01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-12 | 11 | 2026-03-12 | 19 |
| Cycle 2 | 2025-04-10 | 14 | 2025-04-10 | 8 |
| Cycle 3 | 2024-11-01 | 26 | 2024-11-01 | 6 |
CMS CCN 3953112026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bryn Mawr Extended Care Center
956 Railroad Avenue · Bryn Mawr, PA 19010 · Delaware County
Certified beds160CMS provider file
Recent citation rows84current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
84 rows in the current release
4 rows carry G–L scope/severity codes; 2 carry J–L. 15 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-12 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2026-06-05 · complaint2026-03-12 · FIREE0036Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREE0037Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · HEALTHF0559Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · HEALTHF0813Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-04-08 · complaint2026-03-12 · HEALTHF0919Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-12 · FIREK0100Severity F · widespread; potential for more than minimal harm
Construction Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2026-06-132026-03-12 · FIREK0131Severity E · pattern; potential for more than minimal harm
Construction Deficiencies
Meet requirements for sections of health care facilities separated by fire resistive construction.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0225Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0281Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0344Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have an alternate power supply for its alarm system.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-06-132026-03-12 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-06-132026-03-12 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-12 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2026-06-1303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-11-01 | Fine | $12,048 | 0 |
| 2024-02-01 | Fine | $23,877 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BHG AVIV LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 03/01/2016
- VOLPE, BENJAMINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/01/2019
- WEISBERG, WILLIAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/01/2019
- NICOLUZAKIS, GREGORYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2019
- VOLPE, BENJAMINIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2019
- WEISBERG, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2019
- SABER GOVERNANCE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2019
- CARROLL, MICHELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/25/2024
- TALIAFERRO, MICHELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/11/2024
- BNV DYNASTY LLCOrganization · GENERAL PARTNERSHIP INTERESTNOT APPLICABLE · since 01/01/2023
- WIW DYNASTY LLCOrganization · GENERAL PARTNERSHIP INTERESTNOT APPLICABLE · since 01/01/2023
- CITRIN COOPERMAN ADVISORS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/01/2011
- RKL LLPOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/26/2023
- SHG BOA LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2016
- SHG MANAGEMENT LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2016
- TCF NATIONAL BANKOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/19/2019
- CARROLL, MICHELLEIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/25/2024
- GRAF, ANDREWIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2018
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.10per resident day
RN hours0.33per resident day
Weekend nurse hours2.76per resident day
Staff turnover37.7%CMS reported field
06 / LOCAL RECORDS
Open the Bryn Mawr ledger →