Map showing the location of BRYN MAWR VILLAGE in BRYN MAWR, Pennsylvania
773 EAST HAVERFORD ROAD, BRYN MAWR, PA, 19010

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • PennsylvaniaAbove only 42% of peers653 rated homes · average 3.0★
  • Delaware CountyAbove only 30% of peers28 rated homes · average 3.4★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs PA avg
  • StaffingCan add or remove a star3★−0.3 vs PA avg
  • Quality measuresCan add or remove a star5★+1.5 vs PA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 20% of peersPA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 27% of peersPA avg3.3★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 75% of peersPA avg3.5★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.11hrsAbove 72% of peersPA avg3.89Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.79hrsAbove 64% of peersPA avg0.78Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better77%Above only 3% of peersPA avg47%RN turnover88%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$15,902Above only 31% of peersPA avg$28,640Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
35citations
6inspection dates
0actual harm (G–I)
1immediate jeopardy (J–L)
Sep 24, 2025most recent

Citations by monthMar 2023 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 24, 20252 citationsCycle 1worst E · no actual harm
  1. F585Honor 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.Resident RightsD · isolatedCorrection pending
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrection pending
Mar 6, 202511 citationsCycle 1worst D · no actual harm
  1. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 21, 2025
  2. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Apr 21, 2025
  3. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 21, 2025
  4. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
  5. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
  6. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
  7. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
  9. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Apr 21, 2025
  10. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
  11. F578Honor 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.Resident RightsD · isolatedCorrected Apr 21, 2025
May 10, 202412 citationsCycle 2worst J · immediate jeopardy$15,902
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 1, 2024
  2. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Jul 1, 2024
  3. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareJ · isolatedCorrected Jul 1, 2024
  4. F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesD · isolatedCorrected Jul 1, 2024
  5. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Jul 1, 2024
  6. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jul 1, 2024
  7. F803Ensure 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.Nutrition and DietaryD · isolatedCorrected Jul 1, 2024
  8. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Jul 1, 2024
  9. F808Ensure 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.Nutrition and DietaryD · isolatedCorrected Jul 1, 2024
  10. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jul 1, 2024
  11. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationD · isolatedCorrected Jul 1, 2024
  12. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Jul 1, 2024
Feb 14, 20241 citationCycle 2worst D · no actual harm
  1. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Mar 6, 2024
Jul 10, 20238 citationsCycle 3worst E · no actual harm
  1. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected Aug 15, 2023
  2. F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationD · isolatedCorrected Aug 15, 2023
  3. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Aug 15, 2023
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Aug 15, 2023
  5. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Aug 15, 2023
  6. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Aug 15, 2023
  7. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Aug 15, 2023
  8. F887Educate 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.Infection ControlD · isolatedCorrected Aug 15, 2023
Mar 16, 20231 citationCycle 3worst D · no actual harm
  1. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationD · isolatedCorrected Apr 21, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.11hrsAbove 72% of peers+0.22 vs PA avg
  • Registered nursesRN hours only0.79hrsAbove 64% of peers+0.01 vs PA avg
  • Licensed practical nursesLPN hours1.31hrs
  • Nurse aidesCNA hours2.01hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.85hrs
  • Pennsylvania average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better77%Above only 3% of peersPA avg 47%
  • RN turnoverRegistered nurses only88%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy120 certified beds · ~30 residents a day25%Lowest tier among peersPA avg 82%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $15,902In fines
  • 1Fine
  • 0Payment denials
  • $28,640PA avg in fines
Above only 31% of peersFewer fines than 31% of rated homes in Pennsylvania

Actions on record

  1. May 10, 2024Civil money penalty$15,902

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Independent
Certification
Medicare
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Haverford Holding Company INC
Operational or managerial control
  • Compassionate Care Healthcare Consultants LLC
Corporate directors
  • Miriam Braunstein
  • Akiko Ike
  • Cory Wake
Managing employees
  • John Fredericks

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 395095 · 773 EAST HAVERFORD ROAD, BRYN MAWR, PA, 19010.
  • Percentiles compare this facility with every rated nursing home in Pennsylvania and Delaware County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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