Cycle 1
Health 2025-03-06 · Fire 2025-03-06
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Bryn Mawr, PA
Bryn Mawr Village
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
773 East Haverford Road, Bryn Mawr, PA
(610) 525-8300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
0.79
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.95
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
88%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
77%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,974
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.09% · Performance 23.30% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.87% · Performance 7.87% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 44.19% · Performance 72.73% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.72
Baseline 3.11 hours · Performance 4.14 hours · Measure score 3.72 · Achievement 3.72 · Improvement 3.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.27% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 201 · Observed rate 11.94% · Lower 95% interval 8.68% |
| Discharge to community | 53.77% |
50.57%
3.2 pts better
|
No Different than the National Rate · Eligible stays 230 · Observed rate 46.52% · Lower 95% interval 46.97% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.19% |
95.27%
3.9 pts better
|
Numerator 123 · Denominator 124 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 124 |
| Discharge self-care score | 67.09% |
53.69%
13.4 pts better
|
Numerator 53 · Denominator 79 |
| Discharge mobility score | 67.09% |
50.94%
16.2 pts better
|
Numerator 53 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0.81% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 124 · Adjusted rate 0.82% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 10.08% · Lower 95% interval 4.99% |
| Staff COVID-19 vaccination coverage | 1.98% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 101 |
| Staff flu vaccination coverage | 95.16% |
42%
53.2 pts better
|
Numerator 118 · Denominator 124 |
| Discharge function score | 60.76% |
56.45%
4.3 pts better
|
Numerator 48 · Denominator 79 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 98.31% |
96.28%
2 pts better
|
Numerator 58 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 7.27% |
25.2%
17.9 pts worse
|
Numerator 4 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 51.4% |
86.9%
35.5 pts worse
|
93.4%
42 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 51.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.5%
2.9 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.1% |
19.9%
12.8 pts better
|
19.6%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
18.3%
2.5 pts worse
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.7%
1.2 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.8% |
26.4%
13.6 pts better
|
19.8%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.8% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
5.3%
3.9 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.0% |
68.9%
39.9 pts worse
|
81.7%
52.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 40.1% · Q3 36.0% · Q4 20.9% · 4Q avg 29.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
9.8%
2.3 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.5% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.0% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 43.4% |
68.7%
25.3 pts worse
|
79.7%
36.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.3% |
23.1%
9.2 pts worse
|
23.9%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.3% · Observed 32.5% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-10 · Fire 2024-05-10
12 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-07-10 · Fire 2023-07-10
10 health deficiencies
Top issue: Infection Control (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-29
E · Potential for more than minimal harm
2025-03-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-29
E · Potential for more than minimal harm
2024-05-10
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-07-01
F · Potential for more than minimal harm
2023-07-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-10
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-07-10
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-09-05
C · Minimal harm
2023-07-10
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-05
C · Minimal harm
2023-07-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-09-05
C · Minimal harm
2023-07-10
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-09-05
C · Minimal harm
2023-07-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2025-09-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Not marked corrected
D · Potential for more than minimal harm
2025-03-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-06
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 2025-04-21
D · Potential for more than minimal harm
2025-03-06
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 2025-04-21
D · Potential for more than minimal harm
2025-03-06
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 2025-04-21
D · Potential for more than minimal harm
2025-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-06
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-06
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-21
J · Immediate jeopardy
2024-05-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-05-10
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 2024-07-01
E · Potential for more than minimal harm
2024-05-10
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-10
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-10
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-10
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 2024-07-01
D · Potential for more than minimal harm
2024-05-10
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 2024-07-01
D · Potential for more than minimal harm
2024-05-10
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-02-14
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-03-06
E · Potential for more than minimal harm
2023-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-10
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 2023-08-15
D · Potential for more than minimal harm
2023-07-10
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-10
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-10
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-03-16
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
$15,902
2024-05-10
Fine
Fine · fine $15,902
Fine
Ownership
Haverford Holding Company Inc
5% Or Greater Direct Ownership Interest · Organization
Braunstein, Miriam
Corporate Director · Individual
Compassionate Care Healthcare Consultants LLC
Operational/Managerial Control · Organization
Fredericks, John
W-2 Managing Employee · Individual
Ike, Akiko
Corporate Director · Individual
Wake, Cory
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
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
#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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