Willow Terrace: Nurse Aide Fired for Verbal Abuse - PA
That exchange, which took place on March 21, 2026, is the center of a complaint inspection completed by federal surveyors on April 30, 2026. The inspection substantiated verbal abuse. The aide was fired. And yet the inspection record still exists, because what happened in that room happened, and a complaint had been filed, and someone had to come and look.
The inspection narrative is brief. It describes a resident who, at some point during an interaction with nurse aide Employee E3, said something that the aide later characterized as a defense mechanism, her own words, offered in explanation of what came next. What came next was the aide calling the resident a witch. The resident shouted loudly for the nurse.
The narrative does not name the resident. It does not describe the resident's condition, age, or how long they had lived at Willow Terrace. It notes the level of harm as minimal harm or potential for actual harm, and it notes that few residents were affected. Those are regulatory categories. They do not describe what it is like to be elderly, dependent on the people around you for your daily care, and called a witch by one of them.
The facility's own account of what followed is, on its surface, a story of swift action. The Director of Nursing, identified in the report as Employee E2, told inspectors that on the day of the incident, March 21, Employee E3 was immediately suspended. The aide was reached by phone. She gave a statement over the phone that same day. She was then asked to come in and provide a written statement in person.
Employee E3 came in on March 26, five days after the incident, and gave her written statement. The Director of Nursing told inspectors that at that point, the investigation was completed, the abuse was substantiated, and Employee E3 was terminated.
The Nursing Home Administrator, Employee E1, confirmed the same account when inspectors interviewed both of them together on April 30 at 1:20 in the afternoon.
So the facility moved. It suspended the aide the day it happened. It collected a phone statement. It waited five days for a written statement. It fired her. By the time inspectors arrived more than a month later, Employee E3 was already gone.
None of that changes what the inspection found, which is that verbal abuse occurred, that a resident was called a witch by someone employed to care for her, and that the incident rose to the level of a formal complaint that required a federal inspection to resolve.
The word witch is not incidental. In a nursing home, where residents depend on staff for help bathing, dressing, eating, and moving through their days, the power between a nurse aide and a resident is not balanced. A resident who is called a witch by the person helping her is not in a position to simply leave, or to avoid that person tomorrow, or to find someone else. She can shout for the nurse. That is what this resident did.
The aide's explanation, preserved in the inspection narrative, is that her response was a defense mechanism, that she was reacting to something the resident said or did. The report does not detail what the resident said or did before the aide called her a witch. It records the aide's characterization of her own reaction, and it records the outcome: verbal abuse, substantiated.
Inspectors cited three sections of Pennsylvania code. The first, 28 Pa. Code 201.18, covers management and the responsibilities of the facility's administration. The second, 28 Pa. Code 211.10, covers resident care policies. The third, 28 Pa. Code 211.12, covers nursing services. Together they reflect a finding that the incident was not simply an isolated lapse by one employee but a matter that touched the facility's oversight, its written policies, and the conduct of its nursing staff.
Whether those citations resulted in fines, a plan of correction, or additional monitoring is not recorded in the inspection narrative provided. What is recorded is that inspectors came, that the administrator and the director of nursing sat down with them at 1:20 on a Thursday afternoon and confirmed everything, and that the report was written and filed.
Employee E3 is gone. The investigation is closed. The facility's leadership confirmed the findings without dispute.
What the inspection record cannot resolve is the time between March 21 and March 26, the five days between when the aide was suspended by phone and when she came in to give her written statement in person. The report does not describe what happened at Willow Terrace during those five days, who covered the aide's shifts, or whether residents were told anything. It records the dates and moves on.
It also cannot resolve what came before. A complaint inspection is triggered by a complaint. Someone filed one. The report does not say who, or when, or what they described when they made the call. It says only that inspectors came on April 30, more than five weeks after the incident, and found enough to substantiate the violation.
The resident who shouted for the nurse that day in March is identified in the report only as a resident. She is counted among the few residents affected. She is not quoted. Her account of what happened, if she gave one, does not appear in the narrative. What appears is the aide's framing, the facility's timeline, and the inspectors' conclusion.
She called for the nurse. Whether the nurse came quickly, whether anyone sat with her afterward, whether she was asked what she needed, none of that is in the report.
What is in the report is that she was in her home, which is what a nursing home is for the people who live there, and someone who worked there called her a witch, and she had to shout to get help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Terrace from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
WILLOW TERRACE in PHILADELPHIA, PA was cited for abuse-related violations during a health inspection on April 30, 2026.
That exchange, which took place on March 21, 2026, is the center of a complaint inspection completed by federal surveyors on April 30, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.