Haverford, PA

Quadrangle

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

3300 Darby Road, Haverford, PA

(610) 642-3000

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

63

Certified beds

Average residents

60

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Healthpeak Properties, Inc.

Operator or chain grouping

Approved since

1989-07-03

CMS approved date

Coverage

Medicare

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.23

Registered nurse staffing

LPN hours / resident day

1.27

Licensed practical nurse staffing

Aide hours / resident day

2.99

Nurse aide staffing

Weekend hours

5.06

Weekend nurse staffing

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.8
1.7
0.9 pts better
1.9
1.1 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 2.7
1.2
1.5 pts worse
1.8
0.9 pts worse
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 85.2%
86.9%
1.7 pts worse
93.4%
8.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 90.5%
93.5%
3 pts worse
95.5%
5 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 1.1%
3.2%
2.1 pts better
3.3%
2.2 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents who lose too much weight 1.6%
6.5%
4.9 pts better
5.4%
3.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 15.9%
19.9%
4 pts better
19.6%
3.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 12.5%
18.7%
6.2 pts better
16.7%
4.2 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 18.2%
19.6%
1.4 pts better
16.3%
1.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 16.7%
18.3%
1.6 pts better
14.9%
1.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.2%
0.9%
0.3 pts worse
1.0%
0.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 2.4%
1.7%
0.7 pts worse
1.7%
0.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 36.0%
26.4%
9.6 pts worse
19.8%
16.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 9.5%
5.3%
4.2 pts worse
5.1%
4.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 49.1%
68.9%
19.8 pts worse
81.7%
32.6 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 15.0%
9.8%
5.2 pts worse
12.0%
3 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 1.5%
1.5%
About the same
1.6%
0.1 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 47.1%
68.7%
21.6 pts worse
79.7%
32.6 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.5%
23.1%
0.6 pts better
23.9%
1.4 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-03 · Fire 2025-04-03

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-05-22 · Fire 2024-05-22

11 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2023-08-07 · Fire 2023-08-07

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-03

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-06-10

E · Potential for more than minimal harm 2025-04-03

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-06-10

C · Minimal harm 2025-04-03

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-06-10

F · Potential for more than minimal harm 2024-05-22

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-09-24

F · Potential for more than minimal harm 2024-05-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-08-12

E · Potential for more than minimal harm 2024-05-22

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-12

E · Potential for more than minimal harm 2024-05-22

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-12

E · Potential for more than minimal harm 2024-05-22

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-08-12

C · Minimal harm 2024-05-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-09-24

C · Minimal harm 2024-05-22

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2024-09-24

C · Minimal harm 2024-05-22

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-09-24

F · Potential for more than minimal harm 2023-08-07

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 2023-10-15

E · Potential for more than minimal harm 2023-08-07

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-10-15

E · Potential for more than minimal harm 2023-08-07

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-10-15

E · Potential for more than minimal harm 2023-08-07

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-10-15

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-24

D · Potential for more than minimal harm 2025-06-12

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.

Corrected 2025-06-30

F · Potential for more than minimal harm 2025-04-03

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 2025-06-02

F · Potential for more than minimal harm 2025-04-03

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-06-02

E · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-02

G · Actual harm 2025-01-16

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 2025-01-16

D · Potential for more than minimal harm 2025-01-16

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-02-14

E · Potential for more than minimal harm 2024-05-22

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 2024-06-28

E · Potential for more than minimal harm 2024-05-22

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

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 2024-06-13

D · Potential for more than minimal harm 2024-05-22

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

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 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2024-06-28

D · Potential for more than minimal harm 2023-08-07

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

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 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

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 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2023-10-07

Penalties and ownership

What sits behind the stars

$8,278 2025-01-16

Fine

Fine · fine $8,278

Fine

Ownership

Bown, Keith

Operational/Managerial Control · Individual

0% 2 facilities 2025-01-16
Coelho, Andrew

Operational/Managerial Control · Individual

0% 8 facilities 2025-01-16
Desai, Mehir

Operational/Managerial Control · Individual

0% 1 facilities 2025-04-01
Eccles, Susan

Operational/Managerial Control · Individual

0% 1 facilities 2024-10-28
Falco, Denise

Operational/Managerial Control · Individual

0% 8 facilities 2025-01-16
Frantz, Edward

Operational/Managerial Control · Individual

0% 8 facilities 2025-01-16
Kessler, Thomas

Operational/Managerial Control · Individual

0% 7 facilities 2025-01-16
O'riordan, Damien

Operational/Managerial Control · Individual

0% 8 facilities 2025-01-16
Painter, David

Operational/Managerial Control · Individual

0% 8 facilities 2025-01-16
Royal, Patricia

Operational/Managerial Control · Individual

0% 8 facilities 2024-12-02
Sekel, Wendy

Operational/Managerial Control · Individual

0% 8 facilities 2025-01-16
Sunrise Senior Living Management Inc

Operational/Managerial Control · Organization

0% 7 facilities 2020-10-16
Thompson, Lisa

Operational/Managerial Control · Individual

0% 7 facilities 2025-01-16
Verger, Pierre

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-16
Wells, Anja

Operational/Managerial Control · Individual

0% 8 facilities 2025-01-16

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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

Overall
3 / 5
Health
2 / 5
Staffing
3 / 5
Fines
$15,902
#2

Bryn Mawr Extended Care Center

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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

Overall
1 / 5
Health
1 / 5
Staffing
3 / 5
Fines
$42,412

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