Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Care Haven Center during CMS and state inspections, most recent first.
The facility failed to maintain food and beverages at palatable and safe temperatures, contrary to its policy requiring hot foods above 135°F and cold foods below 41°F. Multiple residents reported that hot foods were served cold and meals were not palatable, and a test tray showed bland, barely warm Salisbury steak and scalloped potatoes. Observations of meal service revealed delays as staff plated about a dozen meals at once before delivery, and trays for room service were held on carts until full before being taken to hallways. Temperature checks by the Dining Manager found cold items such as peaches and milk above safe cold-holding temperatures, and residents reported cold hotdogs and soup and very soft ice cream, with the Dining Manager confirming that hot items were too cold and cold items too warm on test trays.
Surveyors identified multiple failures to follow professional food safety standards, including a dietary staff member working without a hairnet and with unrestrained hair, dried sticky residue on the ice maker and in a two-bowl sink, food debris in containers holding lids and ketchup packets, and sugar substitute packets on the dry storage floor. In the walk-in refrigerator, a case of bananas was found dark brown and very soft well after the recorded receive date, and a reach-in refrigerator had a dried white substance along the door edges and gasket. Insulated plate bases on food delivery carts were stacked while still wet, resulting in wet nesting of all observed bases. These conditions occurred while approximately 65 residents depended on the kitchen for nourishment.
Incomplete care plans were identified for three residents. One resident had a nutrition plan directing staff to monitor intake at all meals, but meal percentage documentation was missing or incomplete on multiple days. A second resident, with multiple chronic conditions and nutritional risk, also had repeated gaps in meal intake documentation despite a care plan requiring monitoring at every meal. A third resident admitted to Hospice had no Hospice care plan in place, and the DON confirmed it was missing.
Incomplete meal documentation was identified for a resident after record review showed that over a 23-day period, only six days had all three meals documented. During interview, the DON confirmed that meal documentation should be completed for each meal a resident receives.
A resident receiving IV antibiotics through a PICC line had a dressing that was dated to show it had not been changed within the required interval. The facility policy called for PICC dressings to be changed every 7 days, but the DON confirmed the dressing should have been changed and there were no physician orders for PICC line dressing changes.
Failure to provide ordered fortified foods for two residents. One resident had a physician-ordered diet with fortified foods at each meal, but the lunch tray and tray ticket did not reflect the order, and the Kitchen Account Manager stated she was not on fortified food. Another resident’s tray ticket showed fortified mashed potatoes, but the potatoes were missing from the tray, and the DON confirmed the resident did not receive them as ordered.
A facility failed to adhere to food safety standards during a kitchen tour. The Dietary Manager (DM) was observed using gloved hands to handle food and various surfaces without changing gloves, potentially spreading germs. The DM admitted to insufficient cleaning practices and acknowledged the risk of contamination.
The facility failed to maintain scheduled mealtimes, affecting residents relying on the kitchen for nutrition. An observation revealed that lunch was not served on time, with 16 residents waiting in the dining room. The lunch meal was scheduled for 12:15 PM, but delays were common, as confirmed by a nurse aide. The CDM attributed the delay to a late breakfast service. Drinks were served at 1:05 PM, and the first tray at 1:20 PM.
A resident was observed lying in bed with an unopened meal tray, and later, a nurse aide was seen standing over the resident while feeding her. This was confirmed by the DON, indicating a failure to maintain the resident's dignity during meal service.
A facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form before the end of Medicare Part A covered services. The resident began receiving services in mid-August, with coverage ending later that month. Although a Notice of Medicare Non-Coverage was signed, the SNF ABN form was not issued, which is necessary when Medicare may not cover certain care. This oversight was confirmed by the Clinical Reimbursement Coordinator.
The facility failed to maintain the confidentiality of residents' medical records when a pharmacist's medication review document containing the names and medication information of two residents was scanned into the wrong medical record. This error led to the inappropriate sharing of personal health information, confirmed by the DON.
The facility failed to report an alleged abuse incident involving a resident within the required time-frames. Staff witnessed a nurse aide clapping and yelling at a resident, but the incident was not reported to the appropriate agencies until much later. The Administrator and DON confirmed the delay in reporting, despite all employees being mandatory reporters.
A facility failed to create a comprehensive care plan for a resident with PTSD. The existing plan included general interventions but lacked specific PTSD triggers and staff interventions. A social worker admitted to not knowing the reason for the resident's PTSD diagnosis, highlighting a deficiency in the resident's care planning.
