Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Tree Healthcare Center during CMS and state inspections, most recent first.
A resident with diabetes and other serious health conditions requested a snack at night due to feeling unwell, but a nursing aide told the resident there were no sandwiches and to go to sleep. The resident was later found with a critically low blood glucose level, and records show the request for food was not accommodated. The facility failed to ensure the resident was free from neglect and verbal mistreatment.
A resident with diabetes experienced hypoglycemia and reported that a nursing aide responded inappropriately when he requested food, telling him to "shut up and go to sleep." Although the facility was aware of the incident and made changes to the resident's care, the allegation of verbal mistreatment was not reported to authorities within the required timeframe, resulting in a deficiency for failure to timely report suspected abuse.
Two residents did not receive person-centered care according to professional standards. One resident with multiple chronic conditions experienced prolonged nausea and vomiting without timely hospital referral, only being transferred after family insistence and later diagnosed with serious conditions. Another resident with diabetes was denied a nighttime snack by a nursing aide, leading to hypoglycemia, and later experienced delayed incontinence care. These incidents reflect failures in timely escalation of care, appropriate response to resident needs, and adherence to care protocols.
Multiple resident rooms had visible maintenance deficiencies, including damaged doors, scuffed surfaces, rusted heaters, loose trim, cracked caulking, a loose bathroom floor, and a hole in the drywall. Surveyors also observed low to no water pressure at bathroom faucets in two rooms, and residents reported that water barely ran after prior sink work. Several residents reported seeing mice in their rooms, with traps placed in rooms and staff acknowledging ongoing mouse sightings.
Unsafe food handling and storage practices were observed when an NA touched multiple surfaces while setting up a resident's tray and then fed the resident without washing or sanitizing hands. In addition, food in the walk-in freezer was found open to air, and ice cream cups were observed on the floor before the Dietary Mgr placed them back in the box.
Infection Prevention and Control Deficiencies: Staff passed meal trays between residents without cleaning them, failed to offer hand sanitation to multiple residents during breakfast, and two residents had damaged wheelchair and Geri-chair surfaces exposing inner padding. An LPN and the Facility Corporate RN acknowledged the tray and equipment practices and the need for repair of the damaged seating equipment.
A facility failed to keep call lights within reach for two residents while they were in bed. One resident who used a walker could not reach the call light, which was on the floor about 3 feet away, and another resident had the call button hanging off the bed and on the floor. An NA and an LPN both acknowledged the call lights were not within reach.
Failure to Honor Resident Bathing Preferences: A resident who said bathing choice was very important reported wanting more frequent showers and needing only minimal help, yet the record showed repeated "Response Not Required" entries without documentation that showers were provided. Another resident with impaired cognition could not recall his last shower, and the shower log showed a six-day gap without a shower or bed bath. The DON confirmed the documentation did not show showers were provided or refused.
Failure to timely report an allegation of suspected staff-to-resident verbal abuse. A resident reported that an LPN called her a liar after she said she had not had a BM in 5 days and asked for a laxative. The administrator said he would investigate, but later stated he had not yet reported the allegation to the appropriate state agencies because he was waiting to speak with the LPN.
Failure to provide and document shower assistance for two residents. One resident said she was scheduled for showers twice weekly, wanted more frequent showers, and only needed help scrubbing her back, but the record showed repeated "Response Not Required" entries and one bed bath with no clear evidence showers were provided. Another resident with a low BIMS score could not recall his last shower, and the shower log showed a gap in bathing documentation; the DON confirmed the records did not show showers were provided or that residents had refused care.
A resident with possible shingles was placed on contact isolation and treated with valacyclovir after developing a rash and burning pain, while another resident who had close contact with the infected roommate was allowed unrestricted access throughout the facility. The second resident reported no childhood chickenpox and no temperature checks had been done until after surveyor intervention; the NP initially said room confinement was unnecessary because there were no signs of infection, and no monitoring plan was identified at that time.
A resident’s bedside table had a medicine cup of ointment cream left in the room, and the resident said nurse aides had left it there for use on her bed sores. An LPN later stated she did not know what the ointment was and said it should not have been left in the resident’s room.
A resident experienced an unwitnessed fall and was found confused and unable to follow commands. Required neuro checks were not performed at the 15-minute intervals specified by facility policy, with a gap between assessments. The resident was later found unresponsive, and CPR was initiated. Documentation and staff interviews confirmed the failure to follow post-fall monitoring protocols.
