Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Improper Food Storage and Insect Contamination in Dietary Areas: Surveyors observed multiple food storage and sanitation issues in the dietary dept, including undated foods in the cooler and freezer, opened and exposed food items, and winged insects in the dry storage room and during meal service. Insects were seen landing on cereal, bread, and a plastic lid used to cover food, and the DON confirmed that foods in the cooler and freezer should be dated.
A resident with HTN had an order for diltiazem TID with instructions to hold the med if the HR was below 60 bpm. The MAR showed the med was given 189 times over several months without documented evidence that the HR was checked before administration, and the DON confirmed the HR should have been documented in the MAR.
Meal service was not provided at the scheduled times on one nursing unit and in the main dining room. On the Susquehanna Unit, the lunch cart arrived well after the scheduled delivery times on both halls, and residents stated meals were typically late. In the main dining room, lunch had not been served by the scheduled time, and residents reported that meals were typically served late there; trays were then served 19 to 30 minutes after the scheduled meal time. The Administrator confirmed meal service should have followed the scheduled delivery times.
A resident with anxiety, depression, and cognitive impairment received PRN lorazepam for anxiety without a stop date on the order. The MAR showed the medication was given multiple times, and there was no documented physician re-evaluation of continued use beyond 14 days. The DON confirmed the order did not include a date to stop administering the medication.
Several residents did not receive planned menu items, specifically pumpkin pie, during a lunch meal, and no substitutions were provided. The Dietary Manager confirmed that the item was not served as indicated on the pre-approved menu.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as no soap in a hand wash sink, flies in dishwashing areas, and debris in clean adaptive cups. A cereal container was left open, and debris was found on the floor near juice and ice machines. Trash bags were stored on clean bowls, and ear buds were on a food prep surface. The wall molding was damaged, and debris was found near a clean pot shelf.
The facility failed to follow physician's orders for six residents, resulting in improper medication administration and care. Residents received medications outside prescribed parameters, and heel boots were not applied as ordered for residents at risk of skin breakdown. The administrator confirmed these deficiencies.
A resident with parkinsonism, depression, and muscle weakness was found to have an inaccessible call bell, contrary to their care plan which required it to be within reach due to their fall risk and limited mobility. The call bell was observed on the floor, out of reach, and the resident was unaware of its location.
The facility failed to provide a baseline care plan summary to two residents or their representatives within 48 hours of admission, as required by policy. The baseline care plans were developed, but there was no evidence that the summaries, which should include person-centered care instructions and initial goals, were provided. This was confirmed by the Administrator.
The facility failed to implement comprehensive care plans for three residents. A resident with muscle weakness and depression did not receive fortified mashed potatoes as per the care plan. Another resident with dementia and heart failure lacked interventions for psychotropic medication in their care plan. A third resident at risk for skin breakdown did not have heel boots applied as required. The Administrator and DON confirmed these deficiencies.
The facility failed to implement safety interventions for two residents at risk for falls and did not safely administer medications for another resident. One resident's bed was not kept in the lowest position, and another resident's medications were left unsupervised despite not being approved for self-administration.
A resident with dementia and adult failure to thrive experienced significant weight loss, but the facility did not follow its policy to retake the weight or notify the dietitian. The resident's weight change was not assessed until a month later, as confirmed by the Administrator.
A facility failed to assess and treat an external urinary catheter for a resident with diagnoses including neoplasm of cranial nerves and pulmonary fibrosis. The facility's policy required a physician's order for catheter use and daily assessment and change of the catheter. However, the catheter was not changed until a later date, and there was no documentation of a physician's order or skin assessment until then. The Nursing Home Administrator confirmed these actions were expected but not documented.
A resident with anxiety and depression did not receive prescribed doses of Lorazepam due to unavailability of the medication. The resident reported missed doses, and the Nursing Home Administrator confirmed the failure to administer the medication as ordered, noting that the nursing supervisor did not obtain it from the emergency supply.
Improper Food Storage and Insect Contamination in Dietary Areas
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions in the dietary department. During a tour of the dietary department, surveyors observed an unsealed bag of bran cereal exposed to air with a winged insect on the cereal, three winged insects flying around the dry storage room and landing on food packages including an opened bag of rice cereal, a large pan of sliced deli turkey in the trayline reach-in cooler that was not dated, a torn-open bread bag with bread exposed to air and three winged insects landing directly on the bread, an opened bag of ravioli in the walk-in freezer that was not dated, a box of broccoli with a hole torn in the side of the box and plastic bag exposing the product to air, and a piece of broccoli directly touching the shelf. In the walk-in cooler, a crate with 20 juice cups removed from the original packaging was not dated. During lunch meal service, a winged insect landed on a plastic lid used to cover food at meal time. The Director of Dining confirmed that foods in the cooler and freezer should be dated.
