Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
WYNDMOOR, PA · 77 certified beds · Last Life Safety survey January 10, 2025
CMS Certification Number 396115 · first certified August 2007
Ownership
Operated by LME FAMILY HOLDINGS · For profit - Limited Liability company
- Ownership changed November 15, 2019 (change of ownership)from WYNDMOOR CARE CENTER, LLC
Position within PA
42 citations — more than 99% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 14. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (November 2025 to January 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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7 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 42 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
23 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 42 Life Safety citations above. The Physical Environment Index
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0908 Keep all essential equipment working safely.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 42 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 11, 2023 | 15 |
| February 23, 2024 | 13 |
| January 10, 2025 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-01-10 |
| K-0293 | Have properly located and lighted "Exit" signs. | 3 | 2025-01-10 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 3 | 2025-01-10 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-01-10 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 3 | 2025-01-10 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 3 | 2025-01-10 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2025-01-10 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2025-01-10 |
What the citations cover
- Smoke Deficiencies 13
- Egress Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Miscellaneous Deficiencies 5
- Other 8
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Egress Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 5 |
| Services Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Construction Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 10, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (March 10, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 10, 2025) |
February 23, 2024 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (May 6, 2024) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (May 6, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (May 6, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (May 22, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 22, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (May 6, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 6, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 6, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 6, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (May 22, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (May 22, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (May 22, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 22, 2024) |
May 11, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 14, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 7, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 7, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (August 7, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 7, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 7, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.