All citations for Villas at Bryn Mawr LLC
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
June 17, 2026
Showing 1 to 25 of 31 citations
Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Past non-compliance: already corrected by the time of the inspection (June 10, 2025).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
The home gave a date the problem would be corrected (July 18, 2025).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
The home gave a date the problem would be corrected (July 18, 2025).
No harm, with potential for more than minimal harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
The home gave a date the problem would be corrected (July 18, 2025).
No harm, with potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
The home gave a date the problem would be corrected (July 18, 2025).
No harm, with potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Assure that each resident’s assessment is updated at least once every 3 months.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
PASARR screening for Mental disorders or Intellectual Disabilities
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Assist a resident in gaining access to vision and hearing services.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Provide appropriate foot care.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
The home gave a date the problem would be corrected (April 29, 2025).
No harm, with potential for more than minimal harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
The home gave a date the problem would be corrected (April 29, 2025).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.