Cycle 1
Health 2025-12-03 · Fire 2025-12-03
5 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Roslyn, PA
Brookside Healthcare & Rehabilitation Center
3-star overall rating with 3-star inspections with 5 recent health deficiencies
2630 Woodland Road, Roslyn, PA
(215) 884-6776
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nationwide Healthcare Services
Operator or chain grouping
Approved since
1970-05-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
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
0.52
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,162
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.29
Baseline 24.00% · Performance 19.26% · Measure score 6.29 · Achievement 4.68 · Improvement 6.29
Healthcare-associated infections
1.86
Baseline 5.83% · Performance 7.28% · Measure score 1.86 · Achievement 1.86 · Improvement 0
Total nurse turnover
2.14
Baseline 52.56% · Performance 54.92% · Measure score 2.14 · Achievement 2.14 · Improvement 0
Adjusted total nurse staffing
1.94
Baseline 3.20 hours · Performance 3.63 hours · Measure score 1.94 · Achievement 1.94 · Improvement 1.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.17% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 176 · Observed rate 12.5% · Lower 95% interval 8.07% |
| Discharge to community | 43.68% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 32.86% · Lower 95% interval 34.13% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 145 · Denominator 145 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 145 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 72 · Denominator 108 |
| Discharge mobility score | 49.07% |
50.94%
1.9 pts worse
|
Numerator 53 · Denominator 108 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 145 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 8.74% · Lower 95% interval 4.5% |
| Staff COVID-19 vaccination coverage | 0.71% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 140 |
| Staff flu vaccination coverage | 29.84% |
42%
12.2 pts worse
|
Numerator 57 · Denominator 191 |
| Discharge function score | 71.3% |
56.45%
14.8 pts better
|
Numerator 77 · Denominator 108 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 67.06% |
25.2%
41.9 pts better
|
Numerator 57 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.7
1.8 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
86.9%
11.6 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 97.1% · Q3 98.0% · Q4 100.0% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
93.5%
5.6 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 1.0% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
6.5%
3.8 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 8.7% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.5%
1 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.5% · Q3 8.1% · Q4 10.7% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
19.9%
7.9 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 12.2% · Q3 10.9% · Q4 13.1% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.0% |
18.7%
6.3 pts worse
|
16.7%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 28.2% · Q3 22.8% · Q4 25.4% · 4Q avg 25.0% · 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 | 10.4% |
19.6%
9.2 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 2.6% · Q3 12.9% · Q4 5.7% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
18.3%
0.1 pts better
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 12.8% · Q3 19.3% · Q4 11.5% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 2.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.7% |
26.4%
15.7 pts better
|
19.8%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 12.7% · Q3 12.3% · Q4 6.9% · 4Q avg 10.7% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.3%
0.1 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.9% · Q3 4.6% · Q4 5.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.0% |
68.9%
11.1 pts better
|
81.7%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 88.0% · Q3 79.7% · Q4 72.1% · 4Q avg 80.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
9.8%
0.3 pts worse
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 11.0% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.0% · Q3 0.0% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
68.7%
22.6 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
23.1%
2.3 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 30.9% · Expected 28.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-01 · Fire 2024-11-01
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-11-02 · Fire 2023-11-02
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-02
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-01-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-03
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 2025-12-05
E · Potential for more than minimal harm
2025-12-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-12-03
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-03
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-05-29
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-07-07
F · Potential for more than minimal harm
2024-11-01
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 2024-11-30
E · Potential for more than minimal harm
2024-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-01
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-01
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 2024-11-30
D · Potential for more than minimal harm
2024-11-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-09-23
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 2024-11-04
D · Potential for more than minimal harm
2024-05-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-08
F · Potential for more than minimal harm
2023-11-02
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 2023-12-15
E · Potential for more than minimal harm
2023-11-02
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F808 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-03-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-03-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-02
Penalties and ownership
What sits behind the stars
Ownership
Gelley, Leah
5% Or Greater Direct Ownership Interest · Individual
Gelley, Meir
5% Or Greater Direct Ownership Interest · Individual
Gelley, Meir
W-2 Managing Employee · Individual
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