Willow Terrace: Infection Control Failure During Wound Care - PA
On January 29, 2025, at 11:31 a.m., inspectors at Willow Terrace watched a licensed nurse enter the room of Resident R271 wearing only gloves. The sign on his door required more than that. It called for both a gown and gloves, a precaution in place because R271 was on enhanced barrier precautions, a protocol used to reduce the spread of infectious organisms between patients and staff.
The nurse, identified in inspection records as Employee E10, did not put on a gown. She removed the old dressing from R271's sacrum, cleaned the wound, and applied a new one. The sign remained on the door the entire time.
When inspectors asked her about it, she said she was an agency nurse and that she had not received training on enhanced barrier precautions.
That explanation carries its own weight. Agency nurses are brought in to fill gaps when a facility cannot staff its floors with its own employees. They arrive without the institutional knowledge that comes from orientation, from watching how a particular unit operates, from being told which rooms require what precautions and why. The sign on R271's door was meant to bridge exactly that gap. It was visible. It was specific. It named the required protective equipment.
It did not work.
Enhanced barrier precautions exist for a reason. When a resident carries a resistant or transmissible organism, the risk of spreading it does not stay inside the room. It travels on hands, on clothing, on the surfaces a nurse touches before moving to the next patient. A gown is not a formality. It is a barrier between whatever is in that wound and everywhere the nurse goes next.
R271 had a wound on his sacrum, the bony base of the spine. Sacral wounds are among the most common and most serious pressure injuries in nursing home residents, particularly those who spend significant time in bed or in a chair. They are also among the most vulnerable to infection. The combination of an open sacral wound and an infectious organism serious enough to require enhanced precautions made the protection protocol around R271 more than routine.
Employee E10 said she had not been trained. The inspection report does not say whether Willow Terrace provided her with any orientation materials, whether the facility had a process for briefing agency staff on active isolation precautions, or whether anyone reviewed the enhanced barrier precaution protocol with her before she went on the floor. The report does not say whether she had worked at the facility before that morning or whether January 29 was her first shift there.
What the report says is that she walked into a room with a posted warning, performed a procedure that put her in direct contact with an open wound, and did so without the protective equipment the warning required.
Wound care is not incidental contact. Removing a dressing, irrigating or cleansing a wound, and applying a new one involves sustained, close handling of the most exposed part of a resident's body. If E10's clothing carried anything from another resident or another surface into that room, the dressing she applied went directly over it.
The inspection report does not describe what happened to R271 after the observation. It does not say whether he developed a new infection, whether his wound deteriorated, or whether anyone told him what had occurred during his care that morning. It records what inspectors saw and what the nurse said when they asked her about it.
She had not been trained. The sign was on the door. She went in anyway.
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.
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: August 9, 2026 · Our methodology
WILLOW TERRACE in PHILADELPHIA, PA was cited for violations during a health inspection on January 31, 2025.
On January 29, 2025, at 11:31 a.m., inspectors at Willow Terrace watched a licensed nurse enter the room of Resident R271 wearing only gloves.
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.