Immaculate Mary Center: Infection Control Failures - PA
Inspectors visiting Immaculate Mary Center for Rehabilitation & Healthcare on September 15, 2025, watched Employee E4, a licensed practical nurse, and Employee E5, a nurse aide, treat Resident R5's wounds. The Enhanced Barrier Precautions sign was posted directly on the resident's door. The sign exists specifically because the resident carries a multi-drug resistant organism, the category of infections that standard antibiotics struggle to treat. Both employees went through the procedure unprotected.
A licensed nurse confirmed afterward that neither had worn the required protective equipment.
The following day brought a second problem. During wound care on Resident R4, Employee E6, a licensed nurse, set up her supplies at the foot of the resident's bed. As she cleaned the wound with saline, the solution dripped from the gauze onto the bed linens below. Her gloves, along with the rest of her supplies, were sitting in that same area.
When she finished cleaning and needed fresh gloves, she pulled them from the pile on the bed.
She did not wash her hands first.
The sequence matters. She had just removed contaminated gloves after direct contact with an open wound. Without hand hygiene, she reached into a supply pile that had been sitting near the wound drainage, pulled out new gloves, and continued the procedure.
The facility's own infection control policy, updated September 2024, identifies wound care as a high-contact activity requiring gowns and gloves. It also specifies that supplies should be gathered before entering the room and kept away from contamination sources.
Three staff members across two days, two residents with open wounds, and the same category of failure: the gap between what the precaution signs on the doors demanded and what actually happened inside the rooms.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
IMMACULATEMARYCENTER FOR REHABILITATION&HEALTHCARE in PHILADELPHIA, PA was cited for violations during a health inspection on September 15, 2025.
The Enhanced Barrier Precautions sign was posted directly on the resident's door.
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.