Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Tree Care Center during CMS and state inspections, most recent first.
Failure to Protect Residents from Physical Abuse: A resident with severe cognitive impairment, TBI, dementia, wandering, and aggressive behaviors physically assaulted two other residents in separate incidents. In one event, he forced entry into a resident’s room and shoulder-checked that resident to the floor, resulting in a pelvic fracture. In another, he confronted a second resident over missing shoes, and staff observed a physical struggle that left the second resident with a split lip and chin abrasion.
A resident with hemiplegia, dementia, and difficulty expressing pain was injured during a sit-to-stand transfer when her arm became caught in the sling. Staff gave PRN Tylenol and did not notify the representative right away. Bruising and pain were later noted, but the ordered X-ray was delayed until the fracture was confirmed, and a sling recommended for comfort was also delayed.
Hand hygiene lapses during meal service led to a sanitation deficiency in the kitchen, dining room, and secured memory unit. A dietary employee plated ready-to-eat food while repeatedly touching resident plates with his thumbs, handled a wrapper picked up from the floor with bare hands, and returned to plating without washing his hands. A dietary consultant observed the practice and directed him to hold plates from the side instead of placing his thumb on top of resident plates.
Missing Annual CNA Performance Reviews and In-Service Training: The facility failed to complete annual performance reviews and related in-service education for three CNAs. Record review showed no annual evaluations or training plans based on those reviews for the affected CNAs, and interviews confirmed the reviews were not completed and the reason for the missing training was unknown.
Cold and Unappetizing Meals Served to Residents: Residents reported that meals and room trays were frequently cold, tasteless, or poorly prepared, including cold soup, vegetables, eggs, and tough breakfast items. Surveyors observed uncovered food being plated for delivery, and a test tray showed lukewarm pork and beans and watery, bland broccoli. Staff also reported delayed tray delivery on some halls and kitchen equipment problems, including a steam table not holding temperature and an oven reading inaccurately.
Failure to maintain hand hygiene during meal assistance. Staff did not offer residents hand hygiene before meals in the dining room or secured memory care unit, and hand cleansing wipes were not available until later in the meal. A resident blew his nose at the table and continued eating without hand hygiene afterward. In the secured unit, an RN used the same gloves to assist two residents without changing them, and an AA used gloved hands to assist a coughing and sneezing resident, then touched a keypad, opened a door, and handled napkins before removing the gloves.
Multiple residents reported missing cash from their rooms after receiving money from a bank withdrawal, a family member, or a friend, and investigations confirmed that portions of these funds were unaccounted for despite residents being cognitively intact in two cases and having chronic medical conditions such as COPD, CKD, and muscle weakness. Facility records and interviews showed that documentation in the EMR was minimal or absent, care plans were not timely or not updated with interventions to prevent further misappropriation, and no restitution was made to the affected residents. Staff, including CNAs and an RN, reported they had not received training on prevention of misappropriation of resident property, even though the facility’s policy prohibits exploitation and theft and calls for staff education and QAPI oversight.
A resident with severe cognitive impairment, TBI, dementia, seizure disorder, and documented wandering and elopement risk eloped from a secured memory unit. The resident, known to have a history of kicking out window screens and entering other residents’ rooms, was last seen in bed early in the morning and was found missing shortly thereafter. Facility investigation determined the resident opened a window in an empty room, broke the window safety stop, exited into the secured courtyard, replaced the screen except at the bottom, and then climbed over a six-foot fence to leave the premises. Door alarms were found to be operable and did not sound, indicating the exit was not through a door. The resident was located off premises by police about an hour later with hypothermia, low O2 saturation, abrasions, and scratches, and was treated at a hospital. Progress notes for that date did not document the elopement event itself.
Failure to notify a resident's representative of a significant change in condition after a sit-to-stand lift transfer incident. A resident with severe cognitive impairment and multiple chronic conditions developed bruising to the shoulder, bicep, and forehead/temple, along with new pain to the left arm and shoulder. The physician was contacted for an Xray, but the record did not show that the representative was informed of the incident or the new bruising, and staff said they assumed the family already knew or learned of it later through hospice.
