01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-02-13 | 20 | 2026-02-13 | 3 |
| Cycle 2 | 2025-03-06 | 11 | 2025-03-06 | 2 |
| Cycle 3 | 2024-05-10 | 13 | 2024-05-10 | 1 |
CMS CCN 3950952026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bryn Mawr Village
773 East Haverford Road · Bryn Mawr, PA 19010 · Delaware County
Certified beds120CMS provider file
Recent citation rows50current CMS citation release
Penalty rows1current 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
50 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-13 · FIREE0035Severity B · pattern; potential for minimal harm
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Correction field: Deficient, Provider has date of correction · 2026-04-142026-02-13 · FIREE0036Severity B · pattern; potential for minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2026-04-142026-02-13 · FIREE0037Severity B · pattern; potential for minimal harm
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Correction field: Deficient, Provider has date of correction · 2026-04-142026-02-13 · HEALTHF0552Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · 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 · 2026-04-07 · under IDR/IIDR2026-02-13 · HEALTHF0655Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · 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: Past Non-Compliance · 2025-10-082026-02-13 · HEALTHF0692Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · HEALTHF0838Severity C · widespread; potential for minimal harm
Administration Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-072026-02-13 · 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 · 2026-04-072026-02-13 · 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 · 2026-04-072025-09-24 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has no plan of correction · complaint2025-09-24 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has no plan of correction · complaint2025-03-06 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-2103 / 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 |
|---|---|---|---|
| 2024-05-10 | Fine | $15,902 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HAVERFORD HOLDING COMPANY INCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 08/30/2021
- FREDERICKS, JOHNIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 08/30/2021
- BRAUNSTEIN, MIRIAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/30/2021
- IKE, AKIKOIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/30/2021
- WAKE, CORYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/30/2021
- COMPASSIONATE CARE HEALTHCARE CONSULTANTS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/30/2021
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 hours4.26per resident day
RN hours0.69per resident day
Weekend nurse hours3.79per resident day
Staff turnover73.3%CMS reported field
06 / LOCAL RECORDS
Open the Bryn Mawr ledger →