Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Homewood Living Martinsburg, Inc during CMS and state inspections, most recent first.
A facility failed to provide written notice to residents and their representatives explaining the reason for hospital transfers for four residents. The records showed transfers related to urinary retention, a change in condition, a fall with injury, and respiratory symptoms, but there was no documentation that written notification was sent. The DON and DOR confirmed the notices were not automatically provided and were missing from the charts.
A resident’s Broda chair had a left armrest cover that was torn and shredded over a large area while the resident was resting in the chair on multiple observations. An RN supervisor and the DON confirmed the armrest cover was damaged and should not have been torn or shredded.
A resident with moderate cognitive impairment and hypothyroidism had a physician order for a TSH test, but staff did not obtain the lab as ordered. There was no documented evidence that the test was completed, and the DON confirmed the missing documentation.
The facility failed to update care plans for two residents with specific medical needs. One resident with a midline catheter did not have related care interventions in their plan, and another resident diagnosed with epilepsy lacked a seizure disorder care plan. These omissions were confirmed by the DON.
A facility failed to update a resident's care plan to reflect the need for diuretic medication, despite the resident receiving Furosemide as ordered. The resident, who was cognitively impaired and had diagnoses including respiratory failure and hypertension, required assistance with care needs. The deficiency was confirmed by the DON.
A resident in an LTC facility was mistakenly given another resident's medication due to a staff member's distraction. The resident, who had renal failure and dementia, received multiple incorrect medications and was sent to the ER for evaluation. The incident was confirmed by the DON.
The facility failed to ensure a safe environment and proper resident handling, as evidenced by a hot plate accessible to residents and improper wheelchair transport and transfer techniques. A resident accessed hot water from a hot plate, and another was transported without leg rests. Additionally, a resident was assisted to stand without a gait belt, contrary to policy. The DON was unaware of these issues.
A resident with cognitive impairment and significant weight loss did not have their weight documented on multiple occasions, despite physician's orders for weekly weigh-ins. The resident was on a mechanically altered diet and had several medical conditions, including dementia and respiratory failure. The DON confirmed the weights were not obtained as ordered.
A facility failed to obtain necessary documentation from a hospice provider for a resident receiving end-of-life care. Despite the resident's cognitive impairment and need for assistance, there was no evidence of progress notes from hospice staff in the clinical record. The DON confirmed that hospice communication records should have been accessible but were not.
A registered nurse failed to follow infection control procedures during incontinent care for a resident with moderate cognitive impairment and dementia. The nurse did not remove gloves or perform hand hygiene after providing care and before assisting the resident further, contrary to the facility's hand hygiene policy. Both the nurse and the DON confirmed the lapse in procedure.
The facility failed to follow physician's orders for two residents, leading to significant deficiencies. One resident received another's medication, resulting in hospitalization for bradycardia and hypotension. Another resident did not receive Zoloft for two weeks due to transcription errors. The DON confirmed the errors in both cases.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for hospital transfers for four residents reviewed. The facility’s policy for Admission, Transfer and Discharge Notification, dated January 8, 2025, did not indicate that written notification would be provided upon transfer to the hospital. Review of the records for Resident 9, Resident 37, Resident 76, and Resident 110 showed hospital transfers related to urinary retention and unsuccessful straight catheterization, a change in condition, a fall with injury, and fever with cough and shortness of breath, respectively, but there was no documented evidence that written notice of the transfer reason was given to the residents or their representatives. Resident 9 was cognitively impaired and had an indwelling urinary catheter; he was sent to the emergency room after he could not urinate and attempts to straight catheterize him were unsuccessful. Resident 37 was cognitively intact, required assistance with all daily care needs, and had congestive heart failure; he was transferred to the hospital after a change in condition. Resident 76 was cognitively impaired, required assistance with daily care needs, and had Alzheimer’s disease; she was transferred after a fall with injury. Resident 110 was cognitively intact, required assistance with daily care needs, and had a total hip replacement; he was transferred after developing a temperature, cough, and shortness of breath. The Director of Admissions and the DON confirmed that the facility was not automatically sending written notification and that documentation of written notification was absent for these residents.
