Cycle 1
Health 2025-01-10 · Fire 2025-01-10
29 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Wyndmoor, PA
Wyndmoor Hills Rehabilitation And Nursing Center
1-star overall rating with 1-star inspections with $102,309 in total fines with 29 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
8601 Stenton Avenue, Wyndmoor, PA
(215) 233-6200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lme Family Holdings
Operator or chain grouping
Approved since
2007-08-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.54
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,196
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.37% · Performance 24.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.95
Baseline 6.20% · Performance 6.65% · Measure score 3.95 · Achievement 3.95 · Improvement 0
Total nurse turnover
2.70
Baseline 77.33% · Performance 60.56% · Measure score 2.70 · Achievement 0.76 · Improvement 2.70
Adjusted total nurse staffing
3.16
Baseline 3.22 hours · Performance 3.98 hours · Measure score 3.16 · Achievement 3.16 · Improvement 2.45
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.7% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 15.57% · Lower 95% interval 9.79% |
| Discharge to community | 47.91% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 41.38% · Lower 95% interval 39.43% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 94 · Denominator 94 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 94 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 27 · Denominator 57 |
| Discharge mobility score | 40.35% |
50.94%
10.6 pts worse
|
Numerator 23 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 9.57% |
2.29%
7.3 pts worse
|
Numerator 9 · Denominator 94 · Adjusted rate 10.4% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 5.97% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 1.2% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 83 |
| Staff flu vaccination coverage | 20.2% |
42%
21.8 pts worse
|
Numerator 20 · Denominator 99 |
| Discharge function score | 56.14% |
56.45%
0.3 pts worse
|
Numerator 32 · Denominator 57 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 9.62% |
25.2%
15.6 pts worse
|
Numerator 5 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.2 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
86.9%
1 pts worse
|
93.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.5% · Q2 83.6% · Q3 94.5% · Q4 90.9% · 4Q avg 85.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.1% |
93.5%
0.4 pts worse
|
95.5%
2.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.2%
About the same
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.6% · Q3 3.6% · Q4 3.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.1% |
6.5%
10.6 pts worse
|
11.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 17.4% · Q3 24.0% · Q4 13.0% · 4Q avg 17.1% |
| Percentage of long-stay residents who lose too much weight | 14.8% |
6.5%
8.3 pts worse
|
5.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 18.4% · Q3 18.4% · Q4 12.8% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
19.9%
5 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 15.1% · Q3 23.1% · Q4 45.1% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
18.7%
12.6 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.4% · Q3 8.8% · Q4 8.6% · 4Q avg 6.1% · 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 | 1.0% |
19.6%
18.6 pts better
|
16.3%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.4% |
18.3%
13.9 pts better
|
14.9%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.7% · Q3 0.0% · Q4 7.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 19.5% |
26.4%
6.9 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 20.4% · Q3 21.5% · Q4 19.8% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
5.3%
6.1 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 7.3% · Q3 15.2% · Q4 11.7% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
68.9%
18.9 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.6% · Q2 63.3% · Q3 53.6% · Q4 37.4% · 4Q avg 50.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
9.8%
1 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.2% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.7% |
68.7%
5 pts worse
|
79.7%
16 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.1% |
23.1%
8 pts worse
|
23.9%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.1% · Observed 33.8% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
32 health deficiencies
Top issue: Resident Rights (9 deficiencies)
13 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
20 health deficiencies
Top issue: Nutrition and Dietary (7 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-10
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-10
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-10
C · Minimal harm
2025-01-10
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-03-10
F · Potential for more than minimal harm
2024-02-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-06
F · Potential for more than minimal harm
2024-02-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-02-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-06
F · Potential for more than minimal harm
2024-02-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-02-23
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-02-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-02-23
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-02-23
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-02-23
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-02-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-02-23
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-22
F · Potential for more than minimal harm
2023-05-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-05-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-05-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-05-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-05-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-07
E · Potential for more than minimal harm
2023-05-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-11
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-07
E · Potential for more than minimal harm
2023-05-11
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-08-07
E · Potential for more than minimal harm
2023-05-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-14
C · Minimal harm