Failure to Protect Resident from Neglect and Verbal Mistreatment
Penalty
Summary
A resident with multiple complex medical conditions, including Type II Diabetes Mellitus with hyperglycemia, hemiplegia, bilateral above-knee amputations, chronic obstructive pulmonary disease, dysphagia, and a history of gastrointestinal hemorrhage, requested a snack during the night because he was not feeling well. The resident, who was alert and oriented with a BIMS score of 15, reported that a nursing aide responded to his request by telling him there were no sandwiches and to "shut up and go to sleep." The following morning, the resident was found to have a critically low blood glucose level of 40 mg/dl, requiring immediate intervention per hypoglycemia protocol. Documentation and staff statements revealed that the resident's request for food was not accommodated, and there was conflicting information regarding the staff's response. The nursing aide and an LPN both stated that there were no sandwiches available, but the aide denied using inappropriate language. The resident maintained that he was dismissed and spoken to disrespectfully. Medical records indicated that the facility was aware of the resident's hypoglycemic episode and had implemented new dietary and insulin orders the same day, suggesting awareness of the incident's circumstances. Despite the resident's report of verbal mistreatment and the documented hypoglycemic event, the facility's investigation concluded that there was insufficient evidence to substantiate verbal abuse and stated that no physical or emotional harm was identified. However, the report shows that the resident's request for a snack was not met, and the facility failed to ensure the resident was free from neglect, as required by regulation.
Failure to Timely Report Alleged Verbal Mistreatment of a Resident
Penalty
Summary
The facility failed to ensure that an alleged violation involving verbal mistreatment of a resident was reported immediately, but not later than 2 hours after the allegation was made, as required. A resident with a diagnosis of Type II Diabetes Mellitus and prescribed insulin reported that, during a hypoglycemic episode, he requested food from a nursing aide and was told, "There are no sandwiches, shut up and go to sleep!" The resident expressed distress over the incident. Documentation shows that the resident experienced hypoglycemia, with a blood glucose reading of 40 mg/dl, and that the incident was brought to the attention of nursing staff. However, the initial report to the Office of Health Facility Licensing and Certification (OHFLAC) was not submitted until several days after the incident, exceeding the mandated reporting window for abuse allegations. Record review revealed that the facility was aware of the circumstances surrounding the incident on the same day it occurred, as evidenced by new dietary and insulin orders placed in response to the resident's hypoglycemic episode. Despite this, the facility did not report the allegation of verbal mistreatment to the appropriate authorities within the required timeframe. The delay in reporting was confirmed through interviews and documentation, with the Assistant Director of Nursing stating she was not aware of the details until days later, despite evidence to the contrary in the medical record.
Failure to Provide Person-Centered Care and Timely Medical Intervention
Penalty
Summary
The facility failed to provide person-centered care and treatment in accordance with professional standards of practice for two residents. One resident, who lacked decision-making capacity and had multiple chronic conditions including diabetes, chronic kidney disease, and bilateral lower limb amputations, experienced repeated episodes of nausea and vomiting over more than ten days. Despite ongoing symptoms, abnormal laboratory findings, and a decline in oral intake and mental status, the facility did not refer the resident to the hospital for evaluation until a family member insisted. Upon transfer, the resident was diagnosed and treated for acute metabolic encephalopathy, acute kidney injury, aspiration pneumonia, and a urinary tract infection. Another resident, who was alert and oriented, experienced an episode of hypoglycemia after requesting food at night and being denied by a nursing aide, who reportedly told the resident to "shut up and go to sleep" and that there was nothing to eat. The resident later reported this interaction, and it was confirmed that snacks were not available at night as needed for diabetic management. Documentation showed that the facility was aware of the need for bedtime snacks to prevent hypoglycemia, as evidenced by a physician's order, but failed to ensure this was provided. Additionally, the same resident reported a subsequent incident where a nursing assistant refused to provide timely incontinence care, stating that checks were only every two hours, which was corroborated by the resident's roommate. The events leading to the deficiencies included failure to escalate care for a resident with worsening symptoms and abnormal findings, lack of timely and appropriate response to a resident's request for food to manage hypoglycemia, and failure to provide prompt incontinence care. These actions and inactions demonstrate a lack of adherence to person-centered care and professional standards, resulting in unmet care needs and delayed medical intervention.
