Homewood Living Martinsburg, Inc

In the surveyor’s words

From the most serious findings on record at Homewood Living Martinsburg, Inc, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 14, 2021

  Based on review of clinical records and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, by failing to follow a resident's care plan while providing care for one of two residents reviewed (Resident 1), resulting in harm due to a fall from the bed with a fracture. This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 24, 2021, revealed that the resident had severe cognitive impairment; had impaired hearing; required the extensive assistance of two staff for bed mobility, transfers and toilet use; and had a history of [MEDICAL RECORD OR… […]

• No harm, potential for more than minimal, patternF628Dec 11, 2025

  Based on review of clinical records as well as staff interviews, it was determined that the facility failed to notify the resident and resident representative in writing regarding the reason for hospitalizations, for four of 37 residents reviewed (Resident's R9, R37, R76 and R110). Findings include: The facility's policy for Admission, Transfer and Discharge Notification, dated January 8, 2025, did not indicate that upon transfer to the hospital the resident and legal guardian would be notified in writing. An admission MDS for Resident 9, dated October 19, 2025, indicated that the resident was cognitively impaired and had an indwelling urinary catheter (tube placed in the bladder to drain urine). A nurse's note for Resident 9, dated October 29, 2025, at 7:53 a.m. […]

• No harm, potential for more than minimal, patternF693Jan 6, 2023

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that gastrostomy tube care was provided as ordered by the physician for one of 32 residents reviewed (Resident 50). Findings include: The facility's policy regarding gastric residual volume (GRV), dated January 31, 2022, revealed that staff were to check the GRV when the resident was not tolerating the enteral feedings, had a marked position change of the tube, the appearance and pH (a measure of the acidity) of the aspirate suggest the tube was misplaced, or when ordered by the physician. […]

• No harm, potential for more than minimal, patternF558Feb 3, 2022

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to accommodate the family's preference for a shower or tub bath for one of 43 residents reviewed (Resident 100). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 100, dated November 29, 2021, indicated that the resident was confused, was totally dependent on two staff for bathing, and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment, dated February 17, 2021, indicated that the family participated with the completion of the assessment and preferred that the resident get a tub bath or shower. […]

• No harm, potential for more than minimal, isolatedF584Dec 11, 2025

  Based on observations and staff interviews, it was determined that the facility failed to provide a homelike environment for one of 37 residents reviewed (Resident 14). Findings include: The facility's policy entitled Homelike Environment, dated January 8, 2025, indicated that residents will be provided with a safe, clean comfortable and homelike environment. Observations of Resident 14's Broda Chair (a specialized chair designed primarily for individuals with mobility challenges and physical disabilities) on December 8, 2025 at 10:42 a.m.; December 9, 2025 at 1:19 p.m.; and December 10, 2025, at 2:20 p.m. revealed that the resident was resting in her chair and the left armrest had an area approximately 12 inches by 6 inches that was torn and shredded. […]