Willow Tree Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for two (#33 and #20) of three residents reviewed for abuse out of 37 sample residents. Resident #42 was admitted to the facility on [DATE] with diagnoses of a traumatic brain injury (TBI), altered mental status, other specified disorders of the brain, unspecified dementia of unspecified severity with other behavioral disturbance, alcohol-induced persisting dementia and delirium due to known physiological condition. On 11/15/25 the facility initiated an aggression care plan for Resident #42 which identified that the resident was physically and/or verbally aggressive with staff and residents at times due to poor impulse control, dementia and history of TBI. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#5) of two residents received treatment and care in accordance with professional standards or practice out of 37 sample residents. Resident #5 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (total paralysis on one side of the body) and hemiparesis (weakness affecting one side of the body) affecting the left side. On 2/2/26 Resident #5 was being transferred by licensed practical nurse (LPN) #1 and certified nurse aide (CNA) #3 using the sit-to-stand lift. The resident let go of the handle of the lift, resulting in her left arm getting hung up in the lift sling in an awkward position. Resident #5 was lowered back to her bed and was found to have no bruising at the time to her left arm. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen, main dining room and secured memory unit. Specifically, the facility failed to ensure staff followed accepted hand hygiene practices during the meal service.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of certified nurse aides at least once every 12 months and to provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNAs). Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #3, CNA #6 and CNA #7.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at an appetizing temperature. Specifically, the facility failed to ensure residents were served warm food that was appetizing.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene when assisting residents with eating; and,-Ensure residents were offered the opportunity for hand hygiene prior to eating.

Inspectors wroteBased on interviews and record review, the facility failed to inform the resident's representative when a change in condition occurred for one (#5) of two residents reviewed out of 37 sample residents. Specifically, the facility failed to notify Resident #5's representative when the resident experienced a significant change in physical condition after bruising appeared to her left temple, as well as bruising and new pain to her left arm and shoulder following an incident that occurred during a sit-to-stand lift transfer.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received notification of changes in eligibility for Medicare or Medicaid covered services, what the resident's financial responsibility may be, and their appeal rights for three (#59, #60 and #61) of four residents out of 37 sample residents. Specifically, the facility failed to ensure Resident #59, Resident #60 and Resident #61 were provided with notices of Medicare Non-Coverage when their skilled nursing benefits ended.

Inspectors wroteBased on record review and interviews, the facility failed to prevent misappropriation of property for three (#7, #22 and #57) of eight residents reviewed for personal property out of 37 sample residents. Specifically, the facility failed to prevent the loss of property for Resident #7, Resident #22, and Resident #57 from their rooms.

Inspectors wroteBased on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level I screening from the State Mental Health Agency in the case of residents without serious mental illness or a related condition for one (#7) of three residents reviewed for PASRR out of 37 sample residents. Specifically, the facility failed to follow the recommendation to re-evaluate Resident #7's PASRR level I screening if the resident's symptoms or behavior did not improve or resolve within 60 days of the screening.

Inspectors wroteBased on observations, record review and interviews, the facility failed to to ensure residents received treatment and care in accordance with professional standards of practice for one (#4) of three residents out of 37 sample residents. Specifically, the facility failed to follow the physician ordered parameters for the administration of Resident #4's pain medication.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#42) of six residents reviewed for accident hazards out of 37 sample residents. Specifically, the facility failed to prevent an elopement for Resident #42 on 1/15/26.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for two of four medication storage carts. Specifically, the facility failed to:-Date residents' insulin pens with the date they were opened; and,-Discard expired medications in a timely manner.

Inspectors wroteBased on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for two out of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to ensure CNA #3 and CNA #4 received 12 hours of continuing education annually.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure four (#3, #4, #7 and #8) of eight residents out of 10 sample residents were free from abuse. Specifically, the facility failed to:-Prevent physical abuse between Resident #3 and Resident #4;- Protect Resident #7 from physical abuse by Resident #9; and,- Protect Resident #8 from physical abuse by Resident #4.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one (#4) of seven residents out of 10 sample residents. Specifically, the facility failed to thoroughly investigate two allegations of physical abuse by Resident #4.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#4 and #6) of seven residents reviewed out of 10 sample residents. Specifically, the facility failed to:-Effectively implement person-centered approaches for dementia care to prevent resident-to-resident altercations for Resident #4; and, -Effectively implement person-centered approaches for dementia care to prevent verbal and physical aggressive behavior as well as wandering/elopement behavior for Resident #6.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents received treatment and care for optimal skin condition of a pressure wound, in accordance with professional standards. Specifically, the facility failed to: -Develop and implement a care plan for Resident #1's pressure ulcers; and, -Ensure interventions were implemented timely to prevent the development and worsening of a pressure injury for Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for six residents (#21, #22, #36, #42, #43 and #46) of six out of 32 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure residents and/or resident representatives understood the agreement before signing the arbitration agreement; -Accurately inform residents and/or resident representatives when the agreement could be rescinded before the agreement was signed; and, -Ensure staff reviewing the arbitration agreement with residents and the residents' representatives understood the components of the agreement.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure: -The residents in the dining room did not have prolonged wait times of 30 minutes or longer for their meal to be served; and, -Room trays were delivered to all neighborhoods and served to the residents at the regular posted meal times.

