Willow Tree Healthcare Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents were free from abuse and neglect, as evidenced by the facility staff failing to accommodate the resident's request for a snack. Resident Identifiers: Resident #31. Facility Census: 98. Findings Includea) Resident #31Record review revealed that Resident #31 was diagnosed with the following:Type II Diabetes Mellitus with HyperglycemiaHemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. Acquired absence of left leg above the kneeAcquired absence of right leg above the kneeChronic Obstructive Pulmonary Disease Dysphagia following Cerebral InfarctionGastrointestinal Hemorrhage UnspecifiedMuscle Weakness (Generalized)Unspecified Lack of Coordination Resident #31 has capacity and has a Brief Interview for Mental Status (BIMS) score of 15. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that alleged violations involving abuse, neglect, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made. Resident Identifier: #31. Facility Census: 98. Findings Include Ra) Resident #31Record review revealed that Resident #31 was diagnosed with Type II Diabetes Mellitus with Hyperglycemia. The resident had been prescribed Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 38 units subcutaneously at bedtime for diabetes. During an interview with Resident #31 on 10/28/25 at approximately 9:28 AM, resident stated that on the night of 10/16/25, he was not feeling well and had asked Nursing Aide (NA) #36 for something to eat because he was not feeling well. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents received person-centered care and treatment in accordance with professional standards of practice. Resident Identifiers: Resident #12 and #31. Facility census:98Findings Include The resident had repeated episodes of nausea and vomiting over a period of over ten (10) days, and the facility failed to refer the resident to the hospital for evaluation. The resident was finally transferred to the hospital due to a family member's insistence. At the hospital, he was treated for acute metabolic encephalopathy. Acute kidney injury, aspiration pneumonia, and a UTI.a) Resident #12Resident #12 lacks capacity and has a Brief Interview of Mental Status (BIMS) score of 1. An attempt was made to contact the residents' Power of Attorney (POA), but the call went unanswered. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment relating to maintenance services necessary to maintain a comfortable interior for resident room numbers 112, 119, 121, 123, 124, and 126, pest control for room #'s 118, 121,123,124, and 126 and Low to no water pressure in rooms [ROOM NUMBERS]. These failed practices were random opportunities for discovery. Census 98.

Inspectors wroteBased on observation and staff interview the facility failed to store and serve food in accordance with professional standards for safe food service. This practice had the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 98. During a Dining Room Observation on 07/21/2025 at 12:45 PM, Nurse Aide(NA), #70 was observed touching multiple surfaces while setting up Resident #77's tray and then feeding him without washing hands or using hand sanitizer. In an interview with NA #70 on 07/21/25 at 12:55 PM, she acknowledged she did not wash or sanitize her hands after touching multiple surfaces before setting up Resident #70's tray and then feeding him. An observation on 07/24/25 at 11:30 AM, found: the walk-in freezer with sausage patties , pancakes, and Salisbury steak patties open to air. 3 ice cream cups on the floor. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to, resident hand washing, medical equipment, and meal tray place This practice had the potential to affect all residents that reside in the facility. Facility census: 98.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident's room. This failed practice was a random opportunity for discovery. Resident Identifiers #23, and #50. Facility Census: 98.

Inspectors wroteBased on interview and record review, the facility failed to honor and facilitate the resident's choice and right to self-determination regarding the resident's preference for showers. Resident Identifier #80. Facility Census: 98.a) Resident #80During an interview on 07/22/25 at 12:09 PM, Resident #80 reported that she was scheduled for showers on Tuesdays and Fridays. She expressed a desire to have more frequent showers but noted that the staff were unable to accommodate her request. Additionally, she indicated that once she is seated on the shower chair, she can shower herself; the only assistance she required was with scrubbing her back. [...]

