Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Martinsburg Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple environmental deficiencies in six resident rooms, including loose wallpaper, scuff marks, large holes in bathroom walls, and damaged trim and paint. These issues were confirmed through observation and staff interviews, indicating a failure to maintain a safe, clean, and homelike environment.
The facility did not provide required discharge documentation and notifications for two residents who were hospitalized, including missing Bed Hold Notices and lack of ombudsman notification. The DON and NHA confirmed that the necessary forms could not be located.
Surveyors identified improper food storage, including open bags of hamburger patties and macaroni, and a refrigerator operating above safe temperatures. Additionally, a dietary employee failed to change gloves or wash hands after touching contaminated surfaces before preparing resident food trays. These deficiencies had the potential to affect all residents in the facility.
A dependent resident who lacked capacity was found in bed with soaked sheets and clothing, indicating that timely incontinence care was not provided. Despite documentation from the night shift aide stating the resident had been changed and bathed, subsequent staff discovered the resident in a soiled state and had to perform a full bed bath and linen change.
A resident with respiratory failure and hypoxia was repeatedly observed receiving oxygen at a higher flow rate than prescribed by the physician. Despite orders for 2 liters per minute, the oxygen concentrator was set between 2.5 and 3 liters per minute on several occasions, as confirmed by observation and record review.
A consulting pharmacist did not identify or notify the physician about potential adverse drug reactions from the concurrent use of opioids and benzodiazepines for a resident with multiple diagnoses and a documented allergy to tramadol, which was prescribed despite the allergy. The resident was frequently observed asleep, and there was no documentation addressing drug interactions, adverse reactions, or the resident's sleep patterns.
Surveyors found expired syringes stored in the North Medication Room, with an LPN confirming the presence of 31 expired BD 1 ML syringes and 7 expired Insyte 24 GA x 0.75 in injection syringes. These expired supplies were accessible to staff for resident care, showing a failure to monitor and dispose of expired medical supplies.
Surveyors observed opened boxes of tissues, gloves, wipes, and a roll of garbage bags stored directly on clean linen on a linen cart in the South Hall. Staff, including an LPN and a nurse aide, acknowledged that these items should not be stored with clean linen, confirming a lapse in infection prevention and control practices.
A resident who lacked decision-making capacity was prescribed Sertraline for depressive disorder without the facility informing the resident's representative of the medication's risks, benefits, or alternatives. The DON could not provide an informed consent form, and although there was a documented attempt to contact the representative, no consent was obtained.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in six rooms. Specific environmental deficiencies included loose wallpaper with air bubbles, scuffs and black marks on bathroom doors, large circular holes in bathroom walls behind toilets, scrapes and tears in wallpaper, loose trim, paint chips in wooden trim around air conditioning/heating units, and cracks in paint under grab bars. These issues were identified during a random opportunity for discovery upon survey entrance and were present in multiple resident rooms. During a walkthrough with the administrator, the environmental issues in the identified rooms were acknowledged. The observations were based on direct visual inspection and staff interviews, confirming the presence of the deficiencies in the physical environment of the facility. No information was provided regarding the medical history or condition of the residents occupying the affected rooms at the time of the deficiency.
Failure to Provide Required Discharge Documentation and Notifications
Penalty
Summary
The facility failed to perform an accurate discharge process for two residents who were hospitalized, as evidenced by missing required documentation and notifications. For one resident with capacity to make her own medical decisions, there was no documentation that the ombudsman was notified of her transfer to the hospital, and the facility was unable to provide a Bed Hold Notice for her hospital leave. For another resident who sustained a fall with injury and was transferred to an acute care facility, the facility could not locate a Bed Hold Notice. In both cases, the Director of Nursing and Nursing Home Administrator confirmed during interviews that the required documentation could not be found and no additional information was provided.
