Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
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 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.
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.
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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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.