Missed Medicare Non-Coverage Notices for Three Residents: The facility failed to provide Medicare Non-Coverage notices to three residents when their skilled benefits ended. The SSD could not locate the forms and stated she missed sending out the notices, while the residents had planned discharges and diagnoses including COPD, CVA, CHF, MRSA, diabetes, and anxiety.
A resident with mood and substance-related diagnoses had a PASRR Level I screen that found no qualifying SMI or ID, but it also noted behavioral health symptoms and directed the facility to submit an updated screen if symptoms did not improve within 30 to 60 days. The resident continued to refuse meals, lose weight, and make statements about not wanting to live, yet the care plan did not include the PASRR re-evaluation recommendation and staff interviews showed the SSD and DON were not aware of it.
A resident with chronic pain, osteoarthritis, and shoulder stiffness received hydrocodone/acetaminophen under an order to give the medication only for pain rated 5 to 10, but staff often administered it without documenting a pain assessment at the time and also gave doses when recorded pain scores were below 5. An RN said she did not assess pain with each dose because she believed the order was scheduled, while the DON acknowledged the order indicated a pain assessment was needed at administration and that staff were using prior pain assessments instead of assessing each time.
Improper Storage and Labeling of Insulin Pens: Surveyors found expired and improperly labeled insulin pens in two medication carts, including opened Lantus pens with expired or illegible open dates and an opened NovoLog pen without a cap or open date. RN staff stated the pens should have been checked before administration, and one RN said he had not noticed the problems because the pens were given at bedtime by night shift.
CNA annual in-service training was not completed for two CNAs, and the records did not show the required 12 hours of annual education, including dementia care and abuse prevention training. The NHA stated one CNA’s file lacked the required annual training and another CNA’s file lacked the initial required training for dementia care and abuse, neglect, and exploitation. The staff development coordinator and NHA both acknowledged gaps in tracking and completing the mandatory training and performance review process.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident diagnosed with dementia did not receive the necessary treatment and services to address their condition, as required by care standards.
A resident with multiple health conditions and severe cognitive impairment developed pressure injuries that were not managed according to professional standards. The care plan lacked specific interventions for pressure ulcer prevention and did not reflect changes in the resident's condition. Documentation of wound assessments and treatments was incomplete, and there were delays in implementing physician-ordered interventions such as specialty mattresses. Leadership interviews confirmed gaps in communication, documentation, and care planning, contributing to the worsening of the resident's wounds.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to keep residents free from physical abuse involving a resident with severe cognitive impairment, wandering, and physically aggressive behaviors. Resident #42 had diagnoses including traumatic brain injury, altered mental status, dementia, alcohol-induced persisting dementia, delirium, and epilepsy, and his care plan identified that he was physically and verbally aggressive at times and required monitoring for triggers and danger to self and others. Despite these identified behaviors, he was involved in repeated physical altercations with other residents in the memory care unit. On one occasion, Resident #42 attempted to enter Resident #33’s room after saying he needed to do electrical work there. A CNA tried to redirect him and held the door knob closed, but Resident #42 forced his way into the room, pushed past the CNA, and made physical contact with Resident #33 using his shoulder and upper arm, causing Resident #33 to fall to the floor. Resident #33 had severe cognitive impairment, a BIMS score of 3, and was already using a chair inside his room as a protective measure against unwanted entry. After the incident, Resident #33 was found to have a right inferior pubic rami fracture and was sent to the hospital for evaluation. In a second incident, Resident #42 and Resident #20 were wandering in the same hallway when Resident #42 accused Resident #20 of stealing his shoes. A CNA heard shouting and observed Resident #42 holding Resident #20 by the shirt while Resident #20 had a hand on Resident #42’s shoulder. Staff separated the residents, and Resident #20 was left with a split lip and an abrasion to the chin. Resident #20 had severe cognitive impairment, wandering behaviors, and a history of physical and verbal aggression. The facility substantiated abuse in both incidents based on the injuries and the resident statements and observations documented during the investigations.