Inspectors wroteBased on resident and staff interviews, the facility failed to ensure an allegation of suspected staff to resident verbal abuse was reported to the appropriate State Agencies, within a 2-hour time frame. This failed practice was a random opportunity for discovery. Resident identifier: #47 Facility Census: 98. Findings Include: a) Resident #47 Interview with Resident #47, on 07/22/25 at 9:35AM, she reported Licensed Practical Nurse (LPN) #35 had called her a liar two (2) nights previous when she reported she had not had a bowel movement in five (5) days and asked for a laxative. Facility Policy and Standard Procedures Policy #NS1018-03:Mental Abuse is the use of verbal or nonverbal conduct which causes or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation and may be considered a type of mental abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents with assistance during showers. Resident Identifiers #80 and #19. Facility Census: 98.a) Resident #80 Findings Include: During an interview on 07/22/25 at 12:09 PM, Resident #80 reported that she is scheduled for showers on Tuesdays and Fridays. She expressed a desire to have more frequent showers but noted that the staff were unable to accommodate her request. Additionally, she indicated that once she is seated on the shower chair, she can shower herself; the only assistance she requires is with scrubbing her back. A perusal of records on 07/23/25 at approximately 10:54 AM revealed the following: A resident #80's preferences dated 2/05/25 revealed that the resident's answer to the question; [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not implement proper monitoring and assessments for a resident who had close contact with another resident diagnosed with Varicella. Additionally, the facility failed to recognize and assess the potential risks to other residents due to unrestricted access to all areas of the facility by this resident. This was a random opportunity for discovery. Resident Identifier: #63 and #38. Facility Census: 98.

Inspectors wroteBased on record review, observation, and staff interview the facility failed to ensure theresident environment over which it had control was as free from accident hazards aspossible. This failed practice was a random opportunity for discovery, Resident Identifier #69Facility Census 98 Findings Include:a) Resident #69During the facility entrance interview on 07/22/25 at 1:45 PM an observation revealed a medicine cup of ointment creme was left on the bedside table. Resident #69 stated it was ointment the nurse aides left there for her to use on her bed sores. In an interview with LPN # 6 on 07/22/25, at 1:48 PM, she stated she did not know what the medicine cup of ointment was and stated it should not have been left in the resident's room.

Inspectors wroteBased on interview and record review, the facility failed to follow recognized standards of care, and in addition, failed to follow the facility's own policy and procedures with regards to monitoring residents after a fall. This citation is cited at past non compliance. Resident identifier: #111. Facility Census 107.

Inspectors wroteBased on discharge electronic medical review (EMR) and staff interviews, the facility failed to complete a safe and complete discharge. Resident #103 was discharged to a homeless shelter which did not have an available space and could not meet the medical needs of the resident. This failed practice had the potential to affect a limited number of residents. Resident #103. Facility census: 99.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed. A Nursing Assistant (NA) was observed to not be wearing the proper personal protective equipment (PPE) when providing direct resident care to a resident in EBP due to a wound. This was a random opportunity for discovery. Resident identifier: #28. Facility census: 99.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure residents were not neglected. The facility failed to follow physician's orders in transferring resident. This caused actual harm to the resident by causing bruises to his right elbow, right hand, right wrist, and right forearm. This was true for one (1) of one (1) resident reviewed for neglect. Resident identifier: #1. Facility census: 103.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure injuries of unknown origin were reported in a timely fashion. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 103.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the comprehensive care plan when the resident's capacity to make medical decisions changed. This was a random opportunity for discovery. Resident identifier: #58. Facility census: 103.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an alleged violation involving resident neglect was reported within 24 hours of the event / allegation being brought to the facility's attention, to appropriate state agencies as required. Resident identifier: #7. Facility census: 103.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a thorough investigation of a family member's allegation of resident neglect, maintain documentation that the alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. Resident Identifier: #7. Facility Census: 103.

Inspectors wroteBased on record review and resident interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident receiving dialysis services. This was true for two (2) of two (2) dialysis residents reviewed for dialysis services. Resident identifiers: #92 and #21. Facility Census: 103.

Inspectors wroteBased on record review and resident interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice pertaining to dialysis orders, care plans and pre and post dialysis communication assessments. This was true for two (2) of two (2) residents reviewed for dialysis services. Resident Identifiers: #92 and #21. Facility Census:

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The medication cart was unlocked and unattended. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 103.

