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Health Inspection

Willow Terrace

January 31, 2025 · Philadelphia, PA · One Penn Boulevard
Citations 3
CMS Rating 2/5
Beds 174
Provider ID 396129
Healthcare Facility
Willow Terrace
Philadelphia, PA  ·  View full profile →
Inspection Summary

WILLOW TERRACE in PHILADELPHIA, PA — inspection on January 31, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF755

Observation on January 29, 2025, at 11:31 a.m. revealed that a sign was posted on 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 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

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

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.

396129

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PHILADELPHIA, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WILLOW TERRACE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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