Cycle 1
Health 2025-04-10 · Fire 2025-04-10
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bryn Mawr, PA
Bryn Mawr Extended Care Center
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
956 Railroad Avenue, Bryn Mawr, PA
(610) 525-8412
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1974-05-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.35
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,612
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.29% · Performance 23.61% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.52
Baseline 5.37% · Performance 5.88% · Measure score 6.52 · Achievement 6.52 · Improvement 0
Total nurse turnover
2.81
Baseline 52.17% · Performance 52.21% · Measure score 2.81 · Achievement 2.81 · Improvement 0
Adjusted total nurse staffing
2.38
Baseline 3.20 hours · Performance 3.75 hours · Measure score 2.38 · Achievement 2.38 · Improvement 1.64
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 9.35% · Lower 95% interval 6.91% |
| Discharge to community | 37.55% |
50.57%
13 pts worse
|
Worse than the National Rate · Eligible stays 102 · Observed rate 27.45% · Lower 95% interval 27.23% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 84.15% |
95.27%
11.1 pts worse
|
Numerator 69 · Denominator 82 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 82 |
| Discharge self-care score | 32.61% |
53.69%
21.1 pts worse
|
Numerator 15 · Denominator 46 |
| Discharge mobility score | 17.39% |
50.94%
33.5 pts worse
|
Numerator 8 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.22% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 82 · Adjusted rate 1.1% |
| Healthcare-associated infections requiring hospitalization | 5.89% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 3.9% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | 41.14% |
42%
0.9 pts worse
|
Numerator 65 · Denominator 158 |
| Discharge function score | 19.57% |
56.45%
36.9 pts worse
|
Numerator 9 · Denominator 46 |
| Transfer of health information to provider | 84.38% |
95.95%
11.6 pts worse
|
Numerator 27 · Denominator 32 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 24 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 4.17% |
25.2%
21 pts worse
|
Numerator 2 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.9% |
86.9%
16 pts worse
|
93.4%
22.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.7% · Q2 75.6% · Q3 71.9% · Q4 71.0% · 4Q avg 70.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
93.5%
0.5 pts better
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.2%
0.9 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.4% · Q3 2.2% · Q4 2.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
6.5%
0.9 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.7% · Q3 4.7% · Q4 8.1% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.5%
0.8 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.2% · Q3 6.9% · Q4 8.6% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
19.9%
2.2 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 18.5% · Q3 20.0% · Q4 18.5% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
18.7%
6.5 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 11.7% · Q3 12.2% · Q4 11.8% · 4Q avg 12.2% · 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 | 16.4% |
19.6%
3.2 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 11.6% · Q3 3.2% · Q4 22.5% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
18.3%
6.4 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 7.1% · Q3 3.3% · Q4 18.2% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7% |
26.4%
10.7 pts better
|
19.8%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 5.7% · Q3 17.3% · Q4 23.7% · 4Q avg 15.7% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.3%
About the same
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.0% · Q3 5.0% · Q4 5.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 8.3% |
68.9%
60.6 pts worse
|
81.7%
73.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.7% · Q3 11.2% · Q4 7.3% · 4Q avg 8.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
9.8%
6.8 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 18.8% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
1.5%
3 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.0% · Q3 4.7% · Q4 3.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 11.6% |
68.7%
57.1 pts worse
|
79.7%
68.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 11.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
23.1%
2.3 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 31.9% · Expected 30.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-01 · Fire 2024-11-01
11 health deficiencies
Top issue: Administration (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2024-02-01 · Fire 2024-02-01
29 health deficiencies
Top issue: Resident Rights (6 deficiencies)
27 fire-safety deficiencies
Top issue: Emergency Preparedness (12 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-23
C · Minimal harm
2025-04-10
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-01
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-01
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-02-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-02-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-02-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-01
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-02-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-02-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-02-01
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-02-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-01
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-02-01
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-18
C · Minimal harm
2024-02-01
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-04-12
C · Minimal harm
2024-02-01
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-18
D · Potential for more than minimal harm
2023-05-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-11
E · Potential for more than minimal harm
2025-04-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
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 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-07
G · Actual harm
2024-11-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-11-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-11-01
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-01
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-01
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-01
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-01
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-08-22
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-17
J · Immediate jeopardy
2024-02-29
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-03-11
K · Immediate jeopardy
2024-02-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-11
F · Potential for more than minimal harm
2024-02-01
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-03-11
F · Potential for more than minimal harm
2024-02-01
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-01
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-01
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
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 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-01
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-03-11
D · Potential for more than minimal harm
2023-11-14
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-08-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-09-13
Penalties and ownership
What sits behind the stars
$18,535
2024-11-01
Fine
Fine · fine $18,535
Fine
$23,877
2024-02-01
Fine
Fine · fine $23,877
Fine
Ownership
Saber Pa Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bhg Aviv LLC
5% Or Greater Security Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
General Partnership Interest · Organization
Carroll, Michelle
Operational/Managerial Control · Individual
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Saber Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Taliaferro, Michelle
Operational/Managerial Control · Individual
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Wiw Dynasty LLC
General Partnership Interest · Organization
Nearby options
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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
#2
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
#3
Quadrangle
Haverford, PA
2-star overall rating with 2-star inspections with $8,278 in total fines with 17 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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