Willow Tree Care Center
2050 S Main St, Delta, CO 81416 · Delta County · 80 certified beds · avg 54 residents/day · certified since Mar 1, 1989
Abuse citation flag (CMS)
Part of chain: STELLAR SENIOR LIVING (7 facilities, chain avg rating 2.3★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 26, 2026 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 19, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 26, 2026 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 19, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Oct 5, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Nov 9, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 5, 2022 · F-0690
The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 9, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 5, 2022 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 9, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (52)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 26, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Feb 26, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 26, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 26, 2026 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Feb 26, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 26, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Apr 16, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jan 25, 2024 | F · Potential for harm, facility-wide | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Oct 5, 2022 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 5, 2022 | ▲ G · Actual harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Oct 5, 2022 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Oct 5, 2022 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Oct 5, 2022 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Oct 5, 2022 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
| Oct 5, 2022 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Oct 5, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Oct 5, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Oct 5, 2022 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Oct 5, 2022 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Oct 5, 2022 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (9 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 23 | 3 | H ▲ |
| 2024 | 11 | 0 | F |
| 2025 | 4 | 0 | E |
| 2026 | 14 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $28,756.
| Date | Type | Amount / length |
|---|---|---|
| Feb 26, 2026 | Fine | $28,756 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.91 | 3.89 | 3.95 | top 41% in Colorado; top 43% in the U.S. |
| Registered Nurse hours | 1.09 | 0.86 | 0.69 | top 20% in Colorado; top 12% in the U.S. |
| Weekend total nurse staffing | 3.45 | 3.44 | 3.50 | top 41% in Colorado; top 45% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.69 | 0.61 | 0.48 | top 32% in Colorado; top 17% in the U.S. |
| Total nursing staff turnover (%) | 59.7 | 47.1 | 45.8 | bottom 18% in Colorado; bottom 17% in the U.S. |
| RN turnover (%) | 46.2 | 44.6 | 42.9 | bottom 47% in Colorado; bottom 42% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.31, RN 0.93, weekend 2.93. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Charles Schwab & Co INC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| D.e. Shaw & Co., L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| Diversified Healthcare Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| H/2 Special Opportunities IV L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| SNH Proj Lincoln TRS LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2024 |
| SNH TRS Licensee Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| SNH TRS, INC. | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| Sptihs Properties Trust | Organization | 5% or Greater Direct Ownership Interest | 10% | 01/01/2024 |
| Abp Trust | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/22/2024 |
| Abp Trust | Organization | ADP of the SNF | NOT APPLICABLE | 03/27/2025 |
| Benton, Evrett | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2021 |
| Benton, Evrett | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2021 |
| Bilotto, Christopher | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Blackrock INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/22/2024 |
| Blackrock INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/27/2025 |
| Brown, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2023 |
| Brown, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Horizons Care Center | 8.2 mi | Eckert, CO | ★★★☆☆ | 3/5 | |
| Colorow Care Center | 8.7 mi | Olathe, CO | ★★★☆☆ | 2/5 | abuse |
| Hope Springs Care Center | 19.9 mi | Montrose, CO | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065249.