Willow Tree Care Center

In the surveyor’s words

From the most serious findings on record at Willow Tree Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Oct 5, 2022

  Based 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. […]

• Actual harm, isolatedF600Feb 26, 2026

  Based 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. […]

• Actual harm, isolatedF684Feb 26, 2026

  Based 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. […]

• Actual harm, isolatedF690Oct 5, 2022

  Based 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. […]

• Actual harm, isolatedF692Oct 5, 2022

  Based 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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. […]