Damaged Broda Chair Armrest Left Resident Without a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident, Resident 14, because the left armrest on the resident’s Broda chair was observed to have an area approximately 12 inches by 6 inches that was torn and shredded. Observations on December 8, 2025, December 9, 2025, and December 10, 2025 showed the resident resting in the chair with the damaged armrest cover still present. A RN Supervisor confirmed that the left armrest cover had a large area that was torn and shredding off and stated that it should not be. The DON also confirmed that Resident 14’s Broda chair should not have armrests and/or headrests that are torn or shredded.
Failure to Obtain Ordered TSH Test
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for one resident. The facility’s laboratory and diagnostic test policy stated that the physician would identify and order diagnostic and laboratory testing based on the resident’s diagnostic and monitoring needs. An admission MDS for the resident showed moderate cognitive impairment and a diagnosis of hypothyroidism. Physician orders included a TSH test, but there was no documented evidence that staff obtained the TSH as ordered. The DON confirmed during interview that there was no documented evidence the TSH level was obtained as ordered by the physician.
Failure to Update Care Plans for Residents with Specific Medical Needs
Penalty
Summary
The facility failed to develop individualized care plans for two residents, which is a requirement according to their policy for Comprehensive, Person-Centered Care Plans. Resident 28, who was cognitively impaired and required assistance with care needs, had a midline catheter for intravenous access. However, the resident's care plan did not include any information or interventions related to the care and use of the midline catheter. This omission was confirmed by the Director of Nursing during an interview. Similarly, Resident 105 experienced two seizure episodes and was subsequently diagnosed with epilepsy after being admitted to the hospital. Despite this significant change in the resident's condition, the care plan did not include any information or interventions related to the resident's seizure disorder. This deficiency was also confirmed by the Director of Nursing. The lack of updated care plans for these residents indicates a failure to meet the facility's policy requirements for comprehensive, person-centered care planning.
Failure to Update Resident Care Plan for Diuretic Medication
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect the resident's specific care needs. The deficiency was identified for one of the 44 residents reviewed, specifically Resident 25. The facility's policy for Comprehensive Person-Centered Care Plans requires that care plans be revised as information about the resident's condition changes. However, the care plan for Resident 25 was not updated to include the need for diuretic medication, despite the resident receiving Furosemide as ordered. Resident 25 was cognitively impaired, required assistance with care needs, and had diagnoses including respiratory failure and hypertension. The resident's quarterly Minimum Data Set assessment indicated the need for diuretic medication, which was confirmed by current physician's orders. Despite this, there was no documented evidence that the care plan was revised to reflect the resident's need for diuretic medication. This was confirmed during an interview with the Director of Nursing.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered correctly to a resident, identified as Resident 89. The incident involved a staff member who became distracted and mistakenly administered another resident's medication to Resident 89. This error was documented in a nursing note dated October 21, 2024, at 10:15 p.m. The resident, who was cognitively impaired and required assistance with care needs, had diagnoses including renal failure and dementia. Following the medication error, Resident 89 was sent to the emergency room for further evaluation and treatment to monitor for any possible drug interactions. The medications incorrectly administered to Resident 89 included Tylenol, Zyprexa, Atorvastatin, Famotidine, Levetiracetam, Lithium, Hydroxychloroquine, and Effexor. An interview with the Director of Nursing confirmed the medication error and the subsequent hospital evaluation. The report highlights the failure in medication administration, which was identified as past non-compliance during the review of clinical records, observations, and staff interviews.
Failure to Maintain Safe Environment and Proper Resident Handling
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by the presence of a hot plate in the main dining room that was accessible to residents. Observations revealed that a resident was able to pour hot water from a coffee pot placed on the hot plate, which was at waist height and within reach. Interviews with the resident, a family member, and a dietary aide confirmed that typically staff serve hot beverages to residents, but the hot plate's accessibility posed a potential hazard. The Director of Nursing was unaware of the hot plate's location and acknowledged the need for its immediate removal. Additionally, the facility did not adhere to its policy regarding the safe transportation of residents in wheelchairs. A cognitively impaired resident, dependent on staff for mobility, was transported without leg rests, causing her feet to drag. Nurse aides involved in the transport confirmed the oversight, and the Director of Nursing acknowledged the requirement for leg rests. Furthermore, a resident with moderate cognitive impairment was assisted to stand and walk without the use of a gait belt, contrary to facility policy. The registered nurse involved confirmed the omission, and the Director of Nursing acknowledged the necessity of using a gait belt for safe resident transfers.
