WILLOW TREE CARE CENTER (DELTA, CO) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	18.2%
State:	15.7%

Percent of long-stay residents who self-report moderate to severe pain

Here:	5.5%
State:	12.4%

Percent of long-stay residents who lose too much weight

This Nursing Home:	10.0%
Colorado:	7.7%

Percent of long-stay residents with a urinary tract infection

Here:	5.0%
Colorado:	7.0%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	2.6%
Colorado:	7.1%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	10.0%
Colorado:	4.0%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	100.0%
Colorado:	91.9%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	100.0%
State:	91.4%

Percent of short-stay residents who self-report moderate to severe pain

Here:	17.1%
Colorado:	24.1%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	97.6%
State:	83.9%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	97.7%
State:	78.2%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	15.0%
Colorado:	20.4%

Complaint Deficiency

Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly working alarms on sprinkler valves
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide special eating equipment and utensils for each resident who needs them
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public
- Harm: Potential for minimal harm
- Scope: Some
Protected exits that allow the resident to escape the building
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give the resident's representative the ability to exercise the resident's rights
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide medically-related social services to help each resident achieve the highest possible quality of life
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have enough backup water supply for essential areas of the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Keep signed and dated reports of x-rays and other diagnostic services
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Train all employees on what to do in an emergency, and carry out announced staff drills
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space
- Harm: Potential for minimal harm
- Scope: Some
Make sure that a working call system is available in each resident's room or bathroom and bathing area
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Many
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Restrictions on the use of flammable curtains
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper fire barriers, ventilation and signs for the transport of oxygen
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.710
Colorado:	0.914

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

This Nursing Home:	0.810
Colorado:	0.722

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.520
State:	1.632

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.040
State:	0.109

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.040
State:	0.118

WILLOW TREE CARE CENTER - DELTA, CO

Quality Measures

Complaint Deficiency

Staff Information

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