Cycle 1
Health 2024-11-22 · Fire 2024-11-22
3 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Broomall, PA
Rosewood Gardens Rehabilitation And Nursing Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
146 Marple Road, Broomall, PA
(610) 356-0100
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
146
Certified beds
Average residents
139
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.71
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,999
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9999
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.76
Baseline 23.50% · Performance 20.75% · Measure score 3.76 · Achievement 1.48 · Improvement 3.76
Healthcare-associated infections
4.56
Baseline 9.44% · Performance 7.19% · Measure score 4.56 · Achievement 2.15 · Improvement 4.56
Total nurse turnover
7.97
Baseline 53.95% · Performance 31.11% · Measure score 7.97 · Achievement 7.97 · Improvement 7.35
Adjusted total nurse staffing
2.31
Baseline 3.68 hours · Performance 3.73 hours · Measure score 2.31 · Achievement 2.31 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.6% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 473 · Observed rate 12.26% · Lower 95% interval 9.32% |
| Discharge to community | 57.3% |
50.57%
6.7 pts better
|
Better than the National Rate · Eligible stays 512 · Observed rate 51.17% · Lower 95% interval 52.35% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.4% |
95.27%
3.1 pts better
|
Numerator 370 · Denominator 376 |
| Falls with major injury | 0.8% |
0.77%
About the same
|
Numerator 3 · Denominator 376 |
| Discharge self-care score | 61.73% |
53.69%
8 pts better
|
Numerator 171 · Denominator 277 |
| Discharge mobility score | 66.43% |
50.94%
15.5 pts better
|
Numerator 184 · Denominator 277 |
| Pressure ulcers or injuries, new or worsened | 1.6% |
2.29%
0.7 pts better
|
Numerator 6 · Denominator 376 · Adjusted rate 1.34% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 351 · Observed rate 7.41% · Lower 95% interval 5.34% |
| Staff COVID-19 vaccination coverage | 1.61% |
8.2%
6.6 pts worse
|
Numerator 3 · Denominator 186 |
| Staff flu vaccination coverage | 62.87% |
42%
20.9 pts better
|
Numerator 149 · Denominator 237 |
| Discharge function score | 65.7% |
56.45%
9.2 pts better
|
Numerator 182 · Denominator 277 |
| Transfer of health information to provider | 97.09% |
95.95%
1.1 pts better
|
Numerator 100 · Denominator 103 |
| Transfer of health information to patient | 99.53% |
96.28%
3.2 pts better
|
Numerator 210 · Denominator 211 |
| Resident COVID-19 vaccinations up to date | 51.78% |
25.2%
26.6 pts better
|
Numerator 102 · Denominator 197 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 27.6% |
86.9%
59.3 pts worse
|
93.4%
65.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 25.0% · Q3 29.2% · Q4 32.1% · 4Q avg 27.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| 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 1.9% · Q2 2.8% · Q3 4.7% · Q4 3.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.9% |
6.5%
10.4 pts worse
|
11.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 10.6% · Q3 23.7% · Q4 31.8% · 4Q avg 16.9% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
6.5%
5.9 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
19.9%
1.6 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 22.1% · Q3 20.8% · Q4 21.2% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
18.7%
10.7 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.6% · Q3 9.5% · Q4 8.2% · 4Q avg 8.0% · 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 | 8.5% |
19.6%
11.1 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 7.4% · Q3 7.7% · Q4 9.8% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
18.3%
11.3 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 4.8% · Q3 6.9% · Q4 7.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.7%
2 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 5.8% · Q3 3.0% · Q4 4.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
26.4%
3.1 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 30.8% · Q3 28.2% · Q4 20.9% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.3%
2.9 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.7% · Q3 1.8% · Q4 4.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 7.0% |
68.9%
61.9 pts worse
|
81.7%
74.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.8% · Q3 7.2% · Q4 5.1% · 4Q avg 7.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
9.8%
1.2 pts worse
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 9.5% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.6% · Q4 1.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.6% |
68.7%
18.9 pts better
|
79.7%
7.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
23.1%
1.3 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 23.7% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
0 health deficiencies
No concentrated health issue counts in this cycle.
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-02-27 · Fire 2023-02-27
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-03
F · Potential for more than minimal harm
2024-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-11-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-03
E · Potential for more than minimal harm
2023-12-07
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-12
D · Potential for more than minimal harm
2023-12-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-12
F · Potential for more than minimal harm
2023-02-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-02-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-02-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-02-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-02-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-02-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-12
C · Minimal harm
2023-02-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-12
C · Minimal harm
2023-02-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-12
C · Minimal harm
2023-02-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-22
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-03
D · Potential for more than minimal harm
2023-02-27
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 2023-04-12
D · Potential for more than minimal harm
2023-02-27
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 2023-04-12
D · Potential for more than minimal harm
2023-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-12
Penalties and ownership
What sits behind the stars
Ownership
Rgsh Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Ellenbogen, Moss
5% Or Greater Indirect Ownership Interest · Individual
Kuchinski, Deanna
Operational/Managerial Control · Individual
Megerian, Raffi
Operational/Managerial Control · Individual
Stern, Moshe
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Broomall Manor
Broomall, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#2
Pine View Healthcare And Rehabilitation Center
Broomall, PA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Quadrangle
Haverford, PA
2-star overall rating with 2-star inspections with $8,278 in total fines with 17 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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