Deficiency Records for Wyndmoor Hills Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Wyndmoor Hills Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-26 | 2023-11-17 | Y |
| Keep all essential equipment working safely. | Health | 2023-10-26 | 2023-11-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-26 | 2023-11-17 | Y |
| 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. | Health | 2023-08-30 | 2023-10-25 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-15 | 2023-08-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-15 | 2023-08-07 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-05-15 | 2023-08-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-15 | 2023-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-15 | 2023-08-07 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-15 | 2023-07-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-11 | 2023-07-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-11 | 2023-07-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-07-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-11 | 2023-07-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-11 | 2023-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-11 | 2023-07-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-07-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-11 | 2023-07-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-11 | 2023-07-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-06 | 2023-03-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-19 | 2023-02-17 | Y |
| 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. | Health | 2022-12-19 | 2023-02-16 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-11 | 2022-09-09 | N |
| 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. | Health | 2022-06-30 | 2022-08-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-30 | 2022-08-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-30 | 2022-08-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-30 | 2022-08-29 | N |
| 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. | Health | 2022-06-30 | 2022-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-30 | 2022-08-29 | N |
| Keep all essential equipment working safely. | Health | 2022-06-30 | 2022-08-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-30 | 2022-08-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-03 | 2022-04-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-03 | 2022-04-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-09 | 2022-02-11 | Y |
| Meet other general requirements. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-07 | 2021-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-13 | 2021-10-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-10-12 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-08-13 | 2021-10-12 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-07 | 2021-10-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-07 | 2021-09-05 | N |
| 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. | Health | 2021-06-17 | 2021-08-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-17 | 2021-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-08-16 | N |
