BRYN MAWR VILLAGE
Open-data reference.
BRYN MAWR VILLAGE is a non profit - corporation facility in BRYN MAWR, PA with 120 certified beds and a 3-star overall CMS rating. The facility has 35 deficiency records on file. Total penalties: $16K.
773 EAST HAVERFORD ROAD, BRYN MAWR, PA 19010
Phone: 6105258300
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 395095
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare
- Beds
- 120
- Residents
- 30
- In Hospital
- No
- County
- Delaware
- Last Inspection
- Mar 6, 2025
Staffing Data
- RN Hours
- 0.79 (nat'l avg: 0.68)
- LPN Hours
- 1.31
- CNA Hours
- 2.01
- Total Nursing Hours
- 4.11 (nat'l avg: 3.89)
- PT Hours
- 0.22
- Nursing Turnover
- 77.3%
- RN Turnover
- 87.5%
What the CMS Record Reveals About BRYN MAWR VILLAGE
BRYN MAWR VILLAGE operates 120 certified beds in BRYN MAWR, PA with approximately 30 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (3★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 35 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $16K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.11 total nursing hours per resident day (national average 3.89), with RN coverage at 0.79 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare" provider, BRYN MAWR VILLAGE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 77.3%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (35 most recent)
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation 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.
Category: Resident Rights Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Apr 21, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 21, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 21, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 21, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 21, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 21, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 21, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 21, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 21, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 21, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Apr 21, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Jul 1, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 1, 2024
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 1, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 1, 2024
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 1, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Jul 1, 2024
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 1, 2024
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 1, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 1, 2024
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 1, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 1, 2024
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Jul 1, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Mar 6, 2024
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category: Administration Deficiencies
Corrected: Aug 15, 2023
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Aug 15, 2023
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.
Category: Infection Control Deficiencies
Corrected: Aug 15, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Aug 15, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 15, 2023
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 15, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 15, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Aug 15, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Apr 21, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.6% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.9% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 51.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 29.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | N/A | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 7.1% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | N/A | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 43.4% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 12.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | N/A | Yes |
Penalty History 1 penalties totaling $16K
| Date | Type | Amount |
|---|---|---|
| May 10, 2024 | Fine | $16K |
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Frequently Asked Questions
What is the overall CMS rating for BRYN MAWR VILLAGE?
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How many beds does BRYN MAWR VILLAGE have?
Does BRYN MAWR VILLAGE have any deficiencies on record?
Has BRYN MAWR VILLAGE received any fines or penalties?
Who owns BRYN MAWR VILLAGE?
When was BRYN MAWR VILLAGE last inspected?
What quality measures are tracked for BRYN MAWR VILLAGE?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.