Delayed X-ray and Sling After Transfer-Related Arm Injury
Penalty
Summary
The facility failed to ensure a resident with left-sided hemiplegia/hemiparesis, dementia with severe cognitive impairment, and difficulty expressing pain received timely treatment and care after an incident during a transfer with a sit-to-stand lift. During the transfer, the resident let go of the lift handle and her left arm became caught in the sling in an awkward position. Staff lowered her back to bed, noted no bruising at that time, and gave acetaminophen because she typically had difficulty expressing pain. The resident’s representative was not notified at the time of the incident. Several days later, new bruising was identified on the resident’s left arm and forehead, and the resident was assessed with pain rated 7 out of 10. The physician was notified and recommended an X-ray of the left shoulder/arm area, but the X-ray was not obtained until 11 days after the incident. The X-ray showed an acute displaced fracture of the left humerus at the surgical neck. The record also documented that the resident continued to show pain and nonverbal signs of discomfort during assessments. After the fracture was identified, hospice staff recommended a sling for the resident’s left arm and a physician’s order was obtained, but the sling was not provided until 21 days after the incident and 10 days after the fracture was confirmed. Interviews showed staff were aware of the transfer incident, the bruising, and the resident’s pain, but the X-ray order was not completed when first initiated and the sling was not available when the recommendation and order were made.
Hand Hygiene Lapses During Meal Service
Penalty
Summary
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 because staff did not follow accepted hand hygiene practices during meal service. During a continuous observation of dinner meal service in the kitchen, CK #2 began plating residents’ meals and repeatedly handled ready-to-eat food while holding plates with his thumb on top of the plate surface. He switched between his right and left hands and thumbs while dishing food onto the plates. Later in the same meal service, CK #2 used alcohol wipes to take temperatures of food in the steam table, then collected used wipe wrappers from the counter and dropped one on the floor. He picked up the wrapper with bare hands and threw it away without washing his hands. He then returned to plating food and again placed his thumbs on top of resident plates without performing hand hygiene. A dietary consultant observed the plating process and instructed him to hold the plates from the side and not place his thumb on top of resident plates. The infection preventionist stated that hand hygiene education was provided twice a year, with the last education in January 2026.
Missing Annual CNA Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to complete annual performance reviews for certified nurse aides and failed to provide regular in-service education based on the outcome of those reviews for CNA #3, CNA #6, and CNA #7. Record review showed that annual performance evaluations for 2025 could not be provided for CNA #3, CNA #6, and CNA #7, and none of these CNAs had an in-service education plan based on a completed review. The facility policy stated that all staff are required to participate in regular in-service education and that the training is intended to ensure staff can interact in a manner that enhances residents' quality of life and quality of care and demonstrate competency in required topic areas. During interviews, the staff development coordinator stated she was responsible for training new hires and existing personnel and acknowledged that annual performance reviews and in-service education were required at least once a year, but she was unsure whether the 2025 reviews had been completed because she had only been in her role for a few months. The NHA stated that performance reviews should be completed annually based on each CNA's date of hire, confirmed that reviews were not completed for CNA #3, CNA #6, and CNA #7, and said she was not sure why the training was not completed.
Cold and Unappetizing Meals Served to Residents
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported that meals were frequently cold, including room trays and meals served in the dining area. One resident stated the food was always cold when it arrived in the room and described much of it as tasteless, while another said lunch meals were cold and that complaints had been made to nursing, CNA, dietary staff, and the RD without improvement. Other residents reported cold soup, vegetables, eggs, and breakfast items that were tough, overcooked, or lacked seasoning. Resident council minutes from December 2025 and January 2026 documented resident concerns about cold food being served. In both meetings, the dietary manager acknowledged the concerns and stated she would review or monitor food temperature practices with dietary staff. During the survey, a dietary aide was observed preparing trays in the kitchen and placing broccoli and pork and beans into uncovered bowls on a tray in the cart, rather than keeping them covered to maintain heat. The dietary consultant later instructed staff to cover the bowls before they were placed in the cart for delivery. A dinner test tray was evaluated after the last room tray was delivered. The pork and beans measured 113 degrees Fahrenheit and tasted lukewarm, and the broccoli was described as bland, watery, and very soft. Two residents eating dinner in the dining room said the broccoli was mushy and tasted watery. Staff interviews indicated room trays were often delivered by one CNA alone on two halls, which delayed meal delivery, and the dietary consultant stated the former dietary manager had reported the steam table was not holding temperatures and that the oven temperature was not registering correctly by 15 degrees Fahrenheit. The consultant also stated the dietary staff had been using the wrong switch on the steamer and that the steam table required a new part for repair.