Inspectors wroteBased on interviews and record review, the facility failed to act promptly upon the grievances in the resident council meeting. Specifically, the facility failed to document and respond to the resident council's grievances over the past four months regarding nursing care and dietary concerns.

Inspectors wroteBased on record review and interviews, the facility failed to ensure freedom from resident-to-resident abuse involving four (#33, #201, #21 and #41) of five residents reviewed for abuse out of 33 sample residents. Specifically, the facility failed to: -Investigate and implement measures to prevent altercations between Resident #33 and Resident #201 on 2/20/23 and 6/7/23; -Prevent resident-to-resident abuse involving Resident #33 and Resident #201 on 8/6/23, 8/16/23 and 9/16/23; and, -Prevent resident-to-resident abuse involving Resident #21 and #41 on 1/18/24.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and met the nutritional needs of the residents. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and appearance.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for one (#11) of three residents reviewed for bathing preferences out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #11 was offered showers twice a week on the resident's scheduled and preferred days; -Ensure Resident #11 had opportunities to refuse showers at the time the shower was offered but still had a shower available to him on his preferred day and scheduled day or shortly after; and, -Ensure Resident #11 could choose between showers and the resident's preference to attend activities of choice without losing a shower opportunity.

Inspectors wroteBased on interviews, and record review the facility failed to complete a Level I preadmission screening and resident review (PASARR) for one (#19) of two residents reviewed for PASARR out of 33 sample residents. Specifically, the facility failed to ensure Level I preadmission screening was completed for Resident #19 who had a mental disorder present when admitted to the facility.

Inspectors wroteBased on interviews, and record review, the facility failed to provide person-centered dementia care and services for two (#21 and #41) of five residents reviewed for dementia care out of 33 sample residents. Specifically, the facility failed to: -Provide dementia care services for Residents #21 and #41 to provide their highest practicable quality of life and care; -Address behaviors, prevent resident-to-resident altercation; and, -Ensure appropriate and non-pharmacological approaches were provided by staff to engage residents with life in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs that accommodated resident allergies, intolerances and preferences. Specifically, the facility failed to: -Offer residents more options for alternative choices to the main meal; -Honor requests for items indicated on the alternative menu; and, -Offer the main dish sides with the alternative menu choice.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for one (#20) of three residents out of 33 sample residents. Specifically, the facility failed to ensure medical records were provided timely upon request to Resident #20's representative.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the services provided met professional standards of quality for two residents (#20 and #47) reviewed out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #20 was thoroughly assessed and monitored for injury and safety after the resident spilled a potential hot beverage on herself; and, -Ensure Resident #47 was consistently assessed when she was having a change of condition.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure staff were prepared for a potential threat of fire. The lack of preparation resulted in residents scared, anxious, removed from their beds at night, placed outside in parking lots with smoke filled air, and for some, without supplemental oxygen as needed during a facility wide evacuation on 9/23/22. The lack in preparation for a potential emergent threat, included the failure to have a complete and thorough emergency preparedness training program, specifically fire training, to identify when residents should be evacuated and when residents should be placed behind closed fire doors. According to interviews with management the staff panicked and overreacted. [...]

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#11 and #16) of two reviewed for catheter care out of three residents with catheters. The facility failed to ensure Resident #11's urinary catheter down drain bag was kept from dragging on the floor and the urinary catheter bag was kept below the bladder. There were no physician orders on how to clean the area around the suprapubic catheter site. Due to the facility's failures, Resident # 11 suprapubic urinary catheter line to drag on the floor and no order to cleanse the site, contributed to an infection as evidenced by the purulent (pus) drainage from the catheter exit site which caused pain to the resident. In addition, the facility failed to: [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#12, #28 and #34) of six out of 26 sample residents received the care and services necessary to meet their nutritional needs and to maintain their highest level of physical well being. Resident #12 was admitted on [DATE] with diagnoses of dementia and diabetes. The resident was placed in hospice care on 7/8/22. The resident was weighed on 5/3/22 and again on 5/4/22 at 2:33 p.m., at 100.7 pounds (lbs). Then the resident was not weighed again until 8/1/22 and she was 99.2 lbs, and the last recorded weight was on 9/2/22 at 9:58 a.m. at 92.5 lbs., a loss of 6.7 lbs, which was a 6.5% weight loss over one month considered significant. The resident did not receive a nutritional assessment either after admission or after she sustained a severe weight loss. [...]

