Mifflintown, PA

Brookline Nursing And Rehab

4-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

2 Manor Boulevard, Mifflintown, PA

(717) 436-2178

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1979-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.47

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.98

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.97

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.42

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.13

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.33

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.43

CMS adjusted RN staffing hours

Adjusted total hours

3.13

CMS adjusted total nurse staffing hours

Case-mix index

1.49

Higher values indicate more complex resident acuity

RN turnover

13%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,068

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

30.85

Composite VBP score used to determine payment impact.

Payment multiplier

0.9862

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.83

Baseline 17.85% · Performance 18.27% · Measure score 6.83 · Achievement 6.83 · Improvement 0

Healthcare-associated infections

2.14

Baseline 5.34% · Performance 7.20% · Measure score 2.14 · Achievement 2.14 · Improvement 0

Total nurse turnover

1.88

Baseline 63.38% · Performance 56.00% · Measure score 1.88 · Achievement 1.88 · Improvement 1.42

Adjusted total nurse staffing

1.49

Baseline 3.21 hours · Performance 3.50 hours · Measure score 1.49 · Achievement 1.49 · Improvement 0.65

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.23%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 102 · Observed rate 12.75% · Lower 95% interval 8.35%
Discharge to community	47.23%	50.57% 3.3 pts worse	No Different than the National Rate · Eligible stays 101 · Observed rate 40.59% · Lower 95% interval 39.37%
Medicare spending per beneficiary	0.98	1.02 About the same
Drug regimen review with follow-up	98%	95.27% 2.7 pts better	Numerator 98 · Denominator 100
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 100
Discharge self-care score	58.02%	53.69% 4.3 pts better	Numerator 47 · Denominator 81
Discharge mobility score	56.79%	50.94% 5.9 pts better	Numerator 46 · Denominator 81
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 100 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.19%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 3.95%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 102
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	60.49%	56.45% 4 pts better	Numerator 49 · Denominator 81
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 24 · Denominator 24
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 44 · Denominator 44
Resident COVID-19 vaccinations up to date	40.91%	25.2% 15.7 pts better	Numerator 27 · Denominator 66

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.3	1.7 0.4 pts better	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.1	1.2 1.1 pts better	1.8 1.7 pts better	Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	86.9% 13.1 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	93.5% 5.1 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	3.2% 0.1 pts worse	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.1% · Q3 1.8% · Q4 3.3% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	10.2%	6.5% 3.7 pts worse	11.4% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.8% · Q3 2.2% · Q4 34.7% · 4Q avg 10.2%
Percentage of long-stay residents who lose too much weight	7.3%	6.5% 0.8 pts worse	5.4% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 11.1% · Q3 7.4% · Q4 3.6% · 4Q avg 7.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.4%	19.9% 1.5 pts better	19.6% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 15.6% · Q3 19.3% · Q4 23.3% · 4Q avg 18.4%
Percentage of long-stay residents who received an antipsychotic medication	19.4%	18.7% 0.7 pts worse	16.7% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 25.0% · Q3 18.2% · Q4 15.2% · 4Q avg 19.4% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	25.8%	19.6% 6.2 pts worse	16.3% 9.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 36.9% · 4Q avg 25.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.4%	18.3% 3.9 pts better	14.9% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 29.5% · Q3 9.6% · Q4 5.6% · 4Q avg 14.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.4%	0.9% 1.5 pts worse	1.0% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.6% · Q3 1.5% · Q4 4.3% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.1%	1.7% 0.4 pts worse	1.7% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.2% · Q3 1.9% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	31.1%	26.4% 4.7 pts worse	19.8% 11.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 30.6% · Q3 31.0% · Q4 40.1% · 4Q avg 31.1%
Percentage of long-stay residents with pressure ulcers	3.3%	5.3% 2 pts better	5.1% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.5% · Q3 2.5% · Q4 2.4% · 4Q avg 3.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.8%	68.9% 26.9 pts better	81.7% 14.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 96.6% · Q3 93.7% · Q4 95.2% · 4Q avg 95.8%
Percentage of short-stay residents who had an outpatient emergency department visit	4.0%	9.8% 5.8 pts better	12.0% 8 pts better	Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 4.0% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.5% 1.2 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	68.7% 31.3 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.0%	23.1% 1.1 pts better	23.9% 1.9 pts better	Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 21.3% · Expected 23.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-21 · Fire 2025-03-21

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2024-03-22 · Fire 2024-03-22

9 health deficiencies

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

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-04-21 · Fire 2023-04-21

12 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

4 fire-safety deficiencies

Top issue: Construction (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-03-21

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2025-03-17

E · Potential for more than minimal harm 2024-03-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-04-25

E · Potential for more than minimal harm 2023-04-21

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-04-30

E · Potential for more than minimal harm 2023-04-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-30

C · Minimal harm 2023-04-21

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-04-30

C · Minimal harm 2023-04-21

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2023-04-30

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-22

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2026-02-17

E · Potential for more than minimal harm 2025-03-21

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2025-05-06

E · Potential for more than minimal harm 2025-03-21

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 2025-05-06

E · Potential for more than minimal harm 2025-03-21

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-05-06

D · Potential for more than minimal harm 2025-03-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-05-06

D · Potential for more than minimal harm 2025-03-21

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-05-06

D · Potential for more than minimal harm 2025-03-21

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 2025-05-06

D · Potential for more than minimal harm 2025-03-21

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 2025-05-06

D · Potential for more than minimal harm 2025-03-21

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-06

D · Potential for more than minimal harm 2025-03-21

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2025-05-06

C · Minimal harm 2025-03-21

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 2025-05-06

E · Potential for more than minimal harm 2024-03-22

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-04-30

E · Potential for more than minimal harm 2024-03-22

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-30

E · Potential for more than minimal harm 2024-03-22

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-04-30

D · Potential for more than minimal harm 2024-03-22

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2024-04-30

D · Potential for more than minimal harm 2024-03-22

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 2024-04-30

D · Potential for more than minimal harm 2024-03-22

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-30

D · Potential for more than minimal harm 2024-03-22

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2024-04-30

D · Potential for more than minimal harm 2024-03-22

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-04-30

D · Potential for more than minimal harm 2024-03-22

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2024-04-30

E · Potential for more than minimal harm 2023-04-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-05-23

E · Potential for more than minimal harm 2023-04-21

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-05-23