2023-05-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-14
C · Minimal harm
2023-05-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-12-11
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 2026-01-06
D · Potential for more than minimal harm
2025-12-11
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 2026-01-06
D · Potential for more than minimal harm
2025-12-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-12-11
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 2026-01-06
D · Potential for more than minimal harm
2025-12-03
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 2026-01-06
D · Potential for more than minimal harm
2025-12-03
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 2026-01-06
E · Potential for more than minimal harm
2025-08-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-09-18
E · Potential for more than minimal harm
2025-07-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-05-29
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 2025-06-24
D · Potential for more than minimal harm
2025-05-29
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-02-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-18
K · Immediate jeopardy
2025-02-08
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-02-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-02-20
F · Potential for more than minimal harm
2025-01-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-01-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-01-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-10
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 2025-03-03
D · Potential for more than minimal harm
2025-01-10
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-10
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 2025-03-03
D · Potential for more than minimal harm
2025-01-10
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 2025-03-03
D · Potential for more than minimal harm
2025-01-10
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 2025-03-03
D · Potential for more than minimal harm
2025-01-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-10
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-10
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 2025-03-03
D · Potential for more than minimal harm
2025-01-10
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-10
F743 · Quality of Life and Care Deficiencies
Health
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-10
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 2025-03-03
D · Potential for more than minimal harm
2025-01-10
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 2025-03-03
D · Potential for more than minimal harm
2024-09-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-17
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 2024-10-10
L · Immediate jeopardy
2024-07-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-08-14
K · Immediate jeopardy
2024-07-11
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-08-14
G · Actual harm
2024-02-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-23
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
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 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
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 2024-03-15
D · Potential for more than minimal harm
2024-02-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-23
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 2024-03-15
E · Potential for more than minimal harm
2024-01-04
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-03
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 2024-02-27
F · Potential for more than minimal harm
2024-01-03
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 2024-02-27
E · Potential for more than minimal harm
2024-01-03
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-03
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-27
D · Potential for more than minimal harm
2023-10-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-08-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-25
F · Potential for more than minimal harm
2023-05-11
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 2023-07-10
E · Potential for more than minimal harm
2023-05-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-05-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-05-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-11
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-11
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 2023-07-10
D · Potential for more than minimal harm
2023-05-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-11
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 2023-07-10
E · Potential for more than minimal harm
2023-03-06
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-03-16
Penalties and ownership
What sits behind the stars
$17,614
2025-01-10
Fine
Fine · fine $17,614
Fine
$33,871
2024-07-11
Fine
Fine · fine $33,871
Fine
$50,824
2024-01-03
Fine
Fine · fine $50,824
Fine
Ownership
Bells Healthcare Management LLC
5% Or Greater Direct Ownership Interest · Organization
Be Smarts Tr
5% Or Greater Indirect Ownership Interest · Organization
Braunstein, Barry
Operational/Managerial Control · Individual
Feuer, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Feuer, Samuel
Corporate Director · Individual
Herder, Tynisha
W-2 Managing Employee · Individual
Katz, Larry
5% Or Greater Indirect Ownership Interest · Individual
Leshkowitz, Eli
5% Or Greater Indirect Ownership Interest · Individual
Lme Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wyndmoor El LLC
5% Or Greater Indirect Ownership Interest · Organization
Wyndmoor Managing Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Wyndmoor Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Chestnut Hill Lodge Health And Rehab Ctr
Wyndmoor, PA
2-star overall rating with 3-star inspections with $16,301 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Fairview Rehab And Care Center
Philadelphia, PA
2-star overall rating with 1-star inspections with $47,181 in total fines with 31 recent health deficiencies with 27 fire-safety deficiencies in the latest cycle
#3
Accela Rehab And Care Center At Springfield
Glenside, PA
1-star overall rating with 1-star inspections with abuse icon flag with $69,735 in total fines with 42 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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