Willow Terrace

F-F755.

Observation on January 29, 2025, at 11:31 a.m. revealed that a sign was posted on Resident Resident R271's door indicating that he required enhanced barrier precautions (reduces the risk of spreading infectious organisms). The sign instructed staff to wear a gown and gloves while providing high-contact care activities, such as wound care. Continued observation revealed Employee E10, licensed nurse, entered the room and performed wound care to Resident Resident R271's sacrum, which included removing the old dressing, cleansing the wound and application of a new dressing. Employee E10, licensed nurse, was observed wearing only gloves while providing care. Employee E10, licensed nurse, stated that she was an agency nurse and that she had not received training regarding enhanced barrier precautions. Refer to

F-F759.

Observation on January 29, 2025, at 10:44 a.m. with Employee E7, licensed nurse, of the fourth floor south medication cart, revealed that there was no documentation in the narcotic log book that shift-to-shift counts were completed at any time. Continued observation revealed that the index in the narcotic log book was incomplete and did not match with the individual residents' countdown records. Employee E7, licensed nurse, stated that it was his first day at the facility as an agency nurse, that he did not receive any training by

the facility regarding medication administration or controlled substances and that he did not complete a shift-to-shift count with the previous night shift nurse. Refer to

F-F880.

Review of Employee E8, agency licensed nurse, personnel file revealed that a medication competency

review was conducted on January 20, 2025. Review of the competency evaluation revealed that there were no skills evaluations related to the administration of insulin or topical medication patches. Further review revealed that the evaluation form was not signed by the employee. Continued review of Employee E8, licensed nurse, personnel file revealed that there was no training related to controlled substances or enhanced barrier precautions available for review at the time of the survey.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Review of Employee E7, agency licensed nurse, personnel file revealed that a medication competency

review was not conducted until January 30, 2025, which is after Employee E7, licensed nurse, began Level of Harm - Minimal harm or working at the facility. Continued review of Employee E7, licensed nurse, personnel file revealed that there potential for actual harm was no training related to controlled substances or enhanced barrier precautions available for review at the time of the survey. Residents Affected - Few

Review of Employee E10, agency licensed nurse, personnel file revealed that there was no competency evaluation or training related to medication administration, controlled substances or enhanced barrier precautions available for review at the time of the survey.

Interview on January 31, 2025, at 9:38 a.m. the Director of Nursing confirmed that Employees E8, E7 and E10, agency licensed nurses, did not receive adequate trainings related to medication administration, controlled substances and enhanced barrier precautions. The Director of Nursing stated that the facility's orientation process for agency staff needed to be revised.

28 Pa Code 201.20(b) Staff development

28 Pa Code 211.12(c) Nursing services

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 06525

Residents Affected - Few Based on clinical record reviews, interviews with staff, reviews of policies and procedures and the Department of Human Services assessments, it was determined that the facility failed to provide the necessary behavioral health care and services to attain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and care plan for one of four residents reviewed with mental illness (Residents Resident R17).

Findings include:

Reviews of the facility policy titled Behavioral-Mental Healthcare Substance Use dated May 7, 2024 revealed that the facility was to provide an interdisciplinary approach for the care of residents who have a diagnosis of mental health disorder and decreased social interaction. The policy also indicated that the facility must provide the necessary Behavioral Health care and services to attain or maintain the highest practicable physical, mental and psychosocial well -being of the residents in accordance with their assessment and care plan. This policy said that the facility was required to conduct a preadmission screening and resident review (PASARR) to determine if the resident was qualified for specialized Behavioral Health services.

Review of Resident Resident R17's annual comprehensive Minimun Data Set (MDS- assessment of care needs) dated October 14, 2024 revealed that the resident was mildly cognitiely impaired. Continued review of th assessment indicated that this resident wanted his family and close friend involved with discussions about his care. The assessment indicated that the resident had the following diagnoses: anxiety, depression, schizophrenia and tramatic brain injury.

Clinical record review revealed an assessment dated [DATE REDACTED] and revised on June 1, 2024 through December 23, 2024 that indicated the Department of Human Serives Office of Mental Health and Substance Abuse assessed Resident Resident R17 and determined that this resident was eligible and did qualify for the provision of mental health services such as preparation of systematic plans which are designed to facilitate appropriate behavior, drug therapy and monitoring for effectiveness and side effects, structured social activities, the teaching of daily living skills to enhance self-determination and independence; individual, group or family therapy or personal support networks and formal behavior modification programs provided by qualified personnel.

