Bryn Mawr Village
Inspection Findings
F-Tag F0585
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
that she will have to ask the social worker. Interview with Licensed Nurse Employee E3 conducted on September 24, 2025, at 12:02 PM revealed that last week either Monday (September 15, 2025) or Tuesday (September 16, 2025), Resident Resident R1 asked her to write his complaints against a night shift nurse's aide who was rough with him during care. Further Employee E3 revealed that she wrote Resident Resident R1's complaints in
a grievance form and dropped it into the grievance box located in the unit.Interview with the Social Worker Employee E4 revealed that she regularly checks the grievance box and that did not see any grievance forms in the grievance boxes.Further interview with Employee E4 also revealed that she does not have Resident Resident R1's grievance and that she has not done any investigation related ton Resident Resident R1's complaints because she never got any grievances.Interview with Director Employee E2 confirmed that there was not aware of any grievances submitted by Resident Resident R1.Further interview with Employee E2 confirmed that the facility did not conduct an investigation related to Resident 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.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bryn Mawr Village
773 East Haverford Road Bryn Mawr, PA 19010
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0610
F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
any investigation related ton Resident Resident R1's complaints because she never got any grievances.Interview with Director Employee E2 confirmed that there was not aware of any grievances submitted by Resident Resident R1.Further interview with Employee E2 confirmed that the facility did not conduct an investigation related to Resident Resident R1's complaints that the night shift nurse's aide was rough with him during care.Review of Resident Resident R2's clinical record Reveal that Resident Resident R2 was admitted to the facility on [DATE REDACTED], was discharged on August 28, 2025, and was readmitted on [DATE REDACTED], with the diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Morbid Obesity.Review of Resident Resident R2's MDS (minimum data set-a federally required resident assessment completed at a specific interval), dated September 10, 2025, revealed that under Section C - Cognitive Patterns,0500. BIMS Summary Score (brief interview for mental status) revealed that Resident Resident R1 was coded 14, suggesting that Resident Resident R1 was cognitively intact.Interview with Resident 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 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 Resident R2 revealed that the nurse's aide that was rough with her during care works on the evening shift.
Further Resident Resident R2 revealed that last night during the night shift, an African nurse's aide yelled at her.
Further interview with Resident Resident R2 revealed that resident 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 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 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 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 Resident R2's complaint and interviewed her. Employee E4 revealed that the nurse's aide told her that Resident 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 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 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 Resident R1 and Resident 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
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BRYN MAWR VILLAGE 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 VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.