Inglis House: Wound Left Undocumented, Doctor Unnotified - PA
The inspection, completed August 25, 2025, centered on a single incident from June 27 of that year. During the 3 p.m. to 11 p.m. shift, Resident R1 asked a licensed nurse, identified in the report as Employee E5, to put a bandage on the back of his or her right ankle because it was bleeding. Employee E5 applied a foam dressing and left it at that.
No wound assessment was completed. No measurements were taken. Nothing was entered into the resident's clinical record. The physician was never notified.
When inspectors interviewed Employee E5 on August 25, the nurse confirmed all of it. The reason offered: the resident had said the skin impairment wasn't new, so the nurse assumed the physician was already aware.
That assumption was the entire basis for skipping every step that follows a wound discovery.
Whether the wound was new or not, a nurse who encounters a bleeding injury is responsible for assessing it, measuring it, and documenting what was found. A physician cannot monitor a wound's progression, order treatment, or make informed decisions about a resident's care when no one has told them the wound exists and nothing about it appears in the chart.
Inspectors cited the deficiency under Pennsylvania nursing services and resident care policy regulations. The violation was classified as causing minimal harm or potential for actual harm, and as affecting few residents.
Inglis House is located at 2600 Belmont Avenue in Philadelphia. The facility serves residents with significant physical disabilities, many of whom depend entirely on nursing staff to identify and report changes in their condition. A resident who has to ask a nurse to bandage a bleeding ankle is, by definition, not in a position to follow up on whether the doctor was told.
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.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
INGLIS HOUSE in PHILADELPHIA, PA was cited for violations during a health inspection on August 25, 2025.
The inspection, completed August 25, 2025, centered on a single incident from June 27 of that year.
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.