Maintenance Deficiencies, Mouse Sightings, and Low Water Pressure in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by allowing multiple maintenance problems to remain in resident rooms and bathrooms. Surveyors observed chipped wood on a bathroom door near the handle, black scuff marks on bathroom doors, rust spots on wall heaters, cracked caulking around a sink, a loose bathroom floor with air bubbles underneath, holes and scrapes in a door jamb, a baseboard trim hanging loose from a bathroom wall, and a hole in the drywall near a bedside table. Low to no water pressure was also observed at bathroom faucets in two rooms, and a resident stated that maintenance had worked on the sink a few weeks earlier and the water barely ran afterward. The report also documented ongoing pest control concerns in several resident rooms. During interviews, residents stated they had seen mice in their rooms, including one resident who said mice had been seen in the past week, another who said she saw mice all the time and had 8 traps set in her room, another who reported seeing a mouse the night before and pointed to a trap under a wheelchair, and another who reported seeing mice over the weekend and again the night before. During a walk-through, the Corporate RN acknowledged the maintenance issues and mouse sightings in resident rooms, and the Facility Administrator stated the facility had been logging mouse sightings and working with a pest control company, while acknowledging the mice were still a problem.
Unsafe Food Handling and Storage Practices
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards for safe food service. During a dining room observation, a nurse aide was observed touching multiple surfaces while setting up a resident's tray and then feeding the resident without washing hands or using hand sanitizer. In an interview shortly afterward, the nurse aide acknowledged that she did not wash or sanitize her hands after touching multiple surfaces before setting up the resident's tray and feeding him. On a later observation, the walk-in freezer was found with sausage patties, pancakes, and Salisbury steak patties open to air, and three ice cream cups were observed on the floor. The Dietary Manager later verified that the food was open to air and confirmed the ice cream cups were on the floor before placing them back in the box.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a dining room lunch meal tray pass observation on 07/21/25 at 12:20 PM, staff were observed using three trays to pass meals. A staff member would pass lunch to a resident, return to the service line, and pass the tray down through staff to the steam table for the next resident without cleaning the tray. Licensed Practical Nurse #9 stated this was the practice used to serve meals in the dining room and verified the service tray was never cleaned between residents. On 07/22/25 between 7:45 AM and 7:55 AM, Employee #89 failed to offer hand sanitation to Resident #94 and Resident #21 during breakfast in the main dining room. During the same observation period, Employee #114 failed to offer hand sanitation to Resident #88 and Resident #37 during breakfast in the main dining room. Employee #117 verified this deficient practice. In addition, Resident #72 had a wheelchair near the bed with rips and holes in the plastic cover on both arm rests, the top of the back rest, and the seat, exposing the inner padding, and stated the wheelchair belonged to her. Resident #77 had a Geri-chair with scratches and tears in the head rest exposing the inner padding. During a facility walkthrough on 07/23/25, the Facility Corporate RN acknowledged both Resident #72's wheelchair and Resident #77's Geri-chair needed repair.
Call Lights Not Within Reach of Residents in Bed
Penalty
Summary
The facility failed to ensure the call system was accessible to residents while they were in bed or other sleeping accommodations in their rooms. Resident #23 was observed sitting on the side of the bed with the call light on the floor approximately 3 feet away, and the resident walked with a walker and could not reach the call light. Resident #50 was observed sitting on the right side of the bed with the call button hanging off the left side of the bed on the floor, and she asked the surveyor to get a nurse for her roommate because her own call light was not within reach. During interviews, NA #48 acknowledged that Resident #23's call light was not within reach, and LPN #17 acknowledged that Resident #50's call button was not within reach and stated she was unaware of it because a Nurse Aide had just been in the room with the resident.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident choice and self-determination regarding bathing preferences for two residents. Resident #80 stated during interview that she was scheduled for showers on Tuesdays and Fridays, wanted more frequent showers, and reported that staff were unable to accommodate her request. She also stated that once seated on the shower chair, she could shower herself and only needed assistance scrubbing her back. Her preferences record dated 02/05/25 indicated that choosing between a tub bath, shower, bed bath, or sponge bath was "Very Important!" Record review showed Resident #80 had a bed bath on 06/25/25 and then multiple entries of "Response Not Required" on subsequent scheduled bathing dates, with no documentation that showers were provided. Resident #19, who had a BIMS score of 4, stated he did not remember when he last had a shower. Shower records showed no showers or bed baths between 07/16/25 and 07/23/25, a six-day period, and the available record listed showers, bed baths, and one refusal on earlier dates. During interview, the DON reviewed the shower log and stated she could not understand why the documentation said "Response Not Required," and confirmed the documentation did not indicate showers were provided to either resident and did not show that the residents had refused showers.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of suspected staff-to-resident verbal abuse was reported to the appropriate State Agencies within the required 2-hour time frame. Resident #47 reported that LPN #35 had called her a liar two nights earlier when she said she had not had a bowel movement in five days and requested a laxative. The facility’s policy defines mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation. When the allegation was brought to the Facility Administrator, he stated he would investigate it, but in a follow-up interview he said he had not reported the allegation to the appropriate agencies because he had not yet spoken with LPN #35, who was off the day the report was made and was scheduled to work later that afternoon.
