Pennsylvania Department of Health
WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 171 surveys for this facility. Please select a date to view the survey results.

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WYNDMOOR HILLS REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to one complaint, completed on May 29, 2025, it was determined that Wyndmoor Hills Rehabilitation and Nursing Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policy, resident's clinical record , observation and interview with staff, it was determined that the facility failed to ensure the safety of the resident's environment related to medication left at the bedside for one of ten residents reviewed. (Resident R2)

Findings include:

Review of facility policy titled " Administrating Medications" revised December 2012. revealed that medications shall be administered in a safe and timely manner and as prescribed. Medications must be administered within one hour or prescribed time and the individual administering the medications must verify the resident's identity before giving his or her medications. If a drug is withheld, refused or given at a time other than scheduled time the individual administering the medication shall initial and circle the mar (medication administration record) space provided for that drug induce as required or indicated for the medication the individual administering the medication will record in the resident's medical record the date and time the medication was administered, the dosage, the root of administration, any complaints or symptoms, any results achieved and when those results were observed and the signature entitled the person administering the drug. Residents may self administer their own medications only if the attending physician in conjunction with the inner disciplinary care planning team, has determined that they have the decision making capacity to do so safely .

Review of Resident R2's admission Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated April 7, 2025, revealed Resident R2 was admitted into the facility on April 7 2025, from the hospital with diagnosis including heart failure (the heart cannot pump enough blood), hypertension (high blood pressure), renal failure (the kidneys looses the ability to remove waste and balance fluids), diabetes (a disease characterized by elevated levels of blood glucose), cerebral vascular accident(stroke), and seizure disorder requiring medications such as antipsychotics, anticoagulant s(blood thinner), anti convulsive(seizure preventative) and insulin (regulates blood sugar). Further review of this resident's MDS revealed the resident has a cognition BIMS ( brief interview of mental status) score of 15 indicating that Resident R2's cognition was intact.

Observation of Resident R2 on May 29, 2025 at 11:10a.m. revealed a medication cup consisting of nine pills set on the resident's bedside table.

Interview with the Director of Nursing, Employee E2, at the time of the above observation confirmed that the medication cup was left on the bedside table, which is not facility policy and an inappropriate administration of medication for a resident without order to self administer medication.

28 Pa Code 211 .10 (c) Resident care policies

28 Pa Code 211.12 ( d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/24/2025

1. Facility Immediately removed medication from Resident over bed
table.
2. Audit of Resident rooms was done to ensure no medications were
left unattended.
3. Staff will be educated on the components of this regulation with
an emphasis on ensuring that residence take medication's
immediately, that medications are not left at residents' bedside and
stored properly at all times.
4. DON/designee will complete random visual audits of med pass
and medication storage areas, including carts and medication
rooms to ensure no medication is left unattended 2x a week x4
weeks, 1x week for 2 months then, 2x month for 2 months.
5. The findings of these quality monitoring's to be reported to the
Quality Assurance/Performance Improvement Committee monthly
x6 months.

483.65(a)(1)(2) REQUIREMENT Provide/Obtain Specialized Rehab Services:

§483.65 Specialized rehabilitative services.
§483.65(a) Provision of services.
If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident's comprehensive plan of care, the facility must-

§483.65(a)(1) Provide the required services; or

§483.65(a)(2) In accordance with §483.70(f), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.

Observations:
Based on review of facility documentation, clinical record and staff and family interview, it was determined that the facility failed to ensure that rehabilitation services were provided timely for one of ten residents reviewed. (Resident R1)

Findings include:

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on May 16, 2025.

Interview with Resident R1's family member on May 29, 2025 at 10:40 a.m. revealed that the resident entered the facility following knee surgery, and the resident arrived to the facility at approximately 6:00 pm. The resident's family member stated that her surgeon wanted her to be ambulating as soon as possible, it would benefit her recovery . Resident R1 was placed into bed and told she cannot get out of the bed until assessed by physical therapy. Resident R1 requested assistance to the lavatory but was told she needed to use a bed pan or brief until she was seen and assessed by physical therapy. Resident R1's family asked staff when she could be seen and was told "its the weekend not until Monday."

Interview with Social Worker, Employee E7 revealed that she was aware that the family was not satisfied with the level of care in the facility, the resident was not assessed by physical therapy and this employee could not reach anyone in the physical therapy department to request a consult, and was unsure when the resident would be assessed. Employee E7 tried to transfer the resident to another facility but was unable due to weekend hours.

Interview with Physical Therapy Director, Employee E5 on May 29, 20256 at 1:40 p.m. revealed that Resident R1 entered the facility on Friday May 16, 2025 and was scheduled to see physical therapy on Sunday May 18, 2025. This employee confirmed that the physical therapy department was short staffed that weekend and had no therapist available on Saturday May 17, 2025. Further interview with Employee E5 confirmed that the Resident R1 no being able to get out of the bed was inappropriate, and that the nursing staff was responsible to do the assessment for resident to be able to ambulate.

Interview with Licensed nurse, Employee E6 on May 29, 2025 at 2:00 p.m. revelaed that she believed that the physical therapy team needs to assess the residents to determine the appropiate level of care needed to transfer and ambulate.

Interview with NHA, Employee E1 on May 29, 2025 at 3:40p.m. confirmed there is a breakdown of communication of responsibilities between physical therapy and nursing staff.

28 Pa. code 211.12(a)(c)(d)(3) Nursing services

28 Pa. Code 201.18 (b)(1) Management

Plan of Correction - To be completed: 06/24/2025

1. staff education was done immediately on new admission transfer
status.
2. PT/DON/Designee completed audit to ensure all Residents have a
transfer status in place.
3. Staff will be educated to ensure that transfer status is obtained
upon admission.
4. Audit of new admissions will be done to ensure that they have a
transfer status in place upon admission 1x week for 1 month, 2x
month for 1 month, and then 1x month for 1 month.
5. The findings of these quality monitoring's to be reported to the
Quality Assurance/Performance Improvement Committee monthly
x6 months.

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