A resident was not provided with necessary assistance during meal times, as observed on two occasions. The resident was left with a lunch tray without eating assistance and was later seen with food spillage while trying to drink sherbet. The DON confirmed the resident needed meal assistance and intervened.
A resident was observed on two occasions with a meal tray but without receiving necessary assistance to eat. The resident was not eating during one observation and had food spillage during another. The DON confirmed the resident required meal assistance and intervened.
A resident was found to have conflicting diet orders in their medical record, with one order for a 2 gm Sodium diet with Dysphagia Advanced texture and another for a 2 gm Sodium diet with Regular Texture. The DON confirmed the discrepancy and noted that the regular texture diet should have been discontinued.
The facility failed to maintain accurate medical records for two residents. One resident's record inaccurately documented a nurse practitioner's visit at the facility after the resident had been hospitalized. The DON clarified that the visit was a telehealth session conducted before the hospitalization, and the date was recorded incorrectly.
A resident with a dialysis port in the right upper chest had a physician's order not to take BP in the right arm. Despite this, nurses documented taking BP in the right arm. The DON stated the order was precautionary and not harmful, but the care plan was not followed, resulting in a deficiency.
Failure to Maintain Palatable Food and Safe Serving Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and beverages were palatable and maintained at safe and appetizing temperatures, as required by facility policy. The policy stated that hot foods must be held at greater than 135°F and cold foods at less than 41°F. During the survey, interviews with 18 of 23 sampled residents revealed consistent complaints that hot foods were being served cold and that meals were not palatable. A test tray served to surveyors showed the Salisbury steak tasted bland and the scalloped potatoes had minimal flavor and were barely warm. Resident council and food committee minutes documented that residents, as a group, agreed the food was cold, and the Dietary Manager acknowledged hearing these complaints. Surveyors observed the meal service process, noting that a staff member placed approximately 12 plates on the counter and the cook then added each meal item one by one to all plates, taking up to 10 minutes before the plates were served or placed on trays. Trays for room delivery were loaded onto a meal cart and transported to hallways after the cart was full, further delaying service. Temperature checks by the Dining Manager on test trays showed cold items above required cold-holding temperatures, including peaches at 52.2°F and milk at 48.0°F and 51.1°F. During a noon meal observation, multiple residents reported that hotdogs and soup were cold or only semi-warm, and that ice cream was very soft. The Dining Manager confirmed that the hotdog and soup were too cold and that the ice cream and milk were too warm, demonstrating that hot foods were not consistently served hot and cold foods were not consistently served cold across multiple hallways and meals.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, affecting residents receiving nourishment from the kitchen. Review of facility policy showed that food was to be stored, prepared, distributed, and served in a manner ensuring food service safety, sanitary conditions, and prevention of foodborne illnesses. During a kitchen tour, a staff member was observed working without a hairnet, wearing a cap with unrestrained dreadlocks. The same staff member verified multiple sanitation issues, including a dried sticky substance on top of the ice maker, food debris in a container holding lids, and a dried red sticky residue in a two-bowl sink. In the walk-in refrigerator, a case of bananas dated as received on 12/23/25 was dark brown and very soft. In the dry stock room, food debris was present in the bottom of a container holding ketchup packets, and several packets of sugar substitute were found on the floor. In a reach-in refrigerator, a dried white substance was observed along the edges inside the door and along the gasket. Additionally, surveyors observed insulated plate bases on food delivery carts stacked in a wet-nesting manner, with 10 of 10 bases wet and not properly air-dried, which was verified by the Dining Manager. The facility census at the time of the survey was 65 residents, and the identified issues had the potential to affect more than a limited number of residents receiving nourishment from the kitchen.
Incomplete Care Plans for Nutrition and Hospice Services
Penalty
Summary
The facility failed to develop and/or implement complete care plans related to Hospice services and meal intake percentages for 3 of 23 residents reviewed. For Resident #5, the care plan directed staff to monitor intake at all meals, but meal percentage documentation was incomplete on 15 of 30 days reviewed, with only one or two meals recorded on those dates. The DON confirmed that all three meal percentages had not been documented for this resident. For Resident #12, the comprehensive care plan identified the resident as being at nutritional risk related to multiple diagnoses including Parkinson's disease, DM2, CKD stage 4, anemia, edema, obesity, depression, COPD, GERD, constipation, HTN, and a history of significant weight loss, and it directed staff to monitor intake at all meals, offer alternate choices as needed, and alert the dietitian and physician to any decline in intake. Meal intake percentages were not documented for all three meals on multiple days during the 30-day review period, including days with only one or two meals recorded and several days with no meals documented. For Resident #65, the record showed an order admitting the resident to Hospice Services, but a Hospice care plan had not been put in place, and the DON confirmed that the Hospice care plan was missing.
