Immaculate Mary Center: Infection Control Failures - PA
The resident, identified in inspection records as R5, was sitting in a wheelchair when a licensed practical nurse and a nurse aide began the wound care procedure. Neither wore a gown. Neither wore gloves. The enhanced barrier precautions sign on the door indicated the resident was colonized or infected with a multi-drug resistant organism, the category of pathogens for which the facility's own policy required exactly the protective equipment both employees skipped.
A licensed nurse confirmed to inspectors what they had already watched with their own eyes: the two employees had not worn appropriate personal protective equipment during the procedure.
The following morning brought a second observation, this one of a different resident, R4, with a different nurse. What inspectors found was a different kind of failure, quieter and easier to miss, but no less significant.
The nurse, Employee E6, gathered dressing supplies before entering, which is correct procedure. But she placed all of them, including the clean gloves she would need later, on the foot of the resident's bed. She removed the old dressing. She cleaned the wound with saline. During the cleaning, saline dripped from the gauze onto the bed, contaminating the surface where the clean supplies were sitting.
Then she removed her soiled gloves and picked up new ones from that same bed.
She did not wash her hands or use hand sanitizer between removing the contaminated gloves and putting on the fresh pair. The new gloves went on hands that had not been cleaned after contact with a wound, its drainage, and the materials used to clean it.
The facility's own policy, drawn from CDC infection control guidelines, is specific about when hand hygiene is required: immediately after glove removal is one of them. Wound care supplies are supposed to be placed on a clean surface away from potential contamination before the procedure begins, not on a bed that will collect drips from the wound being treated.
The violations fall under F0880, the federal tag covering infection prevention and control programs. Inspectors cited them at a level of minimal harm or potential for actual harm, with few residents affected. That classification reflects what was documented, not what could have followed. Multi-drug resistant organisms spread through exactly the kind of contact these procedures involved. A wound is an opening. Contaminated hands and contaminated surfaces are how pathogens move from one place to another.
Immaculate Mary Center for Rehabilitation and Healthcare updated its enhanced barrier precautions policy as recently as September 2024. The policy names wound care explicitly as a high-contact activity requiring gowns and gloves. The CDC guidelines the facility references are not ambiguous about hand hygiene between glove changes.
What the inspection captured was not a gap in written policy. It was a gap between what the policy said and what happened in two resident rooms on two consecutive mornings.
R5 sat in a wheelchair while two employees worked on a wound without the protection the warning on the door was there to require. R4's nurse put on clean gloves from a surface wet with saline runoff from a wound she had just cleaned, without washing her hands first.
The inspection was conducted in response to a complaint. Inspectors were at the facility specifically because someone had raised a concern. They arrived and, within the first two days, observed both incidents directly.
Neither resident's outcome is described in the inspection record. What the record contains is what two sets of eyes watched happen, and what a nurse confirmed when asked about it afterward.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Immaculatemarycenter For Rehabilitation&healthcare from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
IMMACULATEMARYCENTER FOR REHABILITATION&HEALTHCARE in PHILADELPHIA, PA was cited for violations during a health inspection on September 15, 2025.
The following morning brought a second observation, this one of a different resident, R4, with a different nurse.
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.