Failure to Document Heart Rate Before Blood Pressure Medication Administration
Penalty
Summary
The facility failed to ensure a physician's order was implemented for one resident with hypertension. The resident had an order dated July 9, 2025, for diltiazem three times daily, with instructions not to administer the medication if the heart rate was less than 60 beats per minute. Review of the resident's MAR for August, September, and October 2025 showed the medication was administered 189 times without documented evidence that the heart rate was assessed before administration as ordered. The facility policy on administering medications required staff to obtain vital signs if necessary and document physician-indicated medication administration information, and the DON stated that the heart rate should have been documented in the MAR.
Late Meal Service on Unit and in Dining Room
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on the Susquehanna Unit and in the main dining room. The facility’s meal schedule showed lunch delivery for the Susquehanna Unit short hall at 12:15 p.m., the long hall at 12:45 p.m., and the main dining room at 1:00 p.m., with a ten-minute grace period before a meal was considered late. On the Susquehanna Unit short hall, the meal cart arrived at 12:45 p.m., 20 minutes after the scheduled delivery time. On the long hall, the meal cart arrived at 1:20 p.m., 25 minutes after the scheduled delivery time. During interviews at that time, Residents 4 and 15 stated that meals were typically late in the Susquehanna Unit long hallway. In the main dining room, lunch had not yet been served at 1:28 p.m., and Residents 17 and 32 stated that meals were typically served late there. The residents seated in the main dining room were then served their lunch trays from 1:29 p.m. through 1:40 p.m., which was 19 to 30 minutes after the scheduled meal time. The Administrator later confirmed that meal service should have been delivered according to the scheduled delivery times.
Unstopped PRN anti-anxiety medication order
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints for one of five sampled residents who received psychotropic medications. The resident had diagnoses of anxiety and depression and was cognitively impaired per the MDS assessment. A physician ordered lorazepam, an anti-anxiety medication, every six hours as needed for anxiety on September 9, 2025, but the order did not include a stop date. The resident’s MAR showed that lorazepam was administered on October 4, 7, and 11, 2025, and there was no documented evidence that the physician re-evaluated the continued use of the as-needed anti-anxiety medication beyond 14 days. During interview, the DON confirmed that no date had been added to the order to indicate when staff were to stop administering the medication.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to follow its pre-approved menus as required, resulting in residents not receiving menu items as planned. Multiple residents reported that menu items were frequently substituted without notification or were not received at all. On a specific lunch meal, the menu indicated that pumpkin pie should have been served, including a pureed version for those requiring texture modification. However, several residents did not receive the pumpkin pie or any substitution for it, as confirmed by review of meal tickets and direct observation. The Dietary Manager acknowledged that the pumpkin pie was not served as planned on the facility menu.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey on October 29, 2024. The deficiencies included the absence of soap in the dispenser at a hand wash sink, the presence of flies in the dishwashing and tray line areas, and a tray of clean adaptive cups containing debris such as crumbs, paper clips, and condiment packets. Additionally, a container of cereal had a broken lid, leaving its contents exposed to air. Further observations revealed debris, including cups, lids, baskets, and trash, on the floor near the juice and ice machines. A roll of trash bags was improperly stored on top of a rack of clean bowls, and ear buds were found on a food preparation surface alongside cooking utensils. The molding at the base of the wall behind a food preparation surface was chipped and marred, and there was an accumulation of debris, including dirt and a metal nail, on the floor by a clean pot shelf.
Failure to Implement Physician's Orders for Medication and Care
Penalty
Summary
The facility failed to implement physician's orders for six residents, leading to deficiencies in medication administration and care. Resident 1, diagnosed with orthostatic hypotension and epilepsy, received midodrine hydrochloride nine times despite having a systolic blood pressure (SBP) above the ordered parameters. Similarly, Resident 12, with hypertension and heart failure, was administered midodrine hydrochloride and metoprolol without proper blood pressure assessment, resulting in multiple instances of medication being given outside the prescribed parameters. Resident 95, diagnosed with Alzheimer's disease and hypertension, received losartan on several occasions when their SBP was below the ordered threshold. Resident 98, with hypertension and cerebral infarction, was given carvedilol without documented heart rate assessment, contrary to physician's orders. Additionally, the facility did not adhere to physician's orders regarding the application of heel boots for Residents 7 and 17, both at risk for skin breakdown. Despite orders to apply heel boots while in bed, observations revealed that these residents were without the protective devices during multiple checks. The facility's administrator confirmed these lapses in care, acknowledging that medications were administered outside of established parameters and heel boots were not applied as ordered.
