Pennsylvania Department of Health
 WILLOW TERRACE
Patient Care Inspection Results

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WILLOW TERRACE
Inspection Results For:

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WILLOW TERRACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on an Abbreviated survey in response to a complaint completed on April 30, 2026, it was determined that Willow Terrace was not in compliance under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.
 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations: Based on review of clinical records, facility documents, and interviews with staff, it was determined the facility failed to ensure one of ten residents reviewed were free from verbal abuse. (Resident R1) Findings Include: Review of the facility policy titled "Abuse Policy-Prevention and Management" last revised September 2022 states verbal abuse is defined as, "Verbal Abuse- Oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: Harassing a resident, Mocking, insulting, ridiculing, yelling or hovering over a resident, with the intent to intimidate, threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends, and isolating a resident from social interaction or activities." Review of facility documentation revealed Resident R1 was admitted to the facility on April 11, 2024 with the following diagnosis: Type Two Diabetes (a chronic condition causing high blood sugar because the body doesn't produce enough or effectively use insulin, leading to insulin resistance), Chronic Kidney Disease Stage 3(involves moderate loss of kidney function, requiring management of complications like high blood pressure, anemia, and bone disease), Anemia (a medical condition defined by a deficiency in the number of healthy red blood cells or the hemoglobin concentration within them, reducing the blood's capacity to transport oxygen throughout the body), Generalized Anxiety a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday thingslike health), and Neuromuscular Dysfunction of Bladder (occurs when nerve damage from diseases or injuries disrupts signals between the brain and bladder, causing loss of bladder control). Review of Resident R1's physician orders revealed an order dated September 24, 2025 "Empty Foley drainage bag every shift and record output". Review of facility Incident/Accident Witness statement, dated March 21, 2026 states, "Resident reported that this he/she requested for his/her foley bag to be emptied because it was almost full. He/She stated nurse aide Employee E3 always comes into his/her room fussing. Nurse Aide Employee E3 refused to empty the bag. Nurse aide Employee E3 stated it was not "full enough". I told nurse aide Employee E3 "I still needed it emptied because I can get an infection. Employee E3 persisted in saying it was not full enough and it began to become uncomfortable because he/ she was yelling so I asked him/her "What are you a witch". Employee E3 then said "your mother". I told him/her if he/she did not want to do it I will get someone else to do it. I began to yell for a nurse loudly and several nurses came to my room." Review of facility Incident Investigation questionnaire signed March 23, 2026 stated, "Did anything happen recently that was upsetting to you? YES- see attached". An attached typed statement from Resident R1 states, "I asked the nurse aide Employee E3 to empty my foley bag because is was ninety-five percent full. The aide pressed the issue that it was not ready to be dumped yet. I told him/her that this is how I get an infection before behind the bag not being emptied. The aide kept pressing the issue about the bag not being full. He/She was combative towards me. He/She called me a liar and I asked him/her was he/she a witch and nurse aide Employee E3 said "no your mother is" I hollered down the hall for the nurse and two nurses came in, and stating he/she cannot be talking to me like that. The nurse aide Employee E1 went to dump my bag and was going to dump it in a basin. The nurse stated that it needs to be dumped in a urinal she cannot dump it in a basin and to put it back. I feel that this was an abuse situation". Review of facility Incident/Accident Witness statement dated March 21, 2026 taken from licensed nurse Employee E4 states, "Resident R1 heard screaming out for a nurse. I immediately went to see what was going on. When approaching the room I heard the resident screaming to "get out of my room". Upon entering room, nurse aide Employee E3 observed arguing with Resident R1. I asked the nurse aide Employee E3 to please leave but he/she continued to argue with the resident. I asked Resident R1 to try to calm down and tell me what happened. Resident R1 told me that he/she called my mother a witch. After saying that, nurse aide Employee E3 went close to Resident R1's face pointing his/her finger and screaming "you're a