Bryn Mawr Extended Care Center
Inspection Findings
F-Tag F0684
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
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 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 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
Residents Affected - Few
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
BRYN MAWR EXTENDED CARE CENTER in BRYN MAWR, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BRYN MAWR, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BRYN MAWR EXTENDED CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.