Martinsburg Healthcare Center

In the surveyor’s words

From the most serious findings on record at Martinsburg Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Jun 25, 2025

  Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in six (6) rooms. Room identifiers: #136, #143, #147, #149, #151, and #160. This was a random opportunity for discovery. Facility census: 117. Findings included: a) Upon survey entrance on 06/16/25 at 1:58PM, it was observed the following issues in Resident room numbers: room [ROOM NUMBER]: - wallpaper loose with air bubbles on the wall beside the bathroom door approximately 3 feet from the floor - wallpaper loose with air bubbles on the window wall beside bed B, approximately 2 feet from the floor - scuffs and black marks on the inside of the bathroom door - A Large circular hole in the bathroom wall behind the toilet approximate size 6 inches… […]

• No harm, potential for more than minimal, patternF628Jun 25, 2025

  Based on record review and staff interviews, the facility failed to perform an accurate discharge process for two (2) of 3 residents reviewed during the survey process for hospitalization. Resident identifiers: #30, and #279. Facility census: 115 Findings included: a) Resident #30 Resident has capacity to make her own medical decision. The resident was on hospital leave from 03/23/25 until 03/26/25. There was no documentation to support the ombudsman was notified of the transfer. The facility was unable to provide a Bed Hold Notice for this hospital leave. This form was requested from the DON on 06/18/25 at 11:57 AM. […]

• No harm, potential for more than minimal, patternF812Jun 25, 2025

  Based on observation, interview and policy review the facility failed to properly store and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility. Facility census: 117. Findings included: a) On 06/16/25 11:35 AM, during the Initial Brief Tour of Kitchen, with Assistant Dietary Manager #182 acknowledged the following: In the Freezer it was observed that a bag of frozen Hamburger patties were left opened and exposed. On 06/17/25 at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. […]

• No harm, potential for more than minimal, patternF880Sep 19, 2023

  Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to resident handwashing. This practice had the potential to affect more than an isolated number of residents. Facility census: 116. Findings included: a) Meal tray pass An observation during dining observation on 09/19/23, at 11:45 PM revealed the residents in the north dining room, did not receive hand hygiene prior to or during the lunch meal tray pass. […]

• No harm, potential for more than minimal, patternF697May 24, 2023

  Based on record review and staff interview, the facility failed to administer pain medication as ordered by the physician. This was true for one (1) of five (5) records reviewed for pain management. This failed practice has the potential to affect a limited number of resdents. Resident identifier: #424 Facility census: #115. Findings included: a) Resident #424 On 05/24/23 at 4:08 PM, it was noted the facility did not follow physicians orders for administering pain medication for Resident #424. The physicians order with a revision date of 11/19/22 was for Oxycodone HCL tablet 5 mg give 1.5 tablet by mouth every 6 hours for pain. For the review period of 11/01/22 through 12/31/22 there were nine (9) doses of Oxycodone not administered. […]