Pennsylvania Department of Health
WILLOW TERRACE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


WILLOW TERRACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on January 21, 2026, it was determined that Willow Terrace had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004 Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures had been updated at least annually, affecting the entire facility. Findings include: 1. Document review on January 21, 2026, at 9:00 a.m., revealed the Facility's Emergency Preparedness Plan had policies and procedures that still required annual review with required revisions. Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the documentation required additional review and revisions.

Plan of Correction - To be completed: 03/06/2026

This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrong doing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

Facility's Emergency Preparedness Plan was reviewed and updated to accurately reflect facility policies and procedures.

Facility NHA or designee will audit the EPP monthly x3 months to ensure EPP policies and procedures are up to date.

Audits will be brought to QAPI Committee for review. QAPI Committee will determine the need for continuance of audits.

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID# 072102Component 01Willow TerraceBased on a Medicare/Medicaid Recertification Survey completed on January 21, 2026, it was determined that Willow Terrace was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a six-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Illumination of Means of Egress:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0281 Based on observation and interview, it was determined that the facility failed to ensure continuous illumination of means of egress, affecting three of six levels. Findings include: 1. Observations on January 21, 2026, at 10:45 a.m., revealed stair tower #2 lacked illumination due to burned out light bulbs on the 4th, 5th, and 6th floors Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the burned out bulbs.

Plan of Correction - To be completed: 03/06/2026

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

K0281

The stair tower illumination was fixed by vendor and all stair towers have appropriate illumination.
Maintenance staff will be educated on the importance of means of egress illumination.
Maintenance Director will perform monthly audits x3 months of facility stair towers to ensure all are fully illuminated.
Audits will be brought to QAPI Committee for review. QAPI Committee will determine the need for continuance of audits.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353 Based on observation, document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility. Findings include: 1. Document review on January 21, 2026, at 9:30 am, revealed November 3, 2025, Sprinkler Inspection Report listed multiple tamper and supervisory deficiencies, evidence of corrective action was unavailable at time of survey. Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the sprinkler system deficiencies.

Plan of Correction - To be completed: 03/06/2026

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

Tamper and supervisory deficiencies on sprinkler inspection report are resolved.
Maintenance staff will be educated on the importance of maintaining automatic sprinkler system components.
Maintenance director or designee will conduct weekly audits x 4 weeks and monthly audits x2 months to ensure sprinkler system components are in compliance.
Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0363 Based on observation and interview it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke, on one of two floors. Findings include: 1. Observation on January 21, 2026, at 11:30 am, revealed 4th floor laundry room corridor door failed to close and latch when tested, due to paper stuffed into the latching mechanism. Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the door failed to close and latch when tested.

Plan of Correction - To be completed: 03/06/2026

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

Paper removed from 4th floor laundry room door.

All staff will be educated on the importance of doors positively latching to resist the passage of smoke.

Maintenance director or designee will conduct weekly audits x 4 weeks and monthly audits x2 months to ensure 4th floor laundry door positively latches.

Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting one of six levels. Findings include: 1. Observation on January 21, 2026, at 10:50 am, revealed 6th floor smoke doors by the Nurse Station failed to close smoke tight when tested due to coordinator malfunction. Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the door failed to close smoke tight.

Plan of Correction - To be completed: 03/06/2026

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

6th floor smoke doors by nurse's station were repaired- coordinator replaced.
Maintenance staff was educated on the importance of ensuring doors in smoke barrier walls are maintained to resist the passage of smoke.

Maintenance director or designee will conduct monthly audits x3 months to ensure 6th floor smoke doors are maintained.

Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511 Based on observation and interview, it was determined the facility failed to comply with NFPA 70 210.8(B)5, National Electric Code, for electrical wiring and equipment, affecting one of six levels. Findings include: 1. Observation on January 21, 2026, revealed, non-GFCI outlet, located within 6 feet of a sink, 6th floor by Nurse Station. Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the unprotected outlet.

Plan of Correction - To be completed: 03/06/2026

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

Non GFCI outlet replaced with GFCI outlet.

Maintenance staff was educated on the importance of ensuring adherence with National Electric Code.

Maintenance director or designee will conduct monthly audits x3 months to ensure GFCI outlet in place.

Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to protect electrical wiring, affecting one of six levels. Findings include: 1. Observation on January 21, 2026, at 11:00 am, revealed, in 6th floor Stair #1, an electrical box housing the key switch was missing its cover, exposing the inner wiring. Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the exposed wiring. ~Refer to the 2011 edition of NFPA 70-314.28.

Plan of Correction - To be completed: 03/06/2026

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

Switch cover replaced for electrical box on 6th floor.

Maintenance staff was educated on the importance of protecting electrical wiring.

Maintenance director or designee will conduct monthly audits x3 months of 6th floor to ensure electrical wiring is protected.

Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0914 Based on document review and interview, it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations, affecting three of six levels. Findings include: 1. Document review on January 21, 2026, at 9:30 am, revealed the facility was unable to provide documentation showing corrective action of the 5- deficient receptacles identified during the January 2026 annual receptacle testing report. Exit interview with the Administrator and Regional Maintenance Manager, on January 21, 2026, at 12:45 p.m., confirmed the documentation was unavailable at time of survey.

Plan of Correction - To be completed: 03/06/2026

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

Deficient receptacles identified were repaired by Maintenance staff.

Maintenance staff was educated on the importance of maintaining protection of electrical wiring, and receptacles free of damage.

Maintenance director/designee will conduct monthly audits x 3 months to ensure all facility receptacles are free of damage.

Audits will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.

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