Inspectors wroteBased on record review and resident interview the facility failed to ensure that residents who required dialysis received services consistent with professional standards of practice. This was true for two (2) of two (2) dialysis residents reviewed for dialysis services. Resident identifiers: #92 and #21. Facility census: 103.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders for weekly weights for one (1) of three (3) residents reviewed for nutrition. The facility failed to ensure pain medications were administered in a timely manner for three (3) of three (3) residents reviewed for receiving pain medications. The facility failed to complete neurological checks after unwitnessed falls for two (2) of two (2) residents reviewed for falls. Resident identifiers: #64, #73, #8, #58, #76, and #98. Facility census: 98.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure accurate and complete medical records for two (2) of two (2) residents receiving nutritional supplements. The amount of nutritional supplement consumed by the residents was not recorded. Resident identifiers: #64 and #98. Facility census: 98.

Inspectors wroteBased on observations, staff interview and policy review the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Infection control issues were observed on two (2) of two (2) medication carts. Observation on one medication cart revealed a glucometer that had not been cleaned and was stored in a medication cart with other medications. Observations on the second medication cart revealed an insulin pen and inhaler laid directly on a resident ' s over bed table and then was also stored in a medication cart with other resident ' s medications. Resident identifiers: #53, #82. Facility census: #98.

Inspectors wroteBased on record review and staff interview, the facility failed to provide pneumococcal vaccinations in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of pneumococcal vaccinations. Resident identifier: #15. Facility census: 98.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan to remove the enhanced barrier precaution isolation focus. This was true for five (5) of thirty four (34) residents reviewed for care plans. Resident Identifiers: #199, #36, #88, #82, #63. Facility census: 98.

Inspectors wroteBased on observation, policy review, record review and staff and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was true for three (3) of three (3) Residents reviewed for the Activity Care Area during the Long Term Care Survey Process. Resident Identifier: Resident #37, Resident # 45 and Resident #53. Facility Census: 98. Findings Included: A review of a facility policy titled Activities Program with no date revealed the following. .Procedure: a. Designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident's needs. .iii. Activities away from the facility . .x. Community activities . .f. reflect the schedules, choices and rights of the resident i. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician orders regarding administering medication based on a pain scale for Resident #21, recording urinary catheter output for Resident #31, and administering medication on time for Resident #199. These were random opportunities for discovery. Resident identifiers: #21, #31, and #199. Facility census: 98.

Inspectors wroteBased on observation, record review, policy review and staff interview the facility failed to ensure a resident who smoked had a current smoking assessment. In addition, the medication cart was found unlocked and unattended and hazardous chemicals were stored next to silverware, plates and cups. This was a random opportunity of discovery. Resident identifier: #82. Facility census: 98.

Inspectors wroteBased on record review and staff interview, the facility failed to have competent staff to administer intravenous (IV) antibiotics. This was true for one (1) of one (1) residents reviewed for IV administration of antibiotics. Resident identifier: #199 Facility census:

Inspectors wroteBased on facility record review and staff interview, the facility failed to complete annual performance reviews for three (3) of four (4) nurse aides reviewed. This practice has the potential to affect more than a limited number of residents. Employee identifiers: #131, #91, and #122. Facility census: 98.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to provide each resident food that was palatable. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 98.

Inspectors wroteBased on observation and staff interview, the facility failed to store flat ware and glasses in accordance with professional standards for food service safety related to storage. This has the potential to affect all Residents that get their nutrition from the kitchen. Facility census: 98.

Inspectors wroteBased on observation, medical record review, staff interview and resident interview, the facility failed to ensure a complete and accurate medical record. This was true for six (6) of 34 sample residents reviewed for the Long Term Care Survey Process. Resident identifiers: Resident # 37, #74, #29, #93, #11 and #2. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to ensure call lights were accessible to residents in their rooms and bathrooms.

Inspectors wroteBased on observations and staff interviews, the facility failed to assure handrail were firmly secured and affixed to the corridor walls. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing on Unit three (3). Facility census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop comprehensive care plans that addressed residents' current medical and nursing needs. Resident (R) #149's care plan includes interventions for Enhance Barrier Precautions (EBP), which the facility is currently not practicing. R# 45's care plan fails to identify the resident's need for assistance with showers. This is true for two (2) of 34 residents reviewed during the survey process. Resident identifiers: #149 and #45. Facility census: 98.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services in the areas of personal hygiene. This was true for two (2) of three (3) residents reviewed under the care area of activities of daily living during the long-term care survey process. Resident identifier: #59 and #45 Facility census: 98.