Inaccessible Call Bell for Resident
Penalty
Summary
The facility failed to ensure that a call bell was accessible for a resident, leading to a deficiency. The resident, who had diagnoses including parkinsonism, depression, and muscle weakness, was identified as being at risk for falls and having limited physical mobility. The care plan for this resident included an intervention for staff to ensure the call bell was within reach and to encourage its use for assistance. However, during an observation, the call bell was found on the floor at the head of the bed, out of the resident's reach. The resident was unaware of the call bell's location, and the situation remained unchanged during a subsequent observation.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to ensure that a baseline care plan summary was provided to the resident or their representative for two of the 33 sampled residents. According to the facility's policy, a baseline care plan should be developed within 48 hours of admission and must include instructions for person-centered care, initial goals based on admission orders, and other relevant orders. This plan should be provided in a language understandable to the resident or their representative. However, for Resident 17, admitted on an unspecified date, the baseline care plan was developed on October 8, 2024, but there was no evidence that the summary was provided to the resident or their representative. Similarly, for Resident 104, admitted on an unspecified date, the baseline care plan was developed on September 23, 2024, but again, there was no evidence that the summary was provided to the resident or their representative. The Administrator confirmed in an interview that there was no evidence of the baseline care plan summary being provided to these residents. This deficiency is a violation of the facility's policy and the regulatory requirement under 28 Pa. Code 201.18 (1) Management.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive care plans for three residents, as identified in their comprehensive assessments. Resident 11, diagnosed with muscle weakness and depression, was underweight and desired to gain weight. Despite a nutrition assessment recommending fortified foods and snacks, the resident did not receive fortified mashed potatoes as specified in the care plan on two observed occasions. The Administrator confirmed that the kitchen staff did not prepare the fortified mashed potatoes on those dates. Resident 12, with dementia and heart failure, had a Minimum Data Set Care Area Assessment indicating that psychotropic medication should be addressed in the care plan. However, there was no evidence of interventions for the psychotropic medication in the current care plan. Resident 21, diagnosed with cerebral infarction, difficulty in walking, and muscle weakness, was at risk for skin breakdown and required heel boots while in bed. Observations revealed that the heel boots were not applied on multiple occasions. The Director of Nursing confirmed the lack of documented evidence that these care areas were addressed or implemented according to the care plans.
Failure to Implement Safety Interventions and Medication Administration
Penalty
Summary
The facility failed to implement safety interventions for two residents at risk for falls and did not safely administer medications for another resident. Resident 7, who had a history of stroke, heart failure, and arthritis, was identified as being at risk for falls. The care plan specified that floor mats should be placed on both sides of the bed and the bed should be kept in the lowest position. However, multiple observations revealed that the resident's bed was elevated and lacked the required fall mats. Similarly, Resident 112, with a history of seizures and cognitive communication deficit, was also at risk for falls. Despite a previous fall from bed, observations showed that the resident's bed was not maintained in the lowest position as required by the care plan. Additionally, the facility failed to safely administer medications to Resident 53, who had diagnoses including dementia, legal blindness, and dysphagia. Physician's orders required staff to administer carvedilol and levetiracetam once daily. However, the resident was observed with a medication cup containing these medications left on the bedside table, indicating that the nurse had left them for the resident to take later. The resident had not been assessed or approved for self-administration of medications, and the Director of Nursing confirmed that the nurse should not have left the medications at the bedside.
Failure to Monitor and Assess Significant Weight Change
Penalty
Summary
The facility failed to adequately monitor and assess significant weight change for a resident at risk for weight loss. According to the facility's policy, any weight change of five percent or more should be retaken the next day for confirmation, and if verified, the dietitian should be notified in writing. The resident, who had diagnoses including dementia and adult failure to thrive, experienced a 7.1% weight loss between February and March, and continued to lose weight in April. However, there was no evidence that a second weight was obtained in March or that the dietitian was notified, as required by the policy. The resident's weight change was not assessed until April, which was confirmed by the Administrator during an interview.
Failure to Assess and Treat External Urinary Catheter
Penalty
Summary
The facility failed to properly assess and treat an external urinary catheter for a resident. The facility's policy required a physician's order for catheter use, and the nursing and interdisciplinary team were to assess and document the ongoing need for the catheter. The catheter was to be removed when no longer required. However, upon review of the clinical records, it was found that the resident, who was admitted with diagnoses including neoplasm of cranial nerves, pulmonary fibrosis, and muscle weakness, had an external urinary catheter that was not changed until September 17, 2024. There was no documentation indicating that a physician's order was obtained, the catheter was changed, or the resident's surrounding skin was assessed until that date. In an interview, the Nursing Home Administrator confirmed that staff were expected to obtain a physician's order, change the external catheter daily, and assess the resident's surrounding skin daily. However, there was no documentation to support that these actions were taken prior to September 17, 2024.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was administered medication as prescribed by the physician. The resident, who had diagnoses of anxiety and depression, was ordered by the physician to receive an anti-anxiety medication, Lorazepam, every eight hours. However, on May 9, 2024, the resident did not receive the scheduled doses of the medication three times because it was not available. This was confirmed during an interview with the resident, who stated that staff did not always administer her medication as ordered. The Nursing Home Administrator acknowledged that the medication was not given as prescribed and that the nursing supervisor failed to obtain the medication from the emergency supply.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roslyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Spring Rehab And Care Center | 1.9 mi | ★★★★★ | 4 | 1 |
| Rydal Park Of Philadelphia Presbytery Homes, Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Edgehill Nursing And Rehab Cen | 2.1 mi | ★★★★★ | 12 | 0 |
| Dresher Hill Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 14 | 0 |
| Wyncote Care Center | 2.9 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.