Failure to Provide and Document Shower Assistance
Penalty
Summary
The facility failed to provide assistance with showers for two residents who were unable to receive the bathing care documented in their records. One resident stated that she was scheduled for showers twice weekly and wanted more frequent showers, but staff were unable to accommodate that request. She also reported that once seated on the shower chair, she could shower herself and only needed help scrubbing her back. Her preferences record indicated that choosing between a tub bath, shower, bed bath, or sponge bath was very important to her, yet the record review showed repeated entries of "Response Not Required" and one bed bath entry, with no documentation that showers were provided on the listed dates. A second resident with a BIMS score of 4 stated that he did not remember when he last had a shower. Review of the shower records showed no showers or bed baths for a six-day period, and the available documentation included a shower, bed baths, and one refused shower entry earlier in the month. No additional shower records were provided for review. The DON reviewed the shower log and stated she could not understand why the documentation said "Response Not Required," and confirmed that the documentation did not indicate showers were provided to either resident and did not show that any residents had refused showers.
Failure to Monitor Resident Exposed to Varicella and Assess Unrestricted Facility Access
Penalty
Summary
The facility did not properly monitor and assess a resident who had close contact with another resident diagnosed with varicella. Resident #38 developed clusters of red rash on the right buttock with a burning and stinging sensation radiating to the right thigh, was placed on contact isolation for possible shingles, and was prescribed valacyclovir. A varicella PCR specimen was obtained from the right posterior thigh, and the resident remained on isolation while labs were pending. One dose of valacyclovir was not given because it was unavailable. The facility also did not recognize and assess the potential risk to another resident who had unrestricted access to the facility. Resident #63 stated that his wife was in isolation due to an infection and that he was allowed to go everywhere in the facility. He reported no childhood chickenpox and said no one had checked his temperature. The NP stated there was no need to confine him to his room because he had no signs of infection, but did not identify any monitoring measures at that time. The RCN stated the resident could not be isolated based on the chance he had contracted the virus, and the facility’s temperature checks and skin assessments were implemented only after surveyor intervention.
Medicine Cup of Ointment Left in Resident Room
Penalty
Summary
The facility failed to ensure the resident environment under its control was as free from accident hazards as possible. During an entrance interview and observation, a medicine cup containing ointment cream was found left on a bedside table in Resident #69’s room. Resident #69 stated the ointment had been left there by nurse aides for use on her bed sores. When interviewed, an LPN stated she did not know what the medicine cup of ointment was and said it should not have been left in the resident’s room.
Failure to Perform Timely Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to follow recognized standards of care and its own policy regarding post-fall monitoring for a resident who experienced an unwitnessed fall. The resident was found on the floor in his room, confused but redirectable, and had removed his oxygen, which was subsequently replaced. Initial assessments noted confusion and an inability to follow commands, including for pupillary checks. Despite the facility's neuro check policy requiring assessments every 15 minutes for the first hour after an unwitnessed fall, documentation showed that neuro checks were not performed at the required intervals. Specifically, the resident was assessed at 9:15 AM and not again until 9:45 AM, missing the mandated 15-minute checks. The nursing notes indicated that the resident was alert but confused after the fall, with baseline cognition and range of motion, and denied pain. However, the resident was later found unresponsive, and CPR was initiated. The facility's neuro check policy was not followed, as confirmed by both documentation review and staff interviews. The lapse in protocol and documentation was acknowledged by facility leadership during the investigation.
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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 Charles Town
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shenandoah Center | 1 mi | ★★★★★ | 10 | 0 |
| Canterbury Center | 11.2 mi | ★★★★★ | 0 | 0 |
| Rose Hill Health And Rehab | 11.2 mi | ★★★★★ | 0 | 0 |
| Care Haven Center | 11.4 mi | ★★★★★ | 7 | 0 |
| Martinsburg Healthcare Center | 15.2 mi | ★★★★★ | 0 | 0 |
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