Interview with Resident Resident R17 at 10:30 a.m., on January 28, 2025 revealed that this resident was reporting boredom. Doesn't have the activities that meet his interest and capabilities. Resident Resident R17 reported that he could use a job.

Interview with the social worker, Employee E18, at 9:30 a.m., on January 29, 2025 revealed that this social worker requested that the physician arrange for the specialized mental health services needs of Resident Resident R17. The physician responded with yes saying that Resident Resident R17 was eligible for specialized services based

on his comprehensive assessment and (PASARR) preadmission screening and resident review document.

The physician reported to the social worker on January 29, 2025 that the next physician scheduled visit was

on February 7, 2025 at that time the physician decided to implement a care plan for Resident Resident R17's mental illnesses and special needs.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Interview with the director of nursing at 1:00 p.m., on January 31, 2025 confirmed that Resident Resident R17 had not been offered behavioral health services: ( preparation of systematic plans which are designed to facilitate Level of Harm - Minimal harm or appropriate behavior, structured social activities, the teaching of daily living skills to enhance potential for actual harm self-determination and independence; individual, group or family therapy or personal support networks and formal behavior modification programs provided by qualified personnel ) to meet his highest practicable Residents Affected - Few well-being since April 21, 2021 and the most recent recertification evaluation conducted on June 1, 2024 to December 23, 2024; which indicated the continued eligibility of special services for Resident Resident R17.

28 PA. Code 211.12(d)(3)(5) Nursing services

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 211.10(d) Resident care policies

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 39344

Residents Affected - Few Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for one of four medication carts reviewed (fourth floor south medication cart), and failed to ensure that medications were readily available for administration for three of 32 residents reviewed (Residents Resident R132, Resident R55, and Resident R142).

Findings include:

Review of facility policy, Narcotic Management dated revised December 24, 2024, revealed, Control/Schedule II-V medication will be counted with two (2) professional nurses at the beginning and end of each shift. Documentation that a count was completed and accurate will be completed at the beginning and end of each shift. Control/Schedule II-V medications will be logged into a bound book or separate master index page once received from the pharmacy as well as individual countdown records.

Observation on January 29, 2025, at 10:44 a.m. with Employee E7, licensed nurse, of the fourth floor south medication cart, revealed that there was no documentation in the narcotic log book that shift-to-shift counts were completed at any time. Continued observation revealed that the index in the narcotic log book was incomplete and did not match with the individual residents' countdown records.

Interview, at the time of the observation, Employee E7, licensed nurse, confirmed the above findings. Employee E7, licensed nurse, stated that it was his first day at the facility as an agency nurse, that he did not receive any training by the facility regarding medication administration and that he did not complete a shift-to-shift count with the previous night shift nurse.

Observation of the fourth floor south medication cart narcotic log book with Employee E9, unit manager, confirmed that the shift-to shift counts and index were not completed. Employee E9, unit manager, stated that staff need to be conducting these counts to prevent potential drug diversion.

Observation of the morning medication pass on January 29, 2025, at 9:38 a.m. revealed Employee E8, licensed nurse, prepare medications for Resident Resident R132. Review of physician orders for Resident Resident R132 revealed an order, dated September 21, 2023, for amlodipine (medication used to treat high blood pressure) 10 m.g (milligrams) tabs, give one tab daily at 9:00 a.m. Employee E8, licensed nurse, was unable to administer Resident Resident R132's amlodipine and stated that the medication was not available in the medication cart.

Review of the facility's emergency pharmacy medication inventory list revealed that amlodipine 10 m.g tablets were available at the facility for administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 396129 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Observation of the morning medication pass on January 29, 2025, at 10:20 a.m. revealed Employee E7, licensed nurse, prepare medications for Resident Resident R55. Review of physician orders for Resident Resident R55 Level of Harm - Minimal harm or revealed an order, dated January 17, 2025, for potassium chloride (treats low potassium levels) oral packet potential for actual harm 20 mEq (milliequivalent) give one packet daily. Employee E7, licensed nurse, was unable to administer Resident Resident R55's potassium chloride and stated that the medication was not available in the medication cart. Residents Affected - Few

Review of medication administration records for Resident Resident R142 for December 2024, revealed physician's orders for levetiracetam (medication used to treat seizures) give 750 m.g two times per day at 9:00 a.m. and 5:00 p.m. Continued review of the medication administration record revealed that the following doses were not administered: December 20, 2024, at 5:00 p.m.; December 21, 2024, at 9:00 a.m.; December 22, 2024, at 9:00 a.m.; December 23, 2024, at 5:00 p.m.; and December 25, 2024, at 9:00 a.m. Review of progress notes from December 20 through 25, 2024, revealed that the medication was not administered due to back order.