Inspectors wroteBased on resident interview, staff interview, and medical record review, the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regards to monitoring pain levels. This is true for two (2) of two (2) Residents reviewed for pain during the Long-Term Survey Process. Resident identifier: #89 and #62. Facility census: 98.

Inspectors wroteBased on observation, resident interview, staff interview and vendor interview, the facility failed to provide Residents with a safe, clean homelike environment. The facility failed to keep rodent feces out of multiple personal resident belongings, contained rooms with multiple rodent traps and failed to keep room walls in a homelike condition. These were random opportunities for discoveries. The practice had the potential to affect an unlimited number of residents. Resident identifiers: #52, #64, #60, #37, #45 and #6. Facility census: 93.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure a safe environment for residents who smoke. There was no visible fire extinguisher and an open Smoker Tower with smoldering cigarette butts. This was a random opportunity for discovery. Residents identifiers: #8, #85, #39, #2, #22, #24. Facility census: 93.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to label and date foods, store clean dishes properly, ensure the stove and drip pan were clean and the ice machine contained a black and pink substance on the inside lip. This failed practice had the potential to affect all residents who receive nutrients from the kitchen and pantries. Facility Census 93.

Inspectors wroteBased on observation, medical record review, facility documentation review and staff interview, the facility failed to post signage on a door of a room on transmission based precautions (TBP). Staff failed to properly don personal protective equipment (PPE) upon entering rooms on TBP and did not utilize hand sanitize between medication passes. The infection control policies were not current. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #286, #192 and #188. Facility census: 93.

Inspectors wroteBased on observation, resident interview, staff interview and vendor interview, the facility failed to ensure an environment for residents that was free of rodents. These were random opportunities for discoveries. The practice had the potential to affect more than a limited number of residents. Resident identifiers: #52, #64, #60, #73, #45 and #53. Facility census: 93.

Inspectors wroteBased on record review, resident representative interview, and staff interview, the facility failed to honor a resident's preference for no meat other than chicken. This was a random opportunity for discovery. Resident identifier: #6. Facility Census: 93.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) of 22 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: Resident #6 and Resident #65. Facility census: 93.

Inspectors wroteBased on record review and staff interview the facility failed to report in a timely manner and not to appropriate agencies. This was a random opportunity for discovery. Resident identifier- #47.

Inspectors wrotetreatment and care in accordance with professional standards of practice. The facility failed to ensure a dietary order was followed for Resident #6. This failed practice was true for one (1) of 22 residents reviewed in the long-term care survey process . Resident Identifier: #6. Facility Census: 93. a) Physician Order A brief record review, completed on 02/28/22 at 3:10 PM, found the following dietary order, Regular diet, Dysphagia Ground texture, Thin consistency, 1:1 assist, NO BREAD / BEEF / PORK / ICE CREAM / CHOCOLATE, double portion veggies, thin liquid in 5cc sips via syringe if unable to contain cup sips (no straws unless used as pipette only). Additionally, there was an order directing ENCOURAGE PT. TO DRINK EXTRA 100ML OF H20 EVERY MED PASS. DO NOT USE STYROFOAM CUP, USE HARD CUP. (DUE TO PT. CHEWING). [...]

Inspectors wroteBased on facility documentation, record review and staff interview, the facility failed to provide assessments of the resident's condition and monitoring for complications before dialysis treatments. This was true for one (1) of two (2) residents reviewed for dialysis. Resident identifier: #189. Facility census: 93.

Inspectors wroteBased on record review, staff interview, and policy review, the pharmacist failed to identify irregularities for medication in excessive does related to acetaminophen. This was true for one (1) of six (6) reviewed for unnecessary medications. Resident identifier #73. Facility census: 93.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure resident #73 was free from unnecessary medications. This was true for one (1) of six (6) reviewed for unnecessary medications. Resident identifier #73. Facility census: 93.