Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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 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 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.
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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.
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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 | — | 2 | 0 |
| Hope Springs Care Center | 19.9 mi | — | 0 | 0 |
| Valley Manor Care Center | 20.4 mi | — | 1 | 0 |
| Paonia Care And Rehabilitation Center | 27.7 mi | — | 0 | 0 |
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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.