Failure to Maintain Hand Hygiene During Meal Assistance
Penalty
Summary
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 disease and infection. The deficiency involved staff not performing appropriate hand hygiene when assisting residents with eating and not ensuring residents were offered hand hygiene before meals. The report also noted that residents who self-propelled wheelchairs touched wheel bases while entering the dining room, which the infection preventionist identified as a particular infection control concern. During a lunch meal observation in the main dining room, hand hygiene was not offered or available to residents between the start of the observation and 12:47 p.m. Hand cleansing wipes or alcohol-based hand rub were not offered by staff and were not within reach at the tables. Several residents used their hands to eat rolls and cake, and one resident blew her nose at the table and continued eating without being provided hand hygiene afterward. Hand hygiene wipes were not offered until later in the meal, when staff told residents the wipes were for after they were finished eating. During a lunch meal observation in the secured memory care unit dining room, residents were not offered hand hygiene before meal service. Staff wore gloves to pass out meal trays, and RN #1 used the same gloves to cut up one resident's food, serve him a bite, adjust another resident's napkin, and then return to the first resident to position his fork without changing gloves between residents. Later, AA #1 assisted a coughing and sneezing resident with food using gloved hands, then used the same gloves to press a keypad, open a nurse office door, collect napkins, and place napkins at another resident's table before removing the gloves.
Failure to Prevent and Address Misappropriation of Residents’ Money
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation and loss of personal money and belongings, as required by its own policy and abuse prevention strategy. The facility’s policy on identifying exploitation, theft, and misappropriation of resident property states that exploitation, theft, and misappropriation are strictly prohibited and that prevention requires staff education and training, with the QAPI committee responsible for reviewing and addressing quality deficiencies that may lead to such events. Despite this, multiple residents experienced missing cash from their rooms, and staff interviews revealed that direct care staff had not been trained on prevention of misappropriation of resident property. One cognitively intact resident with chronic conditions including pressure ulcer, chronic kidney disease, and COPD reported withdrawing $200.00 from a bank, spending $50.00 on a food delivery requested through a nurse, and later being unable to locate the remaining $150.00 in his room. He reported the missing money to facility staff and filed a grievance, but he stated he did not receive restitution and refused to sign the grievance form for that reason. The facility’s investigation confirmed with the resident’s financial advisor that $200.00 had been withdrawn, documented that the resident believed the money might have been stolen or thrown away with his old wallet, and recorded the allegation of missing funds. The resident’s electronic medical record contained minimal documentation related to the missing money, and his safety and security care plan addressing storage of valuables was not initiated until 12 days after he reported the loss. Another cognitively intact resident with diagnoses including muscle weakness, anxiety disorder, and insomnia reported that her daughter had given her $50.00, which she stored in an envelope in her dresser. After being out of her room, she returned to find the drawer open and $30.00 missing. The facility’s investigation documented that the resident’s wallet contained $28.00, that the resident and her daughter confirmed a total of $58.00 should have been present, and that $30.00 was unaccounted for. The investigation also noted a pattern of misappropriation incidents on the same hall involving other missing cash amounts. However, the resident’s care plan was not updated with interventions to prevent further misappropriation, and her progress notes and EMR did not contain documentation of the incident. The grievance form showed the matter was escalated and reported, but there was no documentation that restitution was made. A third resident with severe cognitive impairment and multiple chronic conditions reported missing $64.00 that she stated had been given by a friend. The facility’s investigation included interviews and a search of the room, and it documented inconsistent information from the resident and her family about the amount of cash involved. The investigation could not determine whether the money was lost or stolen and did not identify an alleged assailant or pattern specific to this resident, though it occurred during a period when several misappropriation incidents were reported. The resident’s grievance form confirmed the allegation of missing money and a lower amount reported by the resident’s representative, and the EMR contained no additional information about the incident. The social services director stated she was unable to locate the missing property for the three residents and that they did not receive restitution, and the NHA and DON acknowledged that the incidents were confirmed by families or representatives, while also indicating that staff had not received training related to misappropriation prevention.
