PHILADELPHIA, PA - Willow Terrace nursing home in Philadelphia was cited for multiple serious violations during a January 31, 2025 inspection, including medication administration errors, inadequate staff training, and failures to provide necessary behavioral health services to residents with mental illness.
Critical Medication Management Failures Put Residents at Risk
Inspectors documented serious medication safety violations that exposed residents to potential harm. During observed medication administration rounds, nurses failed to follow proper protocols for time-sensitive medications, creating risks for residents with diabetes and other chronic conditions.
One of the most concerning incidents involved insulin administration for a diabetic resident. The nurse checked the resident's blood sugar level at 9:38 a.m., obtaining a reading of 258, which indicated dangerously high blood sugar levels. The nurse then administered both the standing dose and sliding scale insulin totaling ten units, but only after the resident had already finished breakfast. Both the resident and nurse confirmed that insulin should have been administered before the meal, not after.
This timing error is medically significant because rapid-acting insulin is designed to work with food intake to control blood sugar spikes that occur after eating. When administered after a meal, especially with such a high blood sugar reading, the insulin's effectiveness is compromised and can lead to unpredictable blood sugar swings.
The same nurse also improperly managed pain medication patches for another resident. During observations, the nurse removed lidocaine patches from the resident's knees that were dated January 28, 2025, confirming "the patches should have been removed on January 28, 2025, at 9:00 p.m." The patches had been left on for approximately 14 additional hours beyond the prescribed 12-hour application period.
Medical protocols specify that lidocaine patches should not exceed 8 hours per application and should not be worn continuously without breaks between applications. Extended wear can lead to medication absorption into the bloodstream, potentially causing systemic effects including abnormal heart rhythms, seizures, and respiratory depression.
Unavailable Medications Leave Residents Without Essential Treatments
The inspection revealed that residents were routinely left without prescribed medications due to poor inventory management. Three residents experienced gaps in their medication regimens when prescribed drugs were not available in medication carts.
One resident was unable to receive amlodipine, a blood pressure medication, despite having a standing order for daily administration at 9:00 a.m. Another resident missed doses of potassium chloride, which is prescribed to maintain proper electrolyte balance and prevent dangerous heart rhythm abnormalities.
Most critically, a resident with epilepsy missed multiple doses of levetiracetam, an anti-seizure medication, over a five-day period in December 2024. The missed doses occurred on December 20, 21, 22, 23, and 25, with documentation showing the medication was "back ordered" from the pharmacy.
Gaps in anti-seizure medication can trigger breakthrough seizures and status epilepticus, a life-threatening condition where seizures continue for extended periods. Maintaining consistent blood levels of anti-seizure medications is critical for preventing breakthrough seizures, which can cause brain damage, falls, and other serious injuries.
According to established protocols, when medications are not available in medication carts, nurses should check emergency pharmacy supplies and contact physicians immediately if medications remain unavailable. The facility had amlodipine available in its emergency inventory but failed to utilize this backup system.
Agency Nurses Lack Proper Training and Competency Verification
The facility's use of agency nursing staff created additional safety risks due to inadequate training and competency verification. Three agency nurses were working without proper medication administration training, controlled substance protocols, or enhanced barrier precaution education.
One agency nurse confirmed it was his first day at the facility and that he "did not receive any training by the facility regarding medication administration." The same nurse failed to complete mandatory shift-to-shift controlled substance counts, a critical safety measure designed to prevent drug diversion and ensure accountability for narcotics.
The Director of Nursing confirmed that agency nurses "did not receive adequate trainings related to medication administration, controlled substances and enhanced barrier precautions" and acknowledged that "the facility's orientation process for agency staff needed to be revised."
Federal regulations require nursing facilities to ensure all staff, including temporary agency personnel, receive proper training and demonstrate competency before providing resident care. This includes specific training on medication administration techniques, controlled substance protocols, and infection prevention measures.
Mental Health Services Denied to Eligible Resident
The inspection found that a resident with multiple mental health diagnoses was denied specialized behavioral health services despite being eligible for such care. The resident, diagnosed with anxiety, depression, schizophrenia, and traumatic brain injury, qualified for comprehensive mental health services based on state assessments.
The resident reported experiencing boredom and stated he "could use a job," indicating unmet psychosocial needs. State evaluations determined he was eligible for systematic behavioral plans, structured social activities, daily living skills training, therapy services, and formal behavior modification programs.
However, the Director of Nursing confirmed that the resident "had not been offered behavioral health services" since April 2021, despite continued eligibility determinations through December 2024. Mental health services are essential for residents with serious mental illness to maintain psychological stability, prevent behavioral crises, and optimize quality of life.
Infection Control Protocols Ignored During High-Risk Procedures
Nursing staff violated enhanced barrier precautions during wound care for a resident with a sacral wound who required special infection control measures. Despite clear signage on the resident's door indicating the need for gowns and gloves during high-contact care, two staff members provided wound care wearing only gloves.
The violation occurred when an agency nurse performed wound care that included removing old dressings, cleansing the wound, and applying new dressings, with assistance from a nurse aide. Enhanced barrier precautions are specifically designed to prevent transmission of multidrug-resistant organisms, which can cause serious infections that are difficult to treat.
The agency nurse stated "there were no gowns readily available to wear" and confirmed she "had not received training on enhanced barrier precautions." This represents a systematic failure in both supply management and staff education for critical infection prevention protocols.
Additional Issues Identified
Inspectors documented several other medication safety concerns, including improperly labeled insulin supplies and incomplete controlled substance documentation. The facility's medication error rate reached 12.5%, well above acceptable standards, based on four errors observed during 32 medication administration opportunities.
The inspection also revealed that two residents with significant cognitive impairments were inappropriately asked to sign binding arbitration agreements. One resident scored 2 on a cognitive assessment indicating severe impairment, while another scored 12 indicating moderate impairment, yet both were required to sign complex legal documents.
Multiple insulin vials and pens were found without required dating to track when they were opened, creating risks for administering expired medications that could lose potency and fail to control blood sugar effectively.
The violations identified at Willow Terrace highlight systemic failures in medication management, staff training, and resident care protocols that require immediate corrective action to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Terrace from 2025-01-31 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.