Inspectors wroteBased on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, staff education, staff competencies, and facility based risk assessments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and implement an effective system to identify facility concerns or address need for quality improvement in their QAPI program.

Inspectors wroteBased on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all 36 residents, including four who were currently on antibiotic therapy currently residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of all pertinent State Agencies in the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to make information on how to file a grievance or complaint available, maintain records of grievances and complaints, or to make prompt efforts to resolve grievances the resident(s) may have had. Specifically the facility failed to ensure: -Resident group grievances were resolved; and, -Individual resident grievances were resolved

Inspectors wroteBased on record review and interviews, the facility failed to ensure the minimum data assessment (MDS) accurately reflected the residents' status for four (#5, #26, #33 and #34) of 12 out of 26 sample residents. Specifically, the facility failed to ensure the MDS for Resident #5, #26, #33 and #34 were completed accurately to include their dental status.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to provide an ongoing program to support residents in their chosen activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#9 and #12) of five out of 26 sample residents. Specifically, the facility failed to: -Offer and provide personalized activity programs for Resident #12 and Resident #9; and, -Offer evening and activity outings.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#3 and #5) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, out of 26 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #5 and Resident #3 did not have a potential decline in activities of daily living (ADL).

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice, for three residents (#7, #12 and #26) of eight residents reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #7 had oxygen in her portable tank for mobility and readily available in an event of an emergency; -Ensure Resident #7 was placed on correct order setting for oxygen via nasal cannula; -Ensure Resident #12 had a physician order for specific nasal cannula oxygen requirements and for titration of oxygen requirements; and, -Ensure Resident #26 had a physician order for oxygen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference F689 accident hazards, F692 nutrition, and F744 dementia care.

Inspectors wroteV. Resident #30 A. Resident status Resident #30, age [AGE], was admitted to the facility on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included repeated falls, Parkinson's disease, neurocognitive disorder with Lewy bodies, cognitive communication deficit, difficulty in walking, muscle weakness, and a need for assistance with personal care. According to the 8/27/22 minimum data set (MDS) assessment, a brief interview for mental status (BIMS) was not conducted. According to the staff assessment for mental status, the resident had severe impairment for making decisions regarding tasks of daily life. Resident #30 had a short and long term memory problem. The assessment identified the resident displayed inattention and disorganized thinking. [...]

Inspectors wroteII. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the September computerized physicians orders (CPO), the diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, depression, and generalized anxiety disorder. The 6/20/22 minimum data set (MDS) assessment revealed, the resident had cognitive impairment with a brief mental status score (BIMS) of four out of 15. He had inattention and disorganized thinking. He required supervision with dressing and was independent with all other activities of daily living (ADL). He had no behaviors and did not reject care. He wandered daily which placed him at risk of getting into a potentially dangerous place. He received anti anxiety medication daily. B. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and infection for one out of two units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned high-touch surfaces in resident rooms and follow manufacturer surface contact time during routine daily cleaning; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident rooms and bathrooms; and, -Implement appropriate hand hygiene with glove changes.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all staff had current abuse and dementia care training. Specifically, the facility failed to ensure five out of five licensed nurses and CNAs reviewed within the previous year received dementia management training and abuse prevention training.

Inspectors wroteBased on interviews and record review, the facility failed to ensure nurse aides received the required number of annual in-service training hours to ensure continued competence for four of four staff reviewed. Specifically, the facility failed to ensure certified nurse aides (CNA) #1, #5, #8 and #9 received 12 hours of continuing education annually.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to promote resident dignity and respect one resident (#16) out of 12 residents reviewed for dignity out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #16 treated and spoken to in a dignified manner; and, -Ensure Resident #16's bodily privacy was maintained and personal space respected.

Inspectors wroteBased on record review and interviews the facility failed to fully ensure residents had the right to formulate advance directives by not keeping advance directives updated and current for two (#12 and #27) out of 16 residents reviewed for advance directives out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #12 had the proper legal representation in the record and the medical orders for scope of treatment (MOST) form, the facility utilized for advance directives, was signed appropriately; and -Ensure Resident #27's physician order matched her wishes as signed on the MOST.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure two (#17 and #31) of three residents reviewed for abuse out of 26 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #17 and #31 were kept free from abuse by Resident #4. Cross-reference F744, dementia care.

Inspectors wroteBased on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner, based on medication regimen review (MRR) for two (#28 and #34) of six reviewed for unnecessary medications out of 26 sample residents. Specifically, the facility failed to ensure response to pharmacist recommendations for: -Resident #28, a discontinue order for diazepam (anti anxiety medication) and an order for serum creatinine laboratory (lab) level was not drawn as requested; and, -Resident #34, failed to ensure the drug regimen review was acted upon in a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#9) of five residents reviewed for immunizations out of 26 sample residents. Specifically, the facility failed to provide the pneumococcal 23-valent polysaccharide vaccine (PPSV23) to Resident #9.