Willow Tree Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF600May 22, 2024

  Based 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. Findings included: On 03/20/24 the facility reported an incident to all required entities. […]

• No harm, potential for more than minimal, patternF584Jul 24, 2025

  Based 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. Findings include:a) Maintenance Services:Upon survey entrance on 07/21/25 at 1:30PM, the following issues were observed in room [ROOM NUMBER]-bathroom areas: - approximate1/2-inch-long chip in the wood on the bathroom door near the handle- black scuff marks on backside of bathroom door- Rust spots across the white wall heater on the wall behind the… […]

• No harm, potential for more than minimal, patternF812Jul 24, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF880Jul 24, 2025

  Based 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.Findings included: a) An observation on 07/21/25 at 12:20 PM of the dining room lunch meal tray pass found the staff using three (3) trays to pass meals. Staff would pass lunch to a resident. […]

• No harm, potential for more than minimal, patternF684Sep 20, 2023

  Based 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. Findings included: a) Resident #64 Resident #64 had an order written on 08/28/23 for weekly weights for four (4) weeks, on Mondays. […]