Inglis House: Pressure Wound Left Untreated for Days - PA
The resident, identified in inspection records only as Resident R1, already had two serious pressure wounds when the heel injury surfaced. A wound evaluation from June 24, 2025, five days before the heel was reported, had documented a Stage 3 pressure ulcer to the mid back and a Stage 4 pressure ulcer to the left ischium. Stage 4 is the most severe classification, with damage reaching through all layers of skin to expose muscle, tendon, or bone. The resident was paraplegic, cognitively intact, and dependent on staff to put on and take off footwear.
On the evening of June 27, a nurse aide giving Resident R1 a shower noticed the resident's heel was bleeding. The aide reported it to the licensed nurse on duty, identified in the inspection report as Employee E5. That nurse went to the resident's room. The resident asked her to put a bandage on the back of the ankle because it was bleeding. She applied a foam dressing. She left.
Nothing was entered into the electronic medical record. No registered nurse was contacted. No physician was notified. No treatment orders were obtained. According to the inspection report, there was no documented evidence that Employee E5 measured the wound or assessed it in any way that was recorded.
The wound went unaddressed in any official capacity for two more days.
On June 29, a different licensed nurse, Employee E3, was in Resident R1's room providing wound care for the mid back and ischium injuries. The resident told her about the ankle. She removed the resident's booties and found the foam dressing Employee E5 had placed two days earlier. Resident R1 told her the heel had been bleeding heavily during a shower and that shoes had become difficult to put on.
Employee E3 notified the unit manager. The unit manager assessed the wound and found a Stage 3 pressure ulcer measuring 3.5 centimeters long, 4 centimeters wide, and 0.3 centimeters deep. A facility incident report was filed that same day, June 29, written by a registered nurse identified as Employee E6.
An employee statement from the nurse aide, Employee E4, collected on July 1, confirmed the timeline. The aide had seen the bleeding heel on June 27 and reported it to Employee E5 that same evening.
When inspectors interviewed Employee E5 on August 25, the nurse confirmed the account. She said the resident had asked her to put a bandage on the ankle because it was bleeding. She applied the foam dressing. She did not document the wound, did not notify a physician, and did not obtain any orders for treatment. The inspection report notes that a review of Resident R1's June 2025 physician orders and treatment administration record showed no treatment orders for the right ankle.
The facility's own wound monitoring policy, last revised in September 2016, states that when a new wound is identified, the licensed nurse is responsible for measuring it, documenting findings in the electronic medical record, and notifying both the registered nurse and the physician. Physician orders for wound care are to include a cleansing agent, frequency of treatment, and appropriate dressings.
None of that happened on June 27.
Resident R1 had been on physician orders since July 2024 for daily skin prep to the right medial ankle and right heel, with instructions to cleanse with normal saline, apply skin prep, and leave open to air. Those orders predated the June wound evaluation by nearly a year, suggesting the ankle and heel had been flagged as areas of concern long before the bleeding episode.
The inspection, conducted as a complaint investigation on August 25, 2025, found the facility had failed to provide pressure ulcer treatment consistent with standards of professional practice. The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents.
Resident R1 is paraplegic. Pressure wounds in people with paralysis carry elevated infection risk because sensation is absent, circulation is reduced, and the person cannot shift their own weight to relieve pressure. A Stage 3 wound left without physician-ordered treatment for two days is not a paperwork failure. It is two days in which the wound deepened, the risk of infection grew, and the resident, who had already told one nurse about the bleeding, waited.
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: October 5, 2026 · Our methodology
INGLIS HOUSE in PHILADELPHIA, PA was cited for violations during a health inspection on August 25, 2025.
The resident, identified in inspection records only as Resident R1, already had two serious pressure wounds when the heel injury surfaced.
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.