Bryn Mawr Village.

“Staff person B did not receive training in emergency preparedness procedures and recognition and response to crises and emergency situations during the training year.”

“Staff person A was hired but the criminal background check was not processed timely. The official hire date was incorrect on the Staff Contact List, with the background check request dated 1/7/25.”

“A mirror on the medicine cabinet in a resident's bathroom was broken with broken glass hanging from it, posing a hazard.”

“A medication prescribed for a resident was found in the home's medication cart; however, there was no current order for this medication.”

“Two residents prescribed as-needed medications did not have those medications available in the home at the time they were needed (at 3:10 PM and 3:14 PM respectively).”

“A resident prescribed to receive 2 tablets by mouth 2 times a day at 12 PM and 8 PM did not receive the medication at those times because it was not available in the home.”

“A resident's family member participated in the development of the support plan but did not sign the support plan.”

“A resident was admitted to the Secure Dementia Care Unit but the written cognitive preadmission screening was not completed within 72 hours prior to admission as required.”

“The resident-home contract for a resident was not signed by the resident, the resident's responsible party, administrator or a designee.”

“The home does not have criminal background checks for any of the hospice workers providing services to residents receiving hospice services from Constellation.”

“At 9:58 am, the home did not have a complete staff list that includes agency staff. A separate agency staff list was provided later at 11:22 am.”

“During multiple shifts with 10 residents present in the home, there was no staff person present who was trained in first aid and certified in obstructed airway techniques and CPR, violating the requirement for at least one trained staff person per 50 residents at all times.”

“Staff person B completed CPR training with National CPR foundation, which is not certified as a trainer by a hospital or other recognized health care organization.”

“Staff person C on their first day of work did not receive orientation on evacuation procedures, staff duties during fire drills and emergency evacuation, designated meeting place, smoking safety procedures, fire extinguisher location and use, smoke detectors and fire alarms, and telephone use for emergency services.”

“The home's record of training for staff person C does not include date, source, content, length of each course or copies of any certificates received.”

“Hand soap located in the dining area kitchenette left unattended and accessible to residents was in a softsoap container rather than the original labeled container.”

“Staff person A did not receive fire safety and emergency preparedness orientation on their first work day (8/5/2024). Required topics including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher locations, smoke detectors/alarms, and emergency notification procedures were not completed until 8/26/2024.”

“Staff person A did not complete required 40-hour orientation training in resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reportable incidents/conditions within 40 scheduled working hours. Training was not completed until 8/26/2024.”

“Multiple poisonous materials were found unlocked, unattended, and accessible to residents: Freshscent Deodorant, Periguard Skin Protectant (two instances), and Dawnmist Fluoride Toothpaste, all with manufacturer labels indicating poison control contact. Not all residents have been assessed as capable of safely using or avoiding poisons.”

“Weekly menus were not posted in advance in a conspicuous and public place in the home. The menu for the current week was posted but the upcoming week's menu was not available.”

“Medication storage and security procedures were not properly implemented. A prescribed medication had a missing pill from the blister pack with no documentation of administration or waste on the Medication Administration Record. Additionally, a prescribed medication was incorrectly signed out on an as-needed form instead of the straight order form.”

“Staff violated a resident's privacy by video recording the resident on a personal phone without consent while the resident was in a state of undress/soiled conditions, and then sharing the video with another staff member.”

“Resident records were not kept confidential. A resident task list containing other residents' names and care needs was found on a resident's window ledge, accessible to that resident.”

“A resident requiring assistance with toileting, bladder management, and bowel management did not receive these required ADL services during the overnight shift.”

“A resident's contract did not contain information regarding the Senior Citizens Rebate and Assistance Act, which governs limitations on rent payments from rebate funds.”

“A resident requiring assistance with toileting and bowel/bladder management was left in soiled conditions (urine and feces) on their bed by overnight staff, constituting neglect.”

“A staff person did not have a current list of staff names, addresses, and telephone numbers maintained by the administrator.”

“Three direct care staff persons (Staff A, B, and D) did not receive required first-day orientation on fire safety and emergency preparedness topics including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher use, smoke detectors/fire alarms, and emergency notification procedures.”

“The home did not have a written policy on the prevention, reporting, notification, investigation and management of reportable incidents readily available at the time of inspection.”

“Residents 1 and 2 did not receive prescribed medications on the evening of 5/14/23, and the home did not report these medication errors to the Department within 24 hours.”

“The resident-home contract for resident 1, dated 5/17/23, was not signed by the resident.”

“The home's current license was not posted in a conspicuous and public place in the secured dementia care unit (Impressions) side of the home.”

“Medication errors were not reported to the Department within 24 hours. Resident #1's blood sugar checks were not completed as prescribed and prescribed medications were not received on multiple dates/times. Resident #2 did not receive prescribed medications. This is a repeat violation from 05/18/23.”

“The administrator or designee did not review and explain the resident-home contract to resident #3 prior to the resident's signature, despite electronic signatures from all parties.”

“The resident-home contract for resident #4 was not signed by the administrator, designee, resident, or the resident's Guardian Ad Litem as appointed by the Court. This is a repeat violation from 05/18/23 and 10/17/23.”

“The resident-home contracts for residents #4 and #5 do not include written information on resident rights or complaint procedures as required.”

“The resident-home contracts for residents #2 and #4 do not indicate whether the home collects a portion of the resident's rent rebate benefit.”

“Administrator did not provide immediate access to staff personnel records upon request by Department agents. Staff person A's record was delayed and staff person B's record was never provided.”

“Staff person A was hired without a criminal background check in accordance with the Older Adult Protective Services Act. Staff person B was hired on an unknown date without a required criminal background check.”

“Direct care staff person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. Direct care staff person D does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.”

“The administrator's staff contact list does not include substitute personnel as required. This is a repeat violation from 2/7/23.”

“Staff person A did not receive fire safety orientation on their first day of work covering evacuation procedures, staff duties during emergencies, designated meeting place, smoking safety, fire extinguishers, smoke detectors/alarms, and emergency services notification. Staff person B and Staff person D similarly did not receive required fire safety orientation on their first work day.”

“The home did not have a written policy on the prevention, reporting, notification, investigation and management of reportable incidents readily available at the time of inspection.”

“Residents 1 and 2 did not receive prescribed medications on the evening of 5/14/23, and the home did not report these medication errors to the Department within 24 hours.”

“The resident-home contract for resident 1, dated 5/17/23, was not signed by the resident.”