Interview on January 30, 2025, at 1:21 p.m. Employee E4, Assistant Director of Nursing (ADON), revealed that if medications are not readily available in the medication cart that nurses should check the emergency supply to see if it is available. If the medication is not available, nurses are expected to call the physician.

28 Pa Code 211.9(a)(1) Pharmacy services

28 Pa Code 211.9(k) Pharmacy services

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 39344 potential for actual harm Based on observations, review of facility policies, clinical record review and interviews with staff, it was Residents Affected - Few determined that the facility failed to ensure that the medication error rate was less than five percent for one of three residents observed during medication administration (Resident Resident R132).

Findings include:

The facility's medication error rate was 12.5% based on observation of 32 medication administration opportunities with four errors observed.

Review of facility policy, Medication Administration/Disposition dated reviewed December 2024, revealed, Medications shall be administered in a safe and timely manner, and as prescribed by the physician. Facility staff involved in the administration of resident care will be knowledgeable of the policies and procedures regarding pharmacy services including medication administration. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician. Continued review revealed, Medications must be administered with one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Review of physician orders for Resident Resident R132 revealed an order, dated September 21, 2023, for aspart (rapid acting) insulin (medication used to lower blood sugar levels), inject four units subcutaneously (under

the skin) daily with breakfast. Continued review revealed order, dated September 20, 2023, for aspart insulin sliding scale (variable dosage based on blood sugar level), inject subcutaneously before meals and at bedtime. Both orders for aspart insulin were scheduled to be administered at 7:30 a.m.

Observation of the morning medication pass on January 29, 2025, at 9:38 a.m. revealed Employee E8, licensed nurse, checked Resident Resident R132's blood sugar level with a glucometer, and obtained a value of 258. Employee E8, licensed nurse, verified the physician orders for Resident Resident R132; the sliding scale indicated that six units of insulin should be administered. Employee E8, licensed nurse, drew up a total of ten units of insulin (standing dose of four units plus six units of the sliding scale dose) and administered them to Resident Resident R132. Both Resident Resident R132 and Employee E8, licensed nurse, confirmed that the resident had already finished eating breakfast. Employee E8, licensed nurse, confirmed that Resident Resident R132's insulin should have been administered before the breakfast meal.

Continued review of physician orders for Resident Resident R132 revealed an order, dated January 24, 2025, for lidocaine external 4% patch (medicated patch to relieve pain) apply to left knee at 9:00 a.m. and remove at 9:00 p.m. Further review of physician orders revealed an order, dated January 24, 2025, for lidocaine external 4% patch apply to right knee at 9:00 a.m. and remove at 9:00 p.m.

Review of Medline (national library of medicines) drug information, available at https://medlineplus. gov/druginfo/ revealed that Nonprescription lidocaine transdermal comes as a 4% patch to apply to the skin.

It is applied up to 3 times daily and for no more than 8 hours per application. If you wear too many lidocaine transdermal patches or topical systems or wear them for too long, too much lidocaine may be absorbed into your blood. In that case, you may experience symptoms of an overdose.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Continued observation of the morning medication pass on January 29, 2025, at 10:05 a.m., Employee E8, licensed nurse, removed lidocaine patches from Resident Resident R132's left and right knees; both patches had a Level of Harm - Minimal harm or date of January 28, 2025. Employee E8, licensed nurse, confirmed that the patches dated January 28, 2025, potential for actual harm should have been removed on January 28, 2025, at 9:00 p.m.

Residents Affected - Few Further observation revealed that Employee E8, licensed nurse, administered new lidocaine patches to Resident Resident R132's left and right knees immediately after removing the old patches.

28 Pa. Code 211.9(a)(1) Pharmacy services

28 Pa. Code 211.12 (d)(5) Nursing services

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 39344 Residents Affected - Few Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that insulin pens and vials were labeled in accordance with currently accepted professional principles for one of four medication carts reviewed (fourth floor north medication cart).

