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Complaint Investigation

Bryn Mawr Village

September 24, 2025 · Bryn Mawr, PA · 773 East Haverford Road
Citations 2
CMS Rating 3/5
Beds 120
Provider ID 395095
Healthcare Facility
Bryn Mawr Village
Bryn Mawr, PA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

BRYN MAWR VILLAGE in BRYN MAWR, PA — inspection on September 24, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0585
Resident Rights Deficiencies

complaints in a grievance form and dropped it into the grievance box located in the unit.Interview with

that she does not have Resident R1's grievance and that she has not done any investigation related

E2 confirmed that there was not aware of any grievances submitted by Resident R1.Further interview with Employee E2 confirmed that the facility did not conduct an investigation related to Resident R1's complaints that the night shift nurse's aide was rough with him during care. Pa. 28 Code: 201.29(i) Resident Rights.

395095 09/24/2025

Bryn Mawr Village 773 East Haverford Road Bryn Mawr, PA 19010

shift nurse's aide was rough with him during care.Review of Resident R2's clinical record Reveal that

Disease, Morbid Obesity.Review of Resident R2's MDS (minimum data set-a federally required

Section C - Cognitive Patterns,0500. BIMS Summary Score (brief interview for mental status) revealed that Resident R1 was coded 14, suggesting that Resident R1 was cognitively intact.Interview with Resident R2 conducted on September 24, 2025, at 9:28AM revealed that revealed that the nurse's aides were rough during care and that they yelled at her.

Further, Resident R1 revealed that one time, she pushed the call bells 3 times, the staff came in 3 times, and she turned it off telling her I'm busy, I can't do you right now and when she came back, she was rough with me.Further interview with Resident R2 revealed that the nurse's aide that was rough with her during care works on the evening shift.

Further Resident R2 revealed that last night during the night shift, an African nurse's aide yelled at her.

Further interview with Resident R2 revealed that resident R2 has reported the above complaints to the Director of Nursing and to the Administrator.Review of Resident Concern Report completed by Social Worker Employee E4 dated August 15, 2025, revealed that a voice message from Resident R2's husband was left on August 14, 2025, and was received on August 15, 2025, complaining about being left in bed for hours in feces before someone care in to help her.

Further, the Resident Concern Report also revealed that Resident R2's husband complained that his wife was being manhandled.

Further, the Resident Concern Report section: Document steps taken to investigate and outcome revealed a statement from Resident R2 stating she push the call bell three times nurse's aide came in three times and turned it off, I'm busy I can't do you right now and when she came back, she was rough with me.Further review of Resident Concern Report revealed no documented evidence that a complete investigation was conducted.

There was no statements from staff, there was no findings or conclusion, there was documented action by the facility to address the issues, no staff disciplinary action, there was no staff education.Further review of the report indicated that it was investigated by Employee E2 and Employee E4 on August 15, 2025.Further the facility administrator signed the report on August 18, 2025.Interview with Social Worker Employee E4 conducted on September 24, 2025, at 12:41PM revealed that she identified the nurse's aide involved in Resident R2's complaint and interviewed her.

Employee E4 revealed that the nurse's aide told her that Resident R2 had pressed the call bell at least 50 time in 2 hours and that the nurse's aide said that she can't do Resident R2 alone, and that it's hard not be rough because she is such a big lady, there is no gentle want do it Further interview with Employee E4 confirmed that she did not write her interview with the nurse's aide and her statement was not on file.Interview with DON (director of nursing) Employee E2 conducted on September 24, 2025, at 11:59AM revealed that when asked if she did an investigation on Resident R2's complaints, Employee E2 revealed that she did not know because the facility administrator who was no longer working at the facility took care of that investigation.The facility was not able to provide upon request, documented evidence that an investigation was conducted on Resident R1 and Resident R2's allegations of verbal and physical abuse. 28 Pa.

Code:201.18(a)(1)(3) Management28 Pa.

Code 211.12(c)(d)(1)(3)(5) Nursing Services

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 VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.