Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOW TERRACE
PHILADELPHIA, PA · 174 certified beds · Last Life Safety survey January 31, 2025
CMS Certification Number 396129 · first certified August 2010
Ownership
Operated by JONATHAN BLEIER · For profit - Corporation
- Ownership changed May 13, 2018 (change of ownership)from RC OPERATOR, LLC
Position within PA
14 citations — more than 66% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys on file averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to February 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in PA are typically surveyed 11–12 months after the last one (median 11), measured over 1,101 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0908 Keep all essential equipment working safely.
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 2, 2023 | 6 |
| April 1, 2024 | 4 |
| January 31, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2025-01-31 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 2 | 2025-01-31 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-04-01 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-06-02 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-06-02 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-06-02 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2023-06-02 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 1 | 2023-06-02 |
What the citations cover
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 3
- Egress Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 3 |
| Egress Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 31, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 3, 2025) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (March 3, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (March 3, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 3, 2025) |
April 1, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (May 10, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 10, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 10, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (May 10, 2024) |
June 2, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (July 26, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 26, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 26, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 26, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 26, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 26, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.