Findings include:

Review of facility policy, Medication Administration/Disposition dated reviewed December 2024, revealed, When opening a multi-dose container, the date opened is recorded on the container.

Observation on January 29, 2025, at 10:14 a.m. of the fourth floor north medication cart with Employee E8, licensed nurse, revealed the following:

A lantus (long acting) insulin (medication used to lower blood sugar levels) pen for Resident Resident R17 that was opened and undated;

A lantus insulin vial for Resident Resident R132 that was opened and undated;

A lispro (rapid acting) insulin vial for Resident Resident R95 that was opened and undated; and

An admelog (rapid acting) insulin vial for Resident Resident R83 that was opened and undated.

Interview, at the time of the observation, Employee E8, licensed nurse, confirmed the above findings.

28 Pa Code 211.9(a)(1) Pharmacy services

28 Pa Code 211.12(d)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 396129 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41471 potential for actual harm Based on the review of facility documents and resident clinical record and staff interviews, it was determined Residents Affected - Few that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents reviewed (Resident Resident R147 and Resident Resident R151).

Findings Include:

Review of Resident Resident R147's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 6, 2024, revealed the resident was admitted to the facility on [DATE REDACTED], and had a diagnosis of non-traumatic brain dysfunction and cognitive communication deficit.

Further review of the MDS, Section C - Cognitive Patterns (items in this section are intended to determine

the resident's attention, orientation, and ability to register and recall new information - these items are crucial factors in many care-planning decisions), indicated that Resident Resident R147 scored a 12 on the Brief Interview for Mental Status (BIMS), which indicated the resident had moderate cognitive impairment.

Review of Resident Resident R151's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2024, revealed the resident was admitted to the facility on [DATE REDACTED], and had a diagnosis of altered mental status.

Further review of the MDS, Section C - Cognitive Patterns, indicated that Resident Resident R151 scored a 2 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment.

Review of Resident Resident R147's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated the resident signed the document on May 3, 2024. Further

review of the Binding Arbitration Agreement revealed it was also signed by facility employee, Admission Director, Employee E20.

Review of Resident Resident R151's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated the resident signed the document on May 9, 2024. Further

review of the Binding Arbitration Agreement revealed it was also signed by facility employee, Admission Director, Employee E20.

Interview on January 31, 2025. with Employee E2, Director of Nursing confirmed that Resident Resident R151 and Resident Resident R147 had communication and cognitive deficit and should not be provided with arbitration agreement.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 28 Pa. Code 211.10 (d) Resident care policies

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396129 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Terrace One Penn Boulevard Philadelphia, PA 19144

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 39344 potential for actual harm Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was Residents Affected - Few determined that the facility failed to maintain enhanced barrier precautions during wound care for one of one

observations of wound care performed (Resident Resident R271).

Findings include:

Review of facility policy, Transmission Based Precautions dated revised July 11, 2024, revealed, Enhanced barrier precautions (EBP) are designed to reduce the transmission of multidrug-resistant organisms (MDRO)

in facilities. Continued review revealed that, EBP consists of the use of gowns and gloves for high-contact care activities which include . changing briefs and wound care.

Review of Resident Resident R271's care plan, dated initiated January 29, 2025, revealed that the resident had a sacral wound and to maintain enhanced barrier precautions.

Observation on January 29, 2025, at 11:31 a.m. revealed that a sign was posted on Resident Resident R271's door indicating that he required EBP. The sign instructed staff to wear a gown and gloves while providing high-contact care activities, such as wound and continence care.

Continued observation revealed that Employee E11, nurse aide, was in Resident Resident R271's room providing continence care. Employee E11, nurse aide, was observed wearing only gloves while providing care.

Further observation revealed Employee E10, licensed nurse, entered the room and performed wound care to Resident Resident R271's sacrum, which included removing the old dressing, cleansing the wound and application of

a new dressing. Employee E11, nurse aide, provided assistance to Employee E10, licensed nurse, while the wound care was being performed. Both employees were observed wearing only gloves while providing care.

Interview on January 29, 2025, at 11:50 a.m. Employee E10, licensed nurse, revealed that there were no gowns readily available to wear. Employee E10, licensed nurse, stated that there might be some available in

the treatment cart. Employee E10, licensed nurse, stated that she was an agency nurse and that she had not received training on enhanced barrier precautions.

28 Pa Code 211.10(d) Resident care policies

28 Pa Code 211.12(d)(5) Nursing services

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