Willow Tree Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Resident Rights Deficiencies

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

A survey for Incident #1914851, Incident #1914853, Incident #2569006 and Incident #2569011 was conducted 7/22/25 and 7/23/25. Three deficiencies were cited. Based 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.Findings include: I. Facility policy and procedureThe Dementia Clinical Protocol policy and procedure, revised November 2018, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, "For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-.. Based 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. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention policy, last revised April 2021, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. It read in pertinent part,“Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident' s symptoms.“The resident abuse, neglect and exploitation prevention program consists .. Based 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. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.“All allegations are thoroughly investigated. The administrator initiates investigations.Investigations may be assigned to an individual trained in reviewing, investigating and reporti..

A complaint survey, prompted by #CO39799 was conducted on 4/15/25 to 4/16/25. One deficiency was cited. Based 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.Findings include:I. Professional referenceAccording to the All Wales Tissue Viability Nurse Forum, Best Practice Statement on the Prevention and Management of Moisture Lesions, September 2023, retrieved online 4/4/25 from:chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.wwic.wales/ uploads/files/documents/Professionals/Clinical%20Partners/AWTVNF/All_Wales-Moisture_Lesions_final_final.pdf" Individuals with incontinence may also have problems with mobility and, as a result, be at risk of developing pressure ulcers as well as moisture lesions. Consequently, when inspecting an individual' s skin, it may be difficult to tell if the damage to the skin is caused by moisture alone or moisture in combination with pressure. If the skin is subjected to moisture and pressure, then the treatment strategy will have to overcome both of these insults to the skin. Therefore, along with guidance on how to prevent and manage moisture on the skin, pressure relief will be an important part of care for the individual. Repositioning together with the use of pressure-relieving equipment are the main methods of preventing pressure damage caused by extended periods of localized pressure on the skin. The use of repositioning should be considered in all at-risk individuals as a prevention strategy and should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. The repositioning schedule should take into account the daily activities of the individual, their ability to tolerate pressure when in the seated and lying positions ..

Based on observation, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 7.2.1.6.1 Delayed-Egress Locking Systems.1. A hall, delayed egress door hardware not working on left side2. C hall, delayed egress door hardware not working on left sideNFPA 101 7.2.1.6.1 Delayed-Egress Locking Systems.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within A & C Hall smoke compartments. Deficient item(s) were discussed with the facility maintenance director during the exit conference. The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility' s general characteristics. The facility is a one-story, Type V (000) construction, slab on grade without a basementThe facility was licensed for 80 beds and operated as a non-secured facility at the time of this survey. The census on the day of the survey was 43The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The facility' s fire sprinkler system is a wet system that contains an anti-freeze solution. The survey was conducted on February 15, 2024, for compliance .. Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 101 and NFPA 99. This was evidenced by: 1. Mechanical ventilation in the oxygen transfer room not workingNFPA 99 9.3.7.5Medical Gas Storage or Transfilling.Indoor storage or manifold areas and storage or manifold buildings for medical gases and cryogenic fluids shall be provided with natural ventilation or mechanical exhaust ventilation in accordance with 9.3.7.5.1 through 9.3.7.8.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. The deficient item was discussed with the facility maintenance director during the exit conference. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by: 1. Lacking exit sign for B hall courtyard exit to the public wayNFPA 101 19.2.10.1 & 7.10: Marking of Means of EgressThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within B Hall smoke compartment. Deficient items were discussed with the facility maintenance director during the exit conference. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by: 1. Quick response heads dated 1994 due for UL testing or replacementNFPA 25 5.3.1.1.1.3 Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the facility maintenance director during the exit conference.

A recertification survey with complaint #CO34663 and #CO34569 with Incident #33243 was completed on 1/22/24 to 1/25/24. Eleven deficiencies were cited. An Emergency Preparedness survey was conducted from 1/22/24 to 1/25/24. No deficiencies were cited. Based 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 f.. Based 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 faci.. Based 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 fa.. Based 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 t.. Based 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 fa.. Based 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 alle.. Based 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 wer.. Based 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.. Based 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.. Based 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.. Based 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 fai..