Deficient Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices within the facility's kitchen. During an initial tour, a bag of frozen hamburger patties was found left open and exposed in the freezer, and a bag of macaroni was left open in the pantry. Both instances were in direct violation of the facility's own policies, which require all foods to be stored wrapped or in covered containers, labeled, dated, and properly sealed. Additionally, the kitchen refrigerator was found to be operating at 45 degrees, above the recommended temperature for safe food storage, as verified by two thermometers. Further observations during meal preparation revealed that a dietary employee failed to change gloves or wash hands after touching potentially contaminated surfaces, such as the freezer door and a floor delivery cart, before returning to food tray preparation. These lapses in hand hygiene and glove use were acknowledged by the Dietary Manager. The report notes that these deficiencies had the potential to affect all residents in the facility, which had a census of 117 at the time.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency was identified regarding the failure to provide timely incontinence care to a dependent resident who lacked capacity. Documentation and staff statements revealed that the resident was not assisted with toileting, cleaning, or changing absorbent pads or briefs in a timely manner. On the morning in question, staff discovered the resident in bed with sheets and clothing soaked with urine, and a brown ring was observed on the sheets. Multiple nursing assistants confirmed that the resident was found in this condition during morning rounds, requiring a full bed bath and linen change. The record review indicated that the resident was dependent and unable to care for themselves. Despite a report from the night shift aide stating the resident had been changed and bathed, subsequent staff found the resident in a soiled state. The incident was initially reported as an allegation of neglect, and statements from several nursing assistants corroborated the observation that the resident had not received timely incontinence care.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of acute and chronic respiratory failure with hypoxia was observed receiving oxygen at a rate higher than the physician's prescribed order. Multiple observations over several days showed the resident's oxygen concentrator set at 2.5 to 3 liters per minute, despite the physician's order specifying 2 liters per minute. The resident's care plan noted a tendency to remove oxygen at times, but during the survey period, the resident was consistently observed with the nasal cannula in place. The discrepancy between the ordered and administered oxygen flow rate was confirmed through record review and direct observation.
Pharmacist Failed to Identify and Report Adverse Drug Reactions and Allergy
Penalty
Summary
The consulting pharmacist failed to identify and notify the physician of potential adverse drug reactions (ADRs) related to the concurrent administration of opioids and benzodiazepines for a female resident with multiple complex diagnoses, including acute and chronic respiratory failure, paroxysmal atrial fibrillation, COPD, Alzheimer's disease, major depressive disorder, and atherosclerotic heart disease. The resident, who had a BIMS score of 2 indicating severely impaired cognition, was prescribed lorazepam (a benzodiazepine) as needed for anxiety and tramadol (an opioid) daily, despite a documented allergy to tramadol (hallucinations). The resident was frequently observed asleep throughout the survey period, with little documentation regarding her sleep patterns or quality of life. Record review showed no evidence that the pharmacist identified or communicated the risks of concurrent use of these CNS depressants, nor was there documentation that the physician was notified about the resident's tramadol allergy. Monthly Monitoring Reports and Gradual Dose Reductions did not address the concurrent use of opioids and benzodiazepines, and there was no documentation that drug-to-drug interactions or possible adverse reactions were considered. Interviews with nursing and pharmacy staff confirmed the lack of physician notification and insufficient documentation regarding the resident's medication regimen and its potential risks.
Expired Medical Supplies Found Accessible in Medication Room
Penalty
Summary
During an inspection of the North Medication Room, surveyors observed that medical supplies, specifically 31 BD 1 ML syringes and 7 Insyte 24 GA x 0.75 in injection syringes, were stored in bins despite being past their expiration dates. An LPN present during the inspection counted and confirmed the expired syringes. The expired supplies were accessible for use by staff for resident care, indicating that the facility failed to monitor expiration dates and properly dispose of expired medical supplies as required.
Unsanitary Storage Practices on Linen Cart Compromise Infection Control
Penalty
Summary
The facility failed to maintain an infection prevention and control program by allowing unsanitary practices related to the storage of clean linen. During facility walk-throughs, surveyors observed opened boxes of tissues, gloves, and wipes, as well as a roll of clear garbage bags, placed directly on top of clean linen on the linen cart in the South Hall. These items were found on both the middle and top shelves of the cart, in direct contact with clean linen. Staff members, including an LPN and a nurse aide, acknowledged the presence of these items on the linen cart when interviewed and confirmed that such items should not be stored with clean linen.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of depressive disorder, who lacked capacity to make medical decisions, was prescribed Sertraline HCI 50 mg. The facility did not provide the resident's medical representative with information regarding the risks and benefits of the medication, nor were alternative treatment options discussed. During the survey, the Director of Nursing (DON) was unable to produce an informed consent form for the medication. Although there was documentation of an attempt to contact the resident's representative, there was no evidence that the representative was informed or that consent was obtained prior to administering the medication.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Care Haven Center | 3.9 mi | ★★★★★ | 7 | 0 |
| Canterbury Center | 7.9 mi | ★★★★★ | 0 | 0 |
| Williamsport Health And Rehabilitation Center | 11.1 mi | ★★★★★ | 11 | 1 |
| Homewood Living Williamsport | 12.1 mi | ★★★★★ | 17 | 0 |
| War Memorial Hospital | 13.4 mi | ★★★★★ | 3 | 0 |
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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.