Cycle 1
Health 2025-05-28 · Fire 2025-05-28
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Bryn Mawr, PA
Beaumont At Bryn Mawr
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
601 North Ithan Avenue, Bryn Mawr, PA
(610) 526-7000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-03-25
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.93
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.88
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
6.39
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.52
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
5.70
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.33
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.37
CMS adjusted RN staffing hours
Adjusted total hours
7.83
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
674
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0197
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.56
Baseline 20.21% · Performance 19.78% · Measure score 3.56 · Achievement 3.56 · Improvement 0.86
Healthcare-associated infections
2.67
Baseline 7.00% · Performance 7.04% · Measure score 2.67 · Achievement 2.67 · Improvement 0
Total nurse turnover
10
Baseline 15.56% · Performance 22.00% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.08 hours · Performance 6.95 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.76% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 6% · Lower 95% interval 6.76% |
| Discharge to community | 50.74% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 48.91% · Lower 95% interval 41.77% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.64% |
95.27%
0.6 pts worse
|
Numerator 53 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 44.68% |
53.69%
9 pts worse
|
Numerator 21 · Denominator 47 |
| Discharge mobility score | 63.83% |
50.94%
12.9 pts better
|
Numerator 30 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.79% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 56 · Adjusted rate 2.12% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 4.5% |
| Staff COVID-19 vaccination coverage | 26.6% |
8.2%
18.4 pts better
|
Numerator 25 · Denominator 94 |
| Staff flu vaccination coverage | 97.7% |
42%
55.7 pts better
|
Numerator 85 · Denominator 87 |
| Discharge function score | 55.32% |
56.45%
1.1 pts worse
|
Numerator 26 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 85.71% |
96.28%
10.6 pts worse
|
Numerator 30 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 80.65% |
25.2%
55.5 pts better
|
Numerator 25 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.7 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
86.9%
9.7 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 93.5% · Q3 100.0% · Q4 100.0% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
93.5%
3.6 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.2%
2.8 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.5% · Q3 7.4% · Q4 3.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
6.5%
3.7 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
19.9%
2.8 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 17.2% · Q3 18.5% · Q4 20.0% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
18.7%
4.9 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.1% · Q3 18.2% · Q4 18.2% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.5% |
19.6%
10.1 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
18.3%
0.3 pts worse
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 22.2% · Q3 16.0% · Q4 14.3% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
1.7%
3.6 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.6% · Q3 7.4% · Q4 7.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
26.4%
5.8 pts better
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 17.0% · Q3 15.6% · Q4 23.1% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.3%
1.4 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.6% · Q3 0.0% · Q4 4.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.3% |
68.9%
16.4 pts better
|
81.7%
3.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 80.5% · Q3 94.6% · Q4 93.9% · 4Q avg 85.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
9.8%
5.1 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 3.7% · Expected 8.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.4% |
68.7%
16.7 pts better
|
79.7%
5.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
23.1%
1.7 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 16.7% · Expected 16.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-10-05 · Fire 2023-10-05
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-17
E · Potential for more than minimal harm
2024-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-05
E · Potential for more than minimal harm
2024-08-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-05
E · Potential for more than minimal harm
2023-10-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-15
C · Minimal harm
2023-10-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-14
Penalties and ownership
What sits behind the stars
Ownership
Benchmark Therapies, Inc.
Operational/Managerial Control · Organization
Caulder, Mary
Operational/Managerial Control · Individual
Day, Adam
Operational/Managerial Control · Individual
Eisner Amper, LLC
Operational/Managerial Control · Organization
Eisner Amper, Llp
Operational/Managerial Control · Organization
Forvis Mazars Llp
Operational/Managerial Control · Organization
Harding, Marjorie
Operational/Managerial Control · Individual
Kendra, Susan
Corporate Officer · Individual
Lane-Craskey, Christy
Operational/Managerial Control · Individual
Lane-Craskey, Christy
Corporate Director · Individual
Main Line Healthcare
Operational/Managerial Control · Organization
Mercer Investments, LLC.
Operational/Managerial Control · Organization
Mutual Of America
Operational/Managerial Control · Organization
Peduzzi, Joseph
Corporate Director · Individual
Peduzzi, Joseph
Corporate Officer · Individual
Pharmerica Drug Systems LLC
Operational/Managerial Control · Organization
Roberts, Mark
Operational/Managerial Control · Individual
Vital Healthcare Solutions
Operational/Managerial Control · Organization
Wilmington Savings Fund Society
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Rosemont Center
Rosemont, PA
2-star overall rating with 3-star inspections with $22,935 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Bryn Mawr Extended Care Center
Bryn Mawr, PA
1-star overall rating with 1-star inspections with $42,412 in total fines with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Bryn Mawr Village
Bryn Mawr, PA
3-star overall rating with 2-star inspections with $15,902 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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