Deficiency Index

Wyndmoor Hills Rehabilitation and Nursing Center

Wyndmoor, Pennsylvania · CCN 396115

50 surveys since 2011, 8 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
189
Surveys
50
Harm or worse
8
Immediate jeopardy
4
The record, 2011–2026
’11’15’20’25’26
No harm recordedHarm or worseNot surveyed
Immediate jeopardy4

Findings at the most serious level CMS records.

Beyond CMS’s monthly file31/50

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
77
Ownership
For profit - Limited Liability company
Chain
LME FAMILY HOLDINGS
County
Montgomery
Medicare-certified since
2007

CMS ratings

Overall
1
Health inspection
1
Staffing
1
Quality measures
3

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded more weighted findings than most of its peer group.

Weighted by harm level, against 58 for-profit facilities of 66–99 beds in Pennsylvania.

Last survey on record

Jul 16, 2026

116 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.103.54
Registered-nurse hours per resident day0.64—
Annual nurse turnover47.7%46.3%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

Fines
$102,309 across 3 penalties

Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K22.2%L11.1%
Actual harmG11.1%H—I—
No harm, potential for more than minimalD6469.6%E1617.4%F88.7%
No harm, potential for minimalA—B—C—
CMS’s current file: 92 of the 189 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F5845×

    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.

  • F6895×

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • F9085×

    Keep all essential equipment working safely.

  • F8044×

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • F8124×

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

In the surveyor’s words

From the most serious findings on record at Wyndmoor Hills Rehabilitation and Nursing Center, in the surveyor’s own words.

  • Immediate jeopardy, widespreadF908Jul 11, 2024

    Based on the staff interviews, reviews of facility documents and observation, it was determined that the facility failed to ensure that the central air condition system was maintained in a safe operating condition for two of two chillers. This failure resulted in one non-operational chiller and a second chiller requiring extensive repairs and cleaning. This failure was identified as an Immediate Jeopardy with air temperatures rising above 81 degrees in two of two nursing units (2nd and 3rd floor). Findings include: Review of The Department of Energy's recommendation titled Maintaining Your Air Conditioner revealed that an air conditioner's filters, coils, and fins require regular maintenance for the unit to function effectively and efficiently throughout its years of service. […]

  • Immediate jeopardy, patternF584Feb 8, 2025

    Based on observation, interview with residents and staff, review of facility policy, and facility documentation, it was determined the facility failed to ensure comfortable air temperature levels were provided on two of two nursing units (Second and Third Floor), placing 16 residents at risk for developing hypothermia (condition of having a lower body temperature than normal body temperature). This failure resulted in an Immediate Jeopardy situation with air temperatures ranging between 59 degrees Fahrenheit and 70 degrees Fahrenheit in two of two nursing units. […]

  • Immediate jeopardy, patternF584Jul 11, 2024

    Based on observation, interview with resident and staff, review of facility documentation and review of CDC recommendations, it was determined that the facility failed to ensure comfortable air temperatures between 71 degrees Fahrenheit and 81 degrees. This failure resulted in an Immediate Jeopardy situation with air temperatures ranging between 82.4 degrees Fahrenheit and 90.6 degrees Fahrenheit in two of two nursing units (Second and Third Floor). Findings include: Review of The Center for Disease Control and Prevention recommendation titled Extreme Heat date June 21, 2024, revealed Heat-related illnesses, like heat exhaustion or heat stroke, happen when the body is not able to properly cool itself. […]

  • Actual harm, isolatedF600Feb 23, 2024

    Based on review of facility policy, facility documentation, review of clinical records, interviews with staff and the resident, it was determined that the facility did not ensure residents were free from verbal abuse which resulted in actual harm to Resident R14 who was verbally abuse by a nursing staff for one of 16 residents reviewed. (Resident R14) Findings Include: Review of facility policy titled Abuse Prevention Program dated January 1, 2022 reads, Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation. […]

  • No harm, potential for more than minimal, widespreadF812Jul 16, 2026

    Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store food in accordance with standards for food service safety (main kitchen). Findings include: Review of facility policy Guidelines for Storage undated, revealed Date your products with Use By Dates. A tour of the main kitchen conducted on July 13, 2026, at 9:50 a.m. with Employee E9, Dietary Director, revealed the following: Observation in the dry storage room revealed a wall behind a food rack was soiled with a brown substance; the same wall had openings and holes along the baseboard, which would allow for pests to enter. The floor had a heavy buildup of grime. Observation in the kitchen by the steamer revealed a drain in the floor that was open and uncovered. […]

Read 28 findings in full →The most serious and the most recent: 28 of 189 on record.

Every survey on record

FindingsAt actual harm or above

  • Aug 25, 2026Complaint2 findings
  • Jul 16, 2026Standard6 findings
  • Jun 12, 2026Complaint4 findings
  • Feb 4, 2026Complaint2 findings
  • Dec 11, 2025Complaint5 findings
  • Dec 3, 2025Complaint2 findings
  • Aug 25, 2025Complaint1 finding
  • Jul 7, 2025Complaint1 finding
Show the 42 earlier surveys
  • May 29, 2025Complaint2 findings
  • Feb 26, 2025Complaint3 findings
  • Feb 8, 2025Complaint2 findings · 1 harm
  • Jan 10, 2025Standard18 findings
  • Sep 17, 2024Complaint3 findings
  • Jul 11, 2024Complaint3 findings · 2 harm
  • Feb 23, 2024Standard and complaint21 findings · 1 harm
  • Jan 4, 2024Complaint1 finding
  • Jan 3, 2024Complaint5 findings
  • Oct 26, 2023Complaint3 findings
  • Aug 30, 2023Complaint1 finding
  • May 11, 2023Standard9 findings
  • Mar 6, 2023Complaint1 finding
  • Dec 19, 2022Infection control2 findings
  • Jun 30, 2022Standard8 findings
  • Mar 3, 2022Complaint2 findings
  • Jan 9, 2022Complaint1 finding
  • Aug 13, 2021Complaint3 findings
  • Jun 17, 2021Standard3 findings
  • Dec 7, 2020Complaint3 findings
  • Jan 24, 2020Complaint1 finding
  • Jan 13, 2020Complaint2 findings
  • Nov 20, 2019Complaint3 findings
  • Apr 6, 2019Standard5 findings
  • Jun 20, 2018Standard9 findings
  • Mar 29, 2018Complaint1 finding
  • Dec 21, 2017Complaint1 finding
  • Apr 11, 2017Standard and complaint17 findings · 3 harm
  • Jan 20, 2017Complaint1 finding
  • Oct 13, 2016Complaint1 finding
  • Jun 24, 2016Complaint1 finding
  • Jun 14, 2016Complaint2 findings
  • May 9, 2016Standard4 findings
  • Apr 2, 2015Standard2 findings
  • Aug 14, 2014Complaint1 finding
  • May 20, 2014Standard2 findings
  • Jul 19, 2013—2 findings · 1 harm
  • Apr 11, 2013—3 findings
  • Nov 19, 2012—3 findings
  • May 10, 2012—8 findings
  • Mar 8, 2012—1 finding
  • Aug 9, 2011—2 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction