Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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

A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health on October 7, 2021, at Willow Terrace, found the facility was in compliance with 42 CFR 483.73 related to E-0024(b)(6).

 Plan of Correction:

Initial comments:

Based on the findings of a COVID-19 Focused Infection Control Survey and an Abbreviated survey in response to three complaints completed on October 7, 2021, at Willow Terrace was found to be not in compliance with 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensing Regulations as they relate to the Health portion of the survey process. The facility has implemented the CMS and Center for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

 Plan of Correction:

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(a) Skilled Nursing Facilities
A facility-

483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with 483.70(g) of this part, routine and emergency dental services to meet the needs of each resident;

483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

Based on observation, review of clinical records and interviews with resident and staff, it was determined that the facility failed to ensure that one resident received dental services in a timely manner (Resident R3).

Findings include:

Review of Resident R3's clinical record revealed that the resident was admitted on July 31, 2019, with diagnoses of: Alzheimer's Disease (progressive brain disorder causing memory loss, confusion and impaired reasoning) and dementia (loss of cognitive functioning).

Interview with Resident R3 on October 7, 2021, at 11:30 a.m. it was observed the resident was edentulous (toothless). The inventory sheet of the resident's personal effects brought with the resident during his admission, signed by the facility dated, July 31, 2019 stated that the resident's, "Upper dentures" were included.

Interview with Employee E10, Unit Manager? Register Nurse, on October 7, 2021, at 12:00 p.m. stated, "I don't' think I ever remembered him having dentures since I have been here."

Interview with the Director of Nursing on October 7, 2021 at 3:00 p.m. stated, "I never saw him with dentures."

28 Pa Code: 211.15(a) Dental services.

 Plan of Correction - To be completed: 11/11/2021

This provided 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

A dental consult was obtained for R3 on 10/6/2021 the resident has a scheduled appointment with the dentist on 11/9/2021

An Audit was done by the DON/designee to ensure that residents received dental services in a timely manner

Licensed staff, Social Service, and Medical records were in serviced by the don/designee on the dental service policy.

The DON/designee will do random audits of resident records weekly x 4 weeks to ensure residents received dental services in a timely manner. Results of these audits will be submitted to the quality assurance committee who will determine the need for further audits.

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