Cycle 1
Health 2025-08-14 · Fire 2025-08-14
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Glenside, PA
Edgehill Nursing And Rehab Cen
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
146 Edgehill Road, Glenside, PA
(215) 886-1043
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-08-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.58
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.90
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
3.52
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,006
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.61
Performance 21.15% · Measure score 0.61 · Achievement 0.61 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.13
Performance 7.50% · Measure score 1.13 · Achievement 1.13 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.27
Baseline 56.90% · Performance 58.49% · Measure score 1.27 · Achievement 1.27 · Improvement 0
Adjusted total nurse staffing
2.73
Baseline 3.98 hours · Performance 3.85 hours · Measure score 2.73 · Achievement 2.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 12.9% · Lower 95% interval 8.2% |
| Discharge to community | 43.97% |
50.57%
6.6 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 36.36% · Lower 95% interval 33.91% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.46% |
95.27%
3.2 pts better
|
Numerator 64 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 24 · Denominator 44 |
| Discharge mobility score | 59.09% |
50.94%
8.2 pts better
|
Numerator 26 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 65 · Adjusted rate 1.01% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 68 |
| Staff flu vaccination coverage | 31.17% |
42%
10.8 pts worse
|
Numerator 24 · Denominator 77 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 28 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 97.8% · Q2 98.1% · Q3 98.0% · Q4 100.0% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.5%
2.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.8% · Q3 4.0% · Q4 2.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
6.5%
5.9 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
6.5%
1.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 4.9% · Q3 2.4% · Q4 9.8% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
19.9%
7.4 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 31.2% · Q3 23.3% · Q4 24.4% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
18.7%
2.2 pts worse
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 20.6% · Q3 24.2% · Q4 17.6% · 4Q avg 20.9% · 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 | 13.2% |
19.6%
6.4 pts better
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 10.7% · Q3 21.2% · Q4 15.2% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
18.3%
9.2 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.4% · Q3 2.4% · Q4 12.8% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.7%
1.4 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.1% · Q3 0.0% · Q4 6.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
26.4%
4.9 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 20.5% · Q3 17.4% · Q4 16.6% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.3%
2.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.0% · Q3 1.8% · Q4 1.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
68.9%
18.1 pts better
|
81.7%
5.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 86.0% · Q3 89.1% · Q4 93.5% · 4Q avg 87.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
9.8%
9.8 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.5% |
68.7%
15.8 pts better
|
79.7%
4.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.8% |
23.1%
19.7 pts worse
|
23.9%
18.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 42.8% · Observed 40.4% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-09 · Fire 2024-10-09
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-12-21 · Fire 2023-12-21
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-08-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-10-01
E · Potential for more than minimal harm
2024-10-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-10-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-10-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-10-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-03
C · Minimal harm
2024-10-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-12-03
C · Minimal harm
2024-10-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-03
E · Potential for more than minimal harm
2023-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-25
E · Potential for more than minimal harm
2023-12-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-25
C · Minimal harm
2023-12-21
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-14
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-09-24
F · Potential for more than minimal harm
2025-08-14
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 2025-09-24
D · Potential for more than minimal harm
2025-08-14
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 2025-09-24
D · Potential for more than minimal harm
2025-08-14
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-08-14
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 2025-09-24
D · Potential for more than minimal harm
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-08-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-24
E · Potential for more than minimal harm
2024-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-09
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 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-07-25
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 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-09
D · Potential for more than minimal harm
2023-12-21
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-23
Penalties and ownership
What sits behind the stars
Ownership
Pennsylvania Ltc Inc
5% Or Greater Direct Ownership Interest · Organization
Burghart, Kevin
W-2 Managing Employee · Individual
Delozier, Arthur
Corporate Director · Individual
Duggan, Timothy
Corporate Director · Individual
Keyes, Gloria
W-2 Managing Employee · Individual
Waldrop, Mark
Corporate Director · Individual
Waldrop, Mark
Corporate Officer · Individual
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