liar". Resident was shaking and became increasingly agitated. Nurse aide Employee E3 was asked to stop yelling but he/she continued to scream. Nurse aide Employee E1 then used resident basin to empty his/her foley out. When there was two urinals in his/her bathroom. Nurse aide employee E3 was asked to leave the room and he/she finally left." A phone interview was held with license nurse Employee E4 on April 30, 2026 at 12:14 p.m. Licensed Nurse Employee E4 stated that he/she was the oncoming nurse for the shift so him/her and licensed nurse Employee E5 were at the nurses station counting medications when they heard a call out loud for a nurse from down the hall. Employee E4 stated he/she and Employee E5 went down the hall immediately and upon entering heard and witnessed nurse aide Employee E3 yelling at Resident R1. Employee E4 stated that he/she asked Employee E5 to leave the room but he/she would not. Employee E4 stated he/she attempted to calm down Resident R1 because he/she was visibly upset but nurse aide Employee E3 would not stop yelling, "you're a liar, you're a liar!" and got up in Resident R1's face, pointing his/her finger in Resident R1's face. Employee E4 stated that Employee E3 continued to the bathroom and emptied out the residents foley improperly before being asked to leave again and finally leaving." Review of facility Incident/Accident Witness statement, undated from licensed nurse Employee E5 states, "I heard a loud yelling at the end of the hallway, walked down to figure out what happened. Resident R1 and nurse aide Employee E3 was arguing. I couldn't understand how it started but I was able to break it up and came down resident R1." Review of facility Incident/Accident Witness statement, dated March 26, 2026 from nurse aide Employee E5 states, "I nurse aide Employee E1 was assigned to the sixth floor. Resident R1 was one of my clients. I responded to a call bell for Resident R1 around 1:00 a.m. Resident R1 stated he/she needed pain medication and the nurse was informed about same. Another call was made by another client, on my way to this client, Resident R1 call bell rang for the second time. I stopped at the other client's room to answer their call I left without being able to change him/her as he/she requested. I told him/her I would find out what another client was calling about and I would be "right back" to meet his/her needs. On my arrival to Resident R1's room, he/she stated that his/her urine bag was full and was going to burst any minute now and he/she will get kidney infection and he was going to file law-suit. The urine bag wasn't full as he had stated, so I informed him/her about my findings. That it wasn't full and was not about to burst as he had stated. He started to shout at me that I should empty the bag. I got very nervous, my body felt numb. I told him/her that I needed to get a pair of gloves to empty the bag. I got a pair of gloves and put on same. The bag was held up to my eye level (1,300 milliters) was noted in bag. I tried to show Resident R1 the bag which I had in both of my hands and also tried to tell him/her that the bag had a maximum capacity of 2,000 milliliters. I wasn't given the change to talk to Resident R1. Each time I tried to speak, he/she got louder and louder as if he was preventing me from voicing my findings. I tried to calm him and told him I just wanted him/her to see that I was telling the truth and the bag wasn't full and about to burst. While I was about to empty the urine bag he told me I was a witch and I should leave his room. The fact that he/she lied about the urine bag, shouted at me, and called me a witch and stated that he was going to file a lawsuit pertaining a full bag of urine. I saw all of his actions towards me as his caregiver as very humiliating, it also caused me a painful loss of pride, dignity, as well as deep embarrassment and shame. My humanly defense mechanism chipped in and my response to him calling me a witch was the same like your mother. He shouted loudly for the nurse. " Interview held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 on April 30, 2026 at 1:20 p.m. Noth Employee E1 and Employee E2 confirmed the above findings. The Director of Nursing Employee E2 stated that on March 21, 2026 when the incident occurred, nurse aide Employee E3 was immediately suspended and called over the phone. Employee E3 gave a statement over the phone and was asked to come in and write a statement in person. Employee E2 stated that nurse aide Employee E3 came in and gave her written statement on March 26, 2026. Employee E2 stated that at that time the investigation was completed and substantiated for verbal abuse and Employee E3 was terminated. 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 PA. Code 211.12(c) Nursing services
 Plan of Correction - To be completed: 06/05/2026

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.

