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Deficiency Records for Wyndmoor Hills Rehabilitation and Nursing Center
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.
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? |
|---|---|---|---|---|
| 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 | 2024-07-11 | 2024-08-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-07-11 | 2024-08-14 | Y |
| Keep all essential equipment working safely. | Health | 2024-07-11 | 2024-08-14 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-03-13 | 2024-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-13 | 2024-05-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-03-13 | 2024-05-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-13 | 2024-05-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-13 | 2024-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-13 | 2024-05-22 | N |
| Meet other general requirements. | Fire Safety | 2024-03-13 | 2024-05-06 | N |
| Use approved construction type or materials. | Fire Safety | 2024-03-13 | 2024-05-06 | 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 | 2024-03-13 | 2024-05-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-13 | 2024-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-13 | 2024-05-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-13 | 2024-05-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-13 | 2024-05-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-23 | 2024-03-15 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-23 | 2024-03-15 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-23 | 2024-03-15 | 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 | 2024-02-23 | 2024-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-23 | 2024-03-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-23 | 2024-03-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-23 | 2024-03-15 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-02-23 | 2024-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-23 | 2024-03-15 | 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 | 2024-02-23 | 2024-03-15 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-23 | 2024-03-15 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-02-23 | 2024-03-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-23 | 2024-03-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-23 | 2024-03-15 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-02-23 | 2024-03-15 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-23 | 2024-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-23 | 2024-03-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-02-23 | 2024-03-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-23 | 2024-03-15 | Y |
| Keep all essential equipment working safely. | Health | 2024-02-23 | 2024-03-15 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-23 | 2024-03-15 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-01-03 | 2024-02-27 | 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 | 2024-01-03 | 2024-02-27 | Y |
| 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 | 2024-01-03 | 2024-02-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-03 | 2024-02-27 | Y |
| Dispose of garbage and refuse properly. | Health | 2024-01-03 | 2024-02-27 | Y |
| 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. | Health | 2024-01-04 | 2024-02-13 | Y |
| 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 |
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