Elopement From Secured Memory Unit Through Compromised Window
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for elopement was free from accident hazards and adequately supervised, resulting in an elopement from a secured memory unit. The resident was younger than 65 and had severe cognitive impairment, with a BIMS score of 0/15, and documented wandering behaviors. His diagnoses included a history of traumatic brain injury, Wernicke’s encephalopathy, unspecified dementia with behavioral disturbance, alcohol-induced persisting dementia, delirium due to a physiological condition, and generalized epilepsy. His care plans documented a pattern of elopement attempts, a history of kicking out window screens, slamming windows in attempts to open them, and entering other residents’ rooms and bathrooms. He was identified as an elopement risk with impaired awareness of safety and a history of leaving his home unattended. On the date of the incident, the facility’s investigation documented that the resident was last seen sleeping in his bed on the secured memory unit at 5:30 a.m. When staff checked on him at 6:02 a.m., he could not be located and was determined to be missing from the facility by 6:05 a.m. Staff initiated a search inside and outside the building and contacted the police. The resident was ultimately located off premises by law enforcement at 7:06 a.m., having been missing for approximately one to one and a half hours. The investigation determined that all door alarms were operable and no alarm had sounded, indicating the resident did not exit through a door. The facility’s investigation concluded that the resident eloped by exiting through a window in an empty room on the secured unit and then leaving the secured courtyard. An open window was found with the screen replaced except for the unsecured bottom portion, and a broken safety stop was discovered on the window. The investigation documented that the resident opened the window, broke the safety stop, exited through the window into the courtyard, replaced the screen except at the bottom, and then climbed over the six-foot fence to leave the secure area. The resident’s personal items were later found on the backside of the fence near a tree in the courtyard, supporting this sequence of events. When the resident was returned to the facility, his oxygen saturation was 85% and his temperature was 96.4°F; he had an abrasion on his right elbow, reddened skin on both hands, and scratches on his hands and knees, and he was treated at the hospital for acute hypothermia. Additionally, review of the nursing progress notes did not identify documentation of the elopement event itself on that date. Further observations and interviews showed that the resident continued to demonstrate exit-seeking behavior and attempts to open secured doors. On a later observation date, he was seen repeatedly pushing on emergency push bars at the back door of the memory care unit and attempting to open the main entrance door by pressing keypad buttons. Staff, including an RN, CNA, and activity assistant, attempted to redirect him with verbal cues, activities, and offers to walk with him. The facility’s wandering and elopement policy required identification of residents at risk for unsafe wandering and inclusion of strategies and interventions in the care plan to maintain safety. Despite the resident’s known history of elopement attempts, window-related behaviors, and impaired safety awareness, he was able to manipulate a window safety device, exit through the window, and leave the secured courtyard without triggering door alarms or being detected in time to prevent his elopement.
Failure to Notify Resident Representative of Change in Condition After Transfer Incident
Penalty
Summary
The facility failed to notify the resident's representative when Resident #5 experienced a significant change in condition after an incident during a sit-to-stand lift transfer. Resident #5 was an older adult with multiple diagnoses including hemiplegia and hemiparesis affecting the left side after cerebrovascular disease, dementia with agitation, COPD, diabetes, atrial fibrillation, heart failure, and a displaced fracture of the left humerus. The resident had severe cognitive impairment, difficulty expressing and understanding verbal communication, and required extensive assistance with nearly all activities of daily living. After the transfer incident, new bruising was documented on the resident's shoulder, bicep, and forehead/left temple, along with pain to the left arm and shoulder. The physician was contacted and an Xray of the left shoulder was recommended. However, the record did not show that the resident's representative was notified of the incident, the bruising, or the change in condition. The resident's representative later stated she was never informed by the facility and learned about the situation from the hospice nurse days later. Staff interviews showed that the hospice nurse learned of the bruising and pain from hospice staff and then informed the representative. RN #2 said she assessed the bruising and was told by the DON that the resident had slipped during the sit-to-stand transfer, but she did not contact the representative because she assumed the family had already been notified. The DON and NHA acknowledged the transfer incident and the delay in communication, and the DON stated staff should have contacted the representative when the extensive bruising was found.
