Inglis House: Nurse Skipped Doctor Notification for Wound - PA
That assumption, inspectors found, was wrong.
The incident happened on June 27, 2025, during the evening shift. A nurse aide, identified in inspection records as Employee E4, noticed the bleeding while giving the resident, identified as Resident R1, a shower. The aide reported it to the licensed nurse on duty, Employee E5. When the nurse went to the resident's room, the resident asked her directly to put a bandage on the back of the ankle because it was bleeding. The nurse applied a foam dressing to the right ankle and left.
No wound assessment was documented. No measurements were taken. No physician was notified. Nothing appeared anywhere in the resident's clinical record.
When inspectors interviewed the nurse on August 25, 2025, she confirmed all of it. She had not called the doctor. She had not written up the wound. Her explanation: the resident had told her the skin impairment was not new, so she assumed the physician was already aware.
The physician was not asked. The record contained no evidence the physician had ever been told.
The gap between what the nurse assumed and what the record showed is the entire problem. A bleeding wound on a resident's heel, reported by a nurse aide, acknowledged by the resident, treated with a dressing — and then, officially, it never happened. No documentation meant no follow-up, no monitoring plan, no way for the next nurse on shift to know the wound existed, no way for a physician to order treatment, and no way for anyone reviewing the chart weeks later to see it.
Inspectors classified the violation under the federal tag F0580, which covers a facility's obligation to notify physicians of changes in a resident's condition. The harm level was assessed as minimal or potential, and the finding was listed as affecting few residents. The deficiency was cited under Pennsylvania nursing services and resident care policy codes.
Inglis House is a long-term care facility located at 2600 Belmont Avenue in Philadelphia. The inspection was conducted as a complaint survey and completed on August 25, 2025.
The nurse's reasoning, that a resident saying something is not new means a doctor already knows about it, does not hold. Residents cannot be expected to manage their own physician notifications. A wound that has existed long enough for a resident to recognize it as familiar is, if anything, more reason to document it and verify whether it is being treated, not less.
What the record shows is a nurse aide who did her job, a resident who asked for help and got a bandage, and a licensed nurse who stopped there. The foam dressing went on. The chart stayed blank. And for the weeks between June 27 and the August inspection, Resident R1's right ankle existed in the clinical record as if nothing had ever happened to it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inglis House from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
INGLIS HOUSE in PHILADELPHIA, PA was cited for violations during a health inspection on August 25, 2025.
That assumption, inspectors found, was wrong.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.