Willow Tree Healthcare Center, Charles Town, WV

The Essentials

Summary

Across 8 inspections from March 2022 to October 2025, state surveyors documented 50 findings at Willow Tree Healthcare Center; 50 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections: 8; 2022–2025, complaint and standard
Findings: 50; Deficiencies cited by state inspectors
Corrected: 50; Of 50 findings, with a recorded correction date
Penalties: 1; 1 fine; payment not published

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2022	1	12	0
2023	1	14	0
2024	3	11	1
2025	3	13	0
2026	0	0	0

What the Record Shows

50 of 50 findings have a recorded correction date.
CMS lists 1 enforcement action in the window: 1 fine of $8,018, its payment not published.
5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, July 24, 2025, recorded 9 findings (most serious: Level E).

What to Ask About

Quality of Care, Cited in Six Inspections
Reporting Suspected Abuse, Cited in Five Inspections
Accident Hazards and Supervision, Cited in Four Inspections
Kitchen and Food Safety, Cited in Three Inspections
Infection Control, Cited in Three Inspections
Citation F561, Cited in Two Inspections
A Clean, Homelike Setting, Cited in Two Inspections
Protection From Abuse and Neglect, Cited in Two Inspections
Care Plans, Cited in Two Inspections
Care Plan Timing and Review, Cited in Two Inspections
Help With Daily Living, Cited in Two Inspections
Dialysis Care, Cited in Two Inspections

Report at a Glance

Facility: Willow Tree Healthcare Center
Address: 1263 South George Street, Charles Town, WV 25414
CMS Certification Number: 515156
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 104
Ownership: For profit - Corporation
Record Window: March 2, 2022 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Oct 302025
Complaint investigation
3 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Dec 5, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 5, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 5, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jul 242025
Standard health inspection
9 findings
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Aug 29, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Aug 29, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 29, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Aug 29, 2025
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Aug 29, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 29, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Aug 29, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 29, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 29, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 72025
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 7, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jul 252024
Complaint investigation
2 findings
- F624Prepare residents for a safe transfer or discharge from the nursing home.Level DNo actual harm, potential for moreCorrected Aug 23, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 23, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 222024
Complaint investigation
3 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Mar 28, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 28, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 28, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jan 192024
Complaint investigation
6 findings
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 1, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 1, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 1, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 1, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 1, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 1, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 32023
Standard health inspection
14 findings
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F924Put firmly secured handrails on each side of hallways.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
Enforcement Action
Civil money penalty, $8,018 imposed May 22, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 3, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Mar 22022
Standard health inspection
12 findings
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Mar 31, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Mar 31, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Mar 31, 2022
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 31, 2022
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Mar 31, 2022
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Mar 31, 2022
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Mar 31, 2022
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 31, 2022
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 31, 2022
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 31, 2022
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Mar 31, 2022
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Mar 31, 2022
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Quality of Care, Cited in Six Inspections
Inspectors cited F684 in March 2022, May 2023, January 2024, May 2025, July 2025 and October 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F684 across all 8 inspections, oldest to newest
2
Reporting Suspected Abuse, Cited in Five Inspections
Inspectors cited F609 in March 2022, January 2024, May 2024, July 2025 and October 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F609 across all 8 inspections, oldest to newest
3
Accident Hazards and Supervision, Cited in Four Inspections
Inspectors cited F689 in March 2022, May 2023, January 2024 and July 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F689 across all 8 inspections, oldest to newest
4
Kitchen and Food Safety, Cited in Three Inspections
Inspectors cited F812 in March 2022, May 2023 and July 2025. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F812 across all 8 inspections, oldest to newest
5
Infection Control, Cited in Three Inspections
Inspectors cited F880 in March 2022, July 2024 and July 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F880 across all 8 inspections, oldest to newest
6
Citation F561, Cited in Two Inspections
Inspectors cited F561 in March 2022 and July 2025. The agency describes it this way: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F561 across all 8 inspections, oldest to newest
7
A Clean, Homelike Setting, Cited in Two Inspections
Inspectors cited F584 in March 2022 and July 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F584 across all 8 inspections, oldest to newest
8
Protection From Abuse and Neglect, Cited in Two Inspections
Inspectors cited F600 in May 2024 and October 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F600 across all 8 inspections, oldest to newest
9
Care Plans, Cited in Two Inspections
Inspectors cited F656 in May 2023 and January 2024. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F656 across all 8 inspections, oldest to newest
10
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in May 2023 and May 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F657 across all 8 inspections, oldest to newest
11
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in May 2023 and July 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F677 across all 8 inspections, oldest to newest
12
Dialysis Care, Cited in Two Inspections
Inspectors cited F698 in March 2022 and January 2024. This citation covers care for residents who need dialysis. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242424252525F698 across all 8 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in six inspections, most seriously at level E.
02
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in five inspections, most seriously at level D.
03
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level E.
04
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level E.
05
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
06
What changed after F561 was cited, and how do you check it now?
Citation F561: cited in two inspections, most seriously at level D.
07
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in two inspections, most seriously at level E.
08
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level G.
09
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level D.
10
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level E.
11
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level D.
12
How is dialysis care coordinated, and who monitors residents before and after treatment?
Dialysis Care: cited in two inspections, most seriously at level D.
13
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
14
What led to the 2024 fine, and has it been paid?
An $8,018 civil money penalty was imposed May 22, 2024. CMS publishes the fine, not whether it has been paid.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the West Virginia state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection Mar 2, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection May 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection Jan 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection May 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection Jul 25, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection May 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection Jul 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
West Virginia state survey agency
Inspection Oct 30, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 515156
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowMarch 2, 2022 – October 1, 2026

CMS publishes about three inspection cycles; inspections before March 2022 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.