Following the verbal abuse that occurred on 3/21/26, R1 was seen by his physician on 3/23/26 and was also seen by the facility psychiatrist on 3/27/26 to ensure resident psychosocial well -being was assessed and addressed. The facility is unable to retroactively correct this deficiency.

The DON/designee interviewed residents on the unit to ensure no other residents experienced any type of abuse.

Staff were re-educated on the abuse policy by the facility educator, which includes identifying abuse, reporting abuse, and suspending the perpetrator.

The DON/designee conducted random observation audits for abuse to ensure staff are treating residents with dignity and respect.

Random Audits will continue to be conducted at various times on random units weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

§ 201.19(8) LICENSURE Personnel policies and procedures.:State only Deficiency.
(8) A copy of the final report received from the Pennsylvania State Police and the Federal Bureau of Investigation, as applicable, in accordance with the Older Adults Protective Services Act (35 P. S. §§ 10225.101-10225.5102), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable regulations.

Observations: Based on a review of facility employee files and interviews with staff it was determined that the facility failed to conduct background checks on new employees as required for two of two employee files reviewed (Employee E6 and Employee E7). Findings Include: Review of the facility policy titled "Abuse Policy-Prevention and Management" last revised September 2022 states, "Procedure/Process: Screening- All potential employees will be screened for a history of abuse, neglect, or mistreating residents/ patients during the hiring process. Screening will consist of, but not limited to: Inquiries into State licensing authorities and or State nurse aide registry, Reference checks from previous and/or current employers, Criminal background checks." Interview held with the Director of Human Resources Employee E8 on April 30, 2026 at 1:56 p.m. Employee E8 stated that he was unaware of any criminal background checks not being completed timely. When asked about Employee E6 and E7's criminal background checks, Employee E8 asked what their date of hire was. Employee E6 and Employee E7 were both hired on March 2, 2026. The Director of Human Resources E8 stated that at that time he was out on workers compensation after being assaulted at work from January 19, 2026 through March 26, 2026. At that time the Nursing Home Administrator Employee E1 was asked who was responsible for screening employees before hire he/she stated , "it would have been myself and one other person Employee E9 who works at a sister facility". The Nursing Home Administrator Employee E1 confirmed at 1:59 p.m. that Employee E6 and Employee E7 did not have a Pennsylvania criminal background check completed prior to employment. Employee E6 was a floor tech hired on March 2, 2026. The facility completed a Pennsylvania criminal background check on April 30, 2026 after the request was made for the employee file. The result of the Pennsylvania criminal background check read, "request under review for control". Interview held with the Director of Human Resources Employee E8 at 2:02 p.m. and was asked what "request under review for control" meant. Employee E8 stated that the "the background check isn't complete and needs to be further looked into". Review of Employee E6's employe daily timecard revealed the employee worked as a floor tech on the following dates: March 2, 3, 4, 5, 9, 18, 24, 25. April 9, 10, 16, 21, 22, 23, 25, 26, 28, 29. Employee E7 is a dietary aide who was hired March 2, 2026. The facility completed a criminal background check on April 30, 2026 after the request was made for the employee file. The findings above were confirmed with the Nursing Home Administrator at 2:05 p.m. 28 Pa. Code 210.18(b)(3) Management
 Plan of Correction - To be completed: 06/05/2026

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.

Background checks were completed for E6 and E7.

NHA re-educated by Regional Nurse Consultant on abuse policy, importance of screening all potential employees and that background checks are to be completed for all new hires.

NHA/Designee completed audit of all new hires from January 19 2026 to present day to ensure background checks completed.

NHA/Designee will be responsible for conducting audits of all new hires to ensure background checks are completed.

All new hires will be conducted monthly x 2 months, then random audits times two months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

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