Willow Tree Healthcare: Care Protocol Failures - WV
The incident at Willow Tree Healthcare Center came to light during a complaint investigation completed October 30. Federal inspectors found that Nursing Assistant #90 had been instructed to help Resident #31 but abandoned the task, forcing the resident to remain in unsanitary conditions.
Resident #31 told investigators exactly what happened. The nursing assistant had been called to clean him up after he soiled himself. Instead of providing the care, NA #90 simply walked away from his room.
"I heard it!" Resident #31 told inspectors, describing how he had to call out for help after being left alone.
The resident remained in his soiled condition until a nurse entered his room sometime later. When Resident #31 complained to the nurse about what had happened, she immediately checked on him and discovered he was still sitting in waste.
The nurse then had to call NA #90 back to the room and specifically ask her to clean up the resident - the same task the aide had already been instructed to perform and had ignored.
The Director of Nursing learned about the incident only when federal inspectors interviewed her at 10:00 AM on October 28. She told investigators she had been completely unaware that one of her nursing assistants had abandoned a resident in need of basic hygiene care.
Upon hearing about the incident for the first time, the DON immediately launched an internal investigation. She also submitted an initial report to the Office of Health Facility Licensing and Certification, the state agency that oversees nursing home operations.
The violation represents a breakdown in the most fundamental aspect of nursing home care - ensuring residents receive assistance with basic hygiene needs. Federal regulations require facilities to provide necessary care and services to maintain each resident's dignity and physical well-being.
Leaving a resident sitting in waste creates multiple health risks, including skin breakdown, infections, and urinary tract complications. The situation becomes particularly concerning for elderly residents who may have compromised immune systems or existing medical conditions that make them more vulnerable to complications from poor hygiene.
The incident also highlights potential staffing or training issues at the facility. Nursing assistants are specifically trained to provide personal care assistance, including cleaning residents who have soiled themselves. Walking away from such a basic care task suggests either inadequate training, supervision problems, or staffing pressures that prevent proper care delivery.
For Resident #31, the experience meant enduring the discomfort and indignity of sitting in waste while waiting for someone to provide the care he needed and had already requested. The fact that he had to advocate for himself by complaining to the nurse who later entered his room underscores how the system failed him.
The timing of the DON's response - immediately beginning an investigation and reporting to state authorities once informed - suggests the facility recognized the seriousness of the violation. However, the incident raises questions about supervision and oversight systems that should prevent such basic care failures from occurring.
Federal inspectors classified the violation as causing minimal harm with few residents affected, but the incident represents exactly the type of neglect that can escalate into more serious health consequences if not addressed promptly.
The case demonstrates how complaint investigations can uncover care failures that facility administrators may not be aware of, highlighting the importance of resident advocacy and external oversight in maintaining care standards.
Resident #31's willingness to speak up about his experience ultimately led to the discovery of the violation and the facility's corrective actions, but only after he had already endured the consequences of inadequate care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Tree Healthcare Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
WILLOW TREE HEALTHCARE CENTER in CHARLES TOWN, WV was cited for violations during a health inspection on October 30, 2025.
The incident at Willow Tree Healthcare Center came to light during a complaint investigation completed October 30.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.