Incomplete Meal Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record related to resident meal percentages for Resident #14. A review of meal documentation for the period from 12/22/25 to 01/14/26 showed that out of 23 days, only six days had all three meals documented. During an interview on 01/20/26 at 10:59 AM, the DON confirmed that documentation should be completed for each meal a resident receives.
PICC Line Dressing Not Changed as Required
Penalty
Summary
The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice for a resident with a PICC line. Resident #30 had a right arm PICC line used to receive intravenous antibiotics, and the facility policy stated that PICC line dressings were to be changed every seven days. On 01/19/26, the dressing on the resident’s PICC line was observed with a date of 01/07/26 written on it to show when it had last been changed. Review of the medical record showed the catheter had been inserted in the hospital before admission, and there were no physician’s orders for PICC line dressing changes. The DON confirmed that the date on the dressing was 01/07/26 and that the dressing should have been changed.
Failure to Provide Ordered Fortified Foods
Penalty
Summary
Therapeutic diets were not followed for fortified foods for two residents. Resident #1 had a physician order dated 12/08/25 for a regular/liberalized diet with regular texture, thin liquids, and fortified food with all meals, including oatmeal with breakfast, mashed potatoes with lunch, and pudding with dinner. On 01/21/26 at 1:14 PM, the resident was observed eating lunch in her room, and her tray did not include mashed potatoes; the meal tray ticket also did not note fortified food. The Kitchen Account Manager stated the resident was not on fortified food, and the Administrator later confirmed that Resident #1 did have an order for fortified food at each meal, but it was not reflected on the meal tray ticket. Resident #14 was observed on 01/21/26 at 1:15 PM eating lunch in bed, and her tray ticket indicated she was to receive 1/2 cup of fortified mashed potatoes, but the mashed potatoes were not on the tray. Resident #14 stated that there were many times she did not get the mashed potatoes, and the DON confirmed that Resident #14 did not receive fortified potatoes as ordered.
Food Safety Standards Not Met in Kitchen
Penalty
Summary
During an initial kitchen tour, the facility was found to have failed to serve food in accordance with professional standards for food safety. The Dietary Manager (DM) was observed using gloved hands to dip food, touch and open hamburger buns, and handle serving scoops, the plate warming cart, the counter, bowls, and the bowl rack, as well as the surrounding environment. The DM was also seen using a plate lifter to retrieve plates from the warmer and suctioning the plate lifter to the countertop when not in use. In an interview, the DM admitted to only cleaning the top counter after breakfast, lunch, and dinner and acknowledged that suctioning the plate lifter to the countertop could spread germs. The DM confirmed touching the environment and the residents' hamburger buns without changing gloves.
Failure to Maintain Scheduled Mealtimes
Penalty
Summary
The facility failed to maintain regularly scheduled mealtimes, which had the potential to affect all residents relying on the kitchen for nutrition. On 09/03/24, an observation at 12:30 PM revealed that the lunch meal had not been served, with 16 residents waiting in the dining room. The posted mealtime for lunch was 12:15 PM daily. Nurse Aide #29 confirmed that the lunch meal was late most days. The Certified Dietary Manager (CDM) verified that the noon meal was not served on time, attributing the delay to a late breakfast service. Drinks were not served until 1:05 PM, and the first tray was served at 1:20 PM.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to treat a resident with respect and dignity during meal service. An observation was made of a resident lying in bed with her noon meal tray sitting unopened on the bedside table. A subsequent observation revealed that a nurse aide was standing over the resident while feeding her in bed. This action was confirmed by the Director of Nursing during an interview, who acknowledged the situation.
Failure to Provide SNF ABN Form to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to a resident during an annual survey. This deficiency was identified through a record review and staff interview, which revealed that the resident, who had been receiving Medicare Part A skilled services, did not receive the SNF ABN form prior to the end of her covered services. The resident began receiving Medicare Part A services on August 15, 2024, with the last covered day being August 28, 2024. Although a Notice of Medicare Non-Coverage (NOMNC) was signed and dated on June 26, 2024, the SNF ABN form was not provided, which is required when care that Medicare usually covers may not be paid for because it is not medically reasonable and necessary or considered custodial. The Clinical Reimbursement Coordinator acknowledged this oversight.