Missed Medicare Non-Coverage Notices for Three Residents
Penalty
Summary
The facility failed to ensure residents received Notice of Medicare Non-Coverage when their skilled nursing benefits ended for three of four sampled residents. The report states that the facility did not have a policy for beneficiary notices and instead used the regulations as guidance. The Notice of Medicare Non-Coverage form, provided by the nursing home administrator, explained that Medicare probably would not pay for current services after the effective date and that the resident may have to pay for services received after that date. Resident #59 was admitted with diagnoses including COPD, unspecified hepatic failure with coma, and chronic respiratory failure with hypoxia, and the MDS documented the discharge as planned. Resident #60 was admitted with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery, diabetes mellitus, and anxiety disorder, and the MDS documented the discharge as planned. Resident #61 was admitted with diagnoses including acute chronic systolic congestive heart failure, MRSA, and anxiety, and the MDS documented the discharge as planned. For each of these residents, the facility requested but did not provide the Notice of Medicare Non-Coverage. The SSD stated she could not find the forms and said she missed sending out the notices for these residents.
PASRR Re-evaluation Recommendation Not Followed
Penalty
Summary
The facility failed to incorporate the recommendations from a PASRR Level I screening for a resident with diagnoses including unspecified mood disorder, psychoactive substance use, psychoactive substance-induced disorder, chronic kidney disease, heart failure, and restlessness and agitation. The PASRR screening found no qualifying serious mental illness or intellectual disability, but it noted low-level behavioral health symptoms that appeared situational and stated that if the resident’s symptoms or behaviors did not improve or resolve within 30 to 60 days, the facility was to submit an updated status change PASRR Level I screen for reevaluation. The resident’s care plan documented the PASRR Level I determination, but it did not include the recommendation to submit for reevaluation if behaviors did not improve or resolve. The resident was cognitively intact with a BIMS score of 15 out of 15, but the MDS showed behaviors of threatening or cursing at others and refusing care. The resident repeatedly refused to eat facility meals, stated he was doing so in protest over perceived poor services, and told staff he was not going to live anymore and no longer wanted to eat. He also declined hospice services and was placed on comfort-focused care per the medical director. Documentation showed continued refusal of food, minimal intake over a 29-day period, and ongoing weight loss, including a 15-pound loss noted in physician communication. Staff interviews showed the interdisciplinary team discussed the resident’s weight loss and behaviors, but the social services director was not aware of the PASRR recommendation to reassess if symptoms did not improve. The DON stated she had not seen the recommendation to reevaluate in 60 days and could not say for certain whether the resident’s behaviors had resolved or improved since admission. The DON also stated she hoped the physician would consider a psychiatric consult when communicating about the resident’s refusal to eat and statements about wanting to die, but the record showed the facility did not follow the PASRR recommendation to re-evaluate the resident’s Level I screening when the behaviors persisted.
Pain medication given without required pain assessment
Penalty
Summary
The facility failed to ensure that pain medication was administered in accordance with the physician’s ordered parameters for one resident with chronic pain syndrome, osteoarthritis, shoulder stiffness, and multiple other chronic conditions. The resident was cognitively intact, dependent on staff for most activities of daily living, and reported constant shoulder pain. The resident stated that staff were using multiple pain interventions, including a pain patch, topical gel, and hydrocodone/acetaminophen as needed, but that pain remained constant despite these measures. The physician order for hydrocodone-acetaminophen 7.5/325 mg directed staff to give one tablet by mouth every six hours for a pain level of 5 to 10. Review of the February 2026 MAR showed multiple administrations of this medication without a documented pain assessment at the time of administration, and multiple other administrations when the recorded pain score was below 5. These administrations occurred on several dates and times throughout the month, including repeated doses given when pain ratings were documented as 0 through 5. An RN stated she assessed the resident for pain every shift but did not assess pain with each administration because she believed the order was scheduled rather than PRN and was not aware of the instruction to administer only for pain rated 5 through 10. The DON stated the order as written indicated the need for a pain assessment at the time of administration and acknowledged that staff had not been documenting pain assessments with each dose. The DON also stated the facility had too many pain assessments for staff to complete and that staff used prior pain assessments instead of assessing at the time of medication administration.
