Willow Tree Healthcare Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

had not made any statement at the time of the hypoglycemic episode because he was out of it. ADON stated that they had been unaware of the incident until she had received the complaint from the resident on 10/20/25.However, record review on 10/28/25 at 10:00 AM revealed that the facility had been aware of the circumstances of the incident on 10/17/25, as evidenced by the following:An order on 10/17/25, which stated:Please give resident a small snack of crackers and cheese before bedtime to prevent hypoglycemia.

In addition, the resident's previous order for insulin dated 01/12/25, which stated:Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 38 units subcutaneously at bedtime for diabetes. had been discontinued on 10/17/25, and a new order had been placed on 10/17/25 which stated:Insulin Glargine yfgn - Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Inject 30 units subcutaneously one time a day for DM2 Further review of records revealed written statements by Licensed Practical Nurse (LPN) #11, and NA #36.LPN #11's statement dated 10/21/25, stated: [Typed as written] I never heard [NA #36] tell resident to shut up. Resident had asked for a sandwich, [NA #36] asked me if we had any. I stated that we don't have any sandwiches. [NA #36] responded to resident saying [LPN #11] said

we don't have any sandwiches. NA #36 and LPN #11 went back to the nurses' station afterward. NA #36's statement dated 10/20/25 stated: [Typed as written] On 10/16/25 at around 1or 2 am, [Resident #31] asked me for a sandwich. [LPN #11] was in the hallway and heard him ask, and she said We don't have any sandwiches. I said to [Resident] that [LPN #11] said we don't have any sandwiches.Someone told me that [Resident #31] said I told him to shut up and go to bed. I may have told him to try to get some sleep which I tell a lot of residents to try to get some sleep. I've been a NA for 32 years and have never told a resident to shut up. On 10/28/25 at approximately 1:55 PM, during an interview with Resident #30, a roommate of Resident #31, Resident #30 stated that he had been out of the facility on 10/16/25. Still, he stated, I heard about it when I got back!Ongoing record review revealed that the five-day follow-up report to OHFLAC had been submitted on 10/22/25 at approximately 3:26 PM.The investigative summary stated the following: On 10/20/25, at approximately 7:20 AM, a resident reported a prior incident allegedly involving verbal mistreatment by an NA that occurred on 10/17/25 around midnight. The resident stated that when he requested food, the NA told him to shut up and go to sleep and that there was nothing to eat.Immediate actions:Resident safety ensured, reassurance provided that the allegation would be reported and investigated as per facility policy. Charge Nurse, Supervisor, and DON notified immediately .NA was suspended pending investigation to protect resident safety and maintain impartiality.Incident reported to the Sheriff's Office per mandatory reporting guidelines. Interviews conducted with the resident, involved NA, and other staff on duty at the time of the alleged incident. No witnesses or corroborating evidence were found to support the allegation. The facility documented that the Investigation had determined that there was insufficient evidence to substantiate the allegation of verbal mistreatment.Notwithstanding the fact that Resident #31 had presented with a blood glucose level of 40 on the morning of 10/17/25, and had also expressed his frustration regarding the incident, the facility investigation and summary of the incident stated that No physical or emotional harm identified in the resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Tree Healthcare Center

1263 South George Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

verbal mistreatment by an NA that occurred on 10/17/25 around midnight. The resident stated that when requesting food, the NA told him to shut up and go to sleep, and there was nothing to eat.Immediate actions:Resident safety ensured, reassurance provided that the allegation would be reported and investigated as per facility policy. Charge Nurse, Supervisor, and DON notified immediately .NA was suspended pending investigation to protect resident safety and maintain impartiality.Incident reported to the Sheriff's Office per mandatory reporting guidelines. Interviews conducted with the resident, involved NA, and other staff on duty at the time of the alleged incident. No witnesses or corroborating evidence were found to support the allegation. The facility documented that the Investigation had determined that there was insufficient evidence to substantiate the allegation of verbal mistreatment.Notwithstanding the fact that Resident #31 had presented with a blood glucose level of 40 mg/dl on the morning of 10/17/25, and had also expressed his frustration regarding the incident, the facility investigation and summary of the incident stated that No physical or emotional harm identified in the resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Tree Healthcare Center

1263 South George Street Charles Town, WV 25414

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #31's statement by saying, I heard it! Resident #31 stated that a nurse had come into the room a little while later, and he had complained to her. The nurse checked him and, upon finding that Resident #31 had soiled himself, called NA #90 back and asked her to get him cleaned up.During an interview with the Director of Nursing (DON) at approximately 10:00 AM, on 10/28/25, the DON stated that she was unaware of the incident. The DON immediately began an investigation and submitted an initial report to the Office of Health Facility Licensing and Certification (OHFLAC).

Event ID:

Facility ID:

If continuation sheet