Failure to Protect Residents' Medical Record Confidentiality
Penalty
Summary
The facility failed to protect the personal privacy and confidentiality of residents' medical records. This deficiency was identified during a survey when a pharmacist's medication regimen review document, dated 8/28/24, was found to contain the names and medication information of two residents on a single printed sheet. The document, titled 'PharMerica Recommendation maintain current dose Citalopram .pdf,' was incorrectly scanned into the medical record of one resident while also being present in the correct resident's record. This error resulted in the combined personal health information of both residents being accessible inappropriately. The Director of Nursing (DON) confirmed the presence of this combined information upon review.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged violation related to neglect or abuse within the prescribed time-frames. An investigation into a Facility Reported Incident of abuse involving a resident revealed that the incident, which occurred on March 23, 2024, was not reported to the appropriate agencies until April 5, 2024. Multiple statements from registered nurses and a nurse aide indicated that they witnessed a nurse aide clapping her hands and yelling at the resident on the date of the incident. During an interview with the Administrator and Director of Nursing on September 5, 2024, it was confirmed that the incident was not reported within the required time-frames. It was also verified that all employees at the facility were mandatory reporters, highlighting a failure in adhering to mandatory reporting obligations.
Failure to Develop Comprehensive Care Plan for PTSD Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The care plan for the resident included goals and interventions such as providing a calm environment, explaining care procedures, and offering social service visits. However, during an interview, a social worker admitted to not knowing the reason for the resident's PTSD diagnosis and acknowledged the absence of care-planned PTSD triggers or appropriate staff interventions. This deficiency was identified during a record review and staff interview, affecting the resident's ability to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to ensure that a resident received necessary assistance with meals, as observed during two separate meal services. On one occasion, a lunch tray was placed in front of the resident, who was not eating and was not offered any assistance. On another occasion, the resident was observed with food spillage all over her while attempting to drink her sherbet, with a phone receiver lying in the middle of her tray. During an interview, the Director of Nursing confirmed that the resident required assistance with meals and subsequently went to provide help.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to ensure that a resident received necessary assistance with meals, which was identified during a survey. On two separate occasions, the resident was observed with a meal tray in front of her but without receiving any assistance to eat. On the first occasion, the resident was not eating, and no staff offered help. On the second occasion, the resident was observed with food spillage and attempting to drink her sherbet, with a phone receiver placed on her tray. During an interview, the Director of Nursing confirmed that the resident required assistance with meals and subsequently went to provide help.
Conflicting Diet Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct therapeutic diet, as evidenced by conflicting diet orders in the resident's medical record. The resident, identified as #119, had two different diet orders: a 2 gm Sodium diet with Dysphagia Advanced texture and Standard Thin Liquids consistency, dated 09/02/24, and a 2 gm Sodium diet with Regular Texture and Standard Thin Liquids consistency, dated 08/26/2024. During an interview, the Director of Nursing confirmed the presence of these conflicting orders and acknowledged that the regular texture diet should have been discontinued from the active orders.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents during the Long-Term Care Survey Process. For one resident, a record review revealed that the resident had been hospitalized and had not returned to the facility. However, there was a nurse practitioner (NP) note dated after the hospitalization, indicating a visit at the facility, which was incorrect. The note detailed the resident's condition, including no signs of pain, a recommendation for hospice care that was declined, and ongoing rehabilitation for weakness. The Director of Nursing (DON) later clarified that the NP visit was a telehealth session conducted before the resident's hospitalization, and the date of service was erroneously recorded in the chart.
Failure to Follow Physician's Orders for Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident had a physician's order dated 08/14/24, specifying that blood pressure (BP) should not be taken in the right arm. However, a medical record review on 09/05/24 revealed that nurses documented taking the resident's BP in the right arm. The resident had a dialysis port located in the right upper chest, and the care plan included monitoring the hemodialysis catheter site for signs of infection, edema, and bleeding. Despite the order, the Director of Nursing stated that the precautionary order was not necessary and that taking BP in the right arm would not harm the resident. The order and care plan were not followed, leading to the deficiency.
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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.
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Nursing homes near Martinsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Martinsburg Healthcare Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Canterbury Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Shenandoah Center | 10.6 mi | ★★★★★ | 10 | 0 |
| Willow Tree Healthcare Center | 11.4 mi | ★★★★★ | 3 | 0 |
| Williamsport Health And Rehabilitation Center | 13.8 mi | ★★★★★ | 11 | 1 |
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