Improper Storage and Labeling of Insulin Pens
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in two medication carts. During observation of the first cart, surveyors found three opened Lantus SoloStar insulin pens for different residents: one was expired, one had a smeared marker so the opened date was no longer legible, and one was also expired. RN #3 stated each insulin pen should have been checked before administration and that expired or unreadable pens should have been removed and replaced. He also stated he had not noticed the expired and mislabeled pens because they were administered at bedtime by night shift. During observation of the second cart, surveyors found an opened NovoLog insulin pen for another resident that did not have a cap and was not labeled with the date it was opened. RN #2 stated that without an open date she could not ensure the insulin was safe to administer and that the pen should be replaced. The DON and NHA were later informed of the findings, and the DON stated each nurse should be checking insulin pen expiration and open dates prior to each administration.
CNA Annual In-Service Training Not Completed
Penalty
Summary
The facility failed to ensure certified nurse aides received at least 12 hours of annual in-service training that included dementia management and resident abuse prevention training. Based on interviews and record review, five randomly selected CNA training records were reviewed, and CNA #3 and CNA #4 did not have documentation showing they received the required 12 hours of annual training. The facility policy stated that all staff were required to participate in regular in-service education annually and as necessary based on the facility assessment, and that required topics included resident rights and responsibilities and preventing abuse, neglect, exploitation, and misappropriation of resident property. The nursing home administrator stated that CNA #3, hired 8/1/21, did not have 12 hours of training in the employee file, and CNA #4, hired 4/25/25, did not have records of the initial required training for dementia care, abuse, neglect, and exploitation of residents. The staff development coordinator said she was responsible for ensuring employees received the required hours of training before having contact with residents and that she was required to collaborate with unit managers and the DON to ensure CNAs completed the mandatory 12 hours of in-service training. The NHA also stated that performance reviews were not completed for CNA #3 and CNA #4 and that she was not sure why the training was not completed.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services as required. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs. This deficiency was identified during the survey process, indicating a lapse in the delivery of care specific to dementia management for the affected resident.
Failure to Provide Timely and Adequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care for optimal skin condition of a pressure wound in accordance with professional standards. The care plan for the resident did not include specific interventions to prevent the development or worsening of pressure ulcers, such as repositioning, offloading, or encouraging the resident to get out of bed. Documentation was inconsistent, with missing or incomplete records regarding wound assessments, measurements, and the implementation of physician-ordered treatments. There was also a lack of timely updates to the care plan when new wounds developed or when interventions were initiated, such as the use of specialty mattresses or pillows for pressure relief. The resident, who had multiple diagnoses including acute kidney failure, prostate cancer, and severe cognitive impairment, was at moderate risk for pressure ulcers according to the Braden Scale. Upon admission, there were no skin issues noted, but over time, the resident developed pressure injuries to the sacrum and buttocks. The facility did not consistently document wound care, assessments, or the application of prescribed treatments. There were delays in implementing recommended interventions, such as the use of a low air loss mattress, and the care plan did not reflect changes in the resident's condition or the need for additional interventions as wounds worsened. Interviews with facility leadership revealed gaps in communication, documentation, and wound care management. The DON acknowledged that care plans did not include necessary interventions or documentation of refusals, and that weekly skin assessments were not completed as required. The facility lacked a wound care certified nurse, and there was uncertainty about whether the resident's physician was kept informed of wound status changes. The resident's wounds deteriorated during the stay, and the facility did not ensure timely or adequate assessment, intervention, or care planning in accordance with professional standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Delta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Horizons Care Center | 8.2 mi | ★★★★★ | 1 | 0 |
| Colorow Care Center | 8.7 mi | ★★★★★ | 7 | 0 |
| Hope Springs Care Center | 19.9 mi | ★★★★★ | 0 | 0 |
| Valley Manor Care Center | 20.4 mi | ★★★★★ | 11 | 0 |
| Paonia Care And Rehabilitation Center | 27.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.