Failure to Obtain Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain weights as ordered by the physician for a resident who experienced weight loss. The resident, who was cognitively impaired and required supervision with eating, was on a mechanically altered diet and had a significant weight loss. The resident also received diuretic medication, oxygen, and had diagnoses of dementia, depression, anxiety, and respiratory failure. Physician's orders required the resident to be weighed weekly over several specified periods, but the facility did not document the resident's weight on multiple occasions. Specifically, the resident's weight was not documented on August 19, September 9, October 18, and November 14, 2024, despite physician's orders to do so. An interview with the Director of Nursing confirmed that the weights were not obtained as ordered on these dates. This failure to follow physician's orders for weight monitoring was identified as a deficiency in the facility's nursing services.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the required information was obtained from the contracted hospice provider for a resident receiving hospice services. The facility's policy indicated that the hospice agency is responsible for the professional management of the plan of care related to the terminal illness and must communicate any changes to the facility. However, there was no documented evidence of progress notes from the hospice registered nurse or the hospice nurse aide in the resident's clinical record since the start of hospice services. The resident in question was cognitively impaired, required assistance for daily care needs, and had diagnoses including dementia and Alzheimer's disease. Despite being admitted to hospice services, the facility did not have the necessary hospice communication records readily accessible in the resident's clinical record. The Director of Nursing confirmed that it was the facility's practice to obtain paperwork from hospice agencies weekly, but this was not done in this case.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to consistently implement infection control procedures during incontinent care for a resident. The facility's policy on hand hygiene, dated January 10, 2024, emphasizes hand hygiene as the primary means to prevent the spread of healthcare-associated infections. It requires hand hygiene after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. An observation on November 18, 2024, revealed that a registered nurse did not follow these procedures while providing care to a resident with moderate cognitive impairment and dementia. During the incident, the registered nurse assisted the resident, who was both continent and incontinent of urine, by removing a soiled brief and changing the resident's soiled pants. The nurse then cleansed the resident's buttocks area and assisted the resident to a standing position without removing her gloves or performing hand hygiene. The nurse continued to assist the resident by rubbing her back and helping her to sit in a recliner, still without removing her gloves. Both the nurse and the Director of Nursing confirmed that the nurse should have removed her gloves and performed hand hygiene after providing toileting care and before touching the resident's belongings.
Medication Administration and Transcription Errors
Penalty
Summary
The facility failed to follow physician's orders and properly administer medication for two residents, leading to significant deficiencies. For one resident, who was cognitively impaired and had Alzheimer's disease, the facility administered another resident's medication, which included Lopressor, Senna, Cardizem, Gabapentin, and Seroquel. This error resulted in the resident experiencing bradycardia, hypotension, and a nosocomial overdose, necessitating hospitalization and admission to the ICU for observation. The Director of Nursing confirmed that the medication nurse did not verify the resident's identity before administering the medication. In another case, the facility failed to transcribe a physician's order correctly for a resident who was also cognitively impaired and had Alzheimer's disease. A verbal order for Zoloft was taken by a registered nurse, but the medication was discontinued in error, and the incorrect start date was recorded. As a result, the resident did not receive the prescribed Zoloft for two weeks. The Director of Nursing confirmed that the registered nurse should have verified the medication transcription to ensure accuracy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 191 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Martinsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morrisons Cove Home | 0.1 mi | ★★★★★ | 8 | 0 |
| Presbyterian Homes-presby | 9.1 mi | ★★★★★ | 8 | 0 |
| Lutheran Home At Hollidaysburg | 9.5 mi | ★★★★★ | 14 | 0 |
| Hollidaysburg Veterans Home | 9.6 mi | ★★★★★ | 6 | 0 |
| Garvey Manor | 10.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Homewood Living Martinsburg, Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.