsule, 20 mg, was to be administered at 9:00 am but was not administered until 12:37 pm on October 1, 2025.28 Pa Code 211.10(c ) Resident care policies28 Pa Code 211.12(d)(5) Nursing services

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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