Inglis House
INGLIS HOUSE in PHILADELPHIA, PA — inspection on August 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
documented a wound assessment, notified the physician of the new skin impairment or obtained
went to Resident R1's room, the resident had asked Licensed Nurse, Employee E5, to put a bandage
applied a foam dressing to the back of Resident R1's right ankle.Further interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, confirmed the physician was not notified regarding the skin impairment and further confirmed a description of the wound (including measurements) was not documented in Resident R1's clinical record.
Licensed Nurse, Employee E5, reported Resident R1 stated that the skin impairment was not new so the employee assumed the physician was already aware. 28 Pa.
Code 211.10 (d) Resident care policies. 28 Pa.
Code 211.12 (d)(5) Nursing services.
395134 08/25/2025
Inglis House 2600 Belmont Avenue Philadelphia, PA 19131
Pa.
Code 211.12 (d)(1) Nursing services.28 Pa.
Code 211.12 (d)(5) Nursing services.
395134 08/25/2025
Inglis House 2600 Belmont Avenue Philadelphia, PA 19131
Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident was cognitively intact and had a diagnosis of paraplegia (paralysis of the legs and lower body).
Continued review of Resident R1's MDS revealed the resident was at risk of developing pressure ulcers/injuries (localized damage to the skin and underlying tissue caused by prolonged pressure, shear, or friction) and was dependent (helper does all the effort) on staff for putting on/taking off footwear.
Review of Resident R1's clinical record revealed a physician order dated July 6, 2024, and July 10, 2024, for skin prep to right medial ankle and right heel every day.
Instructions specified to cleanse the areas with normal saline solution, apply skin prep, and leave open to air.
Review of Resident R1's wound evaluation dated June 24, 2025, revealed the resident had a Stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue) Pressure Ulcer to the mid back inferior and Stage 4 (the most severe stage of a pressure sore, with damage to all layers of the skin, exposing muscle, tendon and bone and has a high risk of infection) Pressure Ulcer to the left ischium.
Review of Resident R1's clinical record revealed a nursing note dated June 29, 2025, by Licensed Nurse, Employee E3, that indicated while this nurse was providing wound care for Resident R1's previously documented wounds (mid back and left ischium) Resident R1 made the Licensed Nurse, Employee E3, aware of a new wound on his/her right ankle.
Continued review of the nursing note dated June 29, 2025, revealed Licensed Nurse, Employee E3, subsequently removed Resident R1's booties to assess the area and observed a foam dressing applied to the right heel.
Resident R1 reported to the Licensed Nurse, Employee E3, that he/she noticed the heel bleeding a lot during his/her shower and that his/her shoes were difficult to put on.
Review of facility incident/accident investigation summary dated June 29, 2025, written up by Registered Nurse, Employee E6, revealed on June 29, 2025, while Licensed Nurse, Employee E3, was providing wound care for Resident R1, the resident stated he/she had a new wound to the right heel/ankle area.
Licensed nurse, Employee E3, subsequently notified the unit manager who further assessed the new skin impairment as a stage 3 pressure wound measuring 3.5 centimeters (cm) (length) by 4.0 cm (width) by 0.3 cm (depth).
Continued review of facility investigation revealed an employee statement by nurse aide, Employee E4, dated July 1, 2025, which revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift while nurse aide, Employee E4, was giving Resident R1 a shower the employee noticed the resident's heel bleeding and subsequently reported it to the licensed nurse, identified as Employee E5.
Review of Resident R1's entire clinical record revealed no documented evidence that licensed nurse, Employee E5, measured the wound and documented findings of the assessment in the EMR.
Further review of Resident R1's clinical record revealed no documented evidence that the Registered nurse or Physician were notified of the new skin impairment or obtained treatment orders for the area.
Interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift when this employee went to Resident R1's room, the resident had asked Licensed Nurse, Employee E5, to put a bandage on the back of his/her ankle because it was bleeding.
Licensed Nurse, Employee E5, subsequently applied a foam dressing to the back of Resident R1's right ankle.
Review of Resident R1's June 2025 Physician orders and Treatment Administration Record revealed no treatment orders were obtained to the resident's right ankle. 28 Pa.
Code 211.10 (d) Resident care policies. 28 Pa.
Code 211.12 (d)(5) Nursing services.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.