Martinsburg Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the resident or resident's representative of the risks and benefits of an anti-psychotic medication. This was found to be true for 1 (one) of six (6) residents reviewed. Resident identifier: #95. Facility census: 115.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a physician's order for oxygen administration was followed. This was a random opportunity for discovery. Resident Identifier: #6. Facility Census: 116.

Inspectors wroteBased on observation, interview and record review, the consulting pharmacist failed to identify and notify the physician of potential Adverse Drug Reactions (ADR's) related to the concurrent administration of opioids, benzodiazepines. Further, the pharmacist failed to identify that a medication had been prescribed to a resident with a documented allergy to it. Resident identifier: #6. Facility Census: 116. Findings Include: a) Resident #6 Record review on 06/16/25 at approximately 12:25 PM revealed that Resident #6 was an [AGE] year-old female. Resident #6 did not have capacity and a Brief Interview for Mental Status (BIMS) assessment on 05/07/25 revealed a BIMS of 02. The resident has been diagnosed with the following: Acute and Chronic Respiratory Failure with Hypoxia. [...]

Inspectors wroteBased on observation and interview the facility failed to monitor the expiration dates of medical supplies. Further, the facility failed to ensure that expired medical supplies were disposed of and not left accessible for use by staff for resident care. Facility Census: 116. Findings Include: a) North Medication Room During an inspection of the North Medication Room on [DATE] at approximately 9:16 AM, accompanied by Licensed Practical Nurse (LPN) #17, the storage bins holding medical supplies revealed the following: 31 - BD 1 ML Syringes - expiration date [DATE] 7 - Insyte 24 GA x 0.75 in injection syringes - expiration date [DATE] LPN #17 counted and confirmed the expiration dates on the syringes. LPN #17 further stated that she would notify the DON of the finding, and dispose of the expired syringes.

Inspectors wroteBased on observation and staff interviews, 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 the residents and unsanitary practices. This failed practice was a random opportunity of discovery. Facility Census: 117.

Inspectors wroteBased on record review and interview, the facility failed to ensure that incontinence care was provided to dependent residents. Namely, dependent residents were not aided with toileting, cleaning themselves, and changing absorbent pads or briefs in a timely manner. This was true for one (1) of four (4) residents surveyed. Resident Identifiers: Resident identifier: #50. Facility Census: 116. Findings Include: a) Resident #50 Record review on 06/18/25 at approximately 10:00 AM revealed that Resident #50 does not have capacity. The record review revealed the following: The facility had submitted an initial report of an allegation of neglect in the area of incontinence care for Resident #50 on 03/26/25 at 1:49 PM. The facility had submitted the five-day follow-up report on 03/28/25 at 1:53 PM. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on review of the concern/grievance forms, review of the facility documentation of reportable occurrences, and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of four (4) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported in a timely manner involving Residents #20 and #119. Resident identifiers: Residents #20 and #119. Facility census: 116.

Inspectors wroteBased on record review and staff interview the facility failed to notify the physician of a significant weight loss to evaluate and manage causes of the resident's nutritional risks and impaired nutritional status. This is true for one (1) of three (3) residents reviewed for weight loss. Resident identifier: # 51. Facility census: 116.

Inspectors wroteBased 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.

Inspectors wroteBased on staff interview, medical record review, and policy review, the facility failed to ensure monthly medication regimen reviews (MRR) were completed by a pharmacist and the physician responded to the pharmacy recommendations in a timely manner. This is true for four (4) of five (5) reviewed for unnecessary medications. Resident identifiers: #7, #34, #8, #22. Facility census: 115.

Inspectors wroteBased on resident interviews during resident council, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided as ordered and/or offered if of ordered between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack. Resident identifiers: #61, #30, #54, #36, and #9. Facility Census: 115.

Inspectors wroteBased on observation and staff interview, the facility failed to complete labeling and dates on refrigerator and freezer items in accordance with professional standards for food service safety related to storage. This has the ability to affect all Residents that receive their nutrition from the kitchen and pantries. Facility census: 115.

Inspectors wroteBased on observation and staff interview, the facility failed to store garbage and refuse in a proper manner. One (1) dumpster did not have a lid, the area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a complete and accurate medical record for four (4) of thirty-two (32) records reviewed. Resident identifiers: #88, #421, #91 and #91. Facility census: 115.

Inspectors wroteBased on observation, record review, staff interview and policy review, the facility failed to have signage on the door and/or a donning/doffing station available at the door of a resident's room designated as a transmission-based precaution (TBP) room. Resident Identifiers: #88, #114, #111 and #101 Facility census: 115.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to protect and promote the rights of Resident #50. The facility failed to issue Resident #50 an invitation to attend two (2) appeals hearings regarding the discharge for nonpayment. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 115.

Inspectors wroteBased on policy review, record review, resident interview and staff interview, the facility failed to immediately inform a resident or the resident representative when there was a need to begin a new form of treatment or a change in care was required for two (2) or 32 residents reviewed. Resident #10's representative was not notified of a facility acquired pressure ulcer or the initiation of treatment for the pressure ulcer and Resident #30 was not notified of a change in a medical appointment. Resident identifiers: Resident #10 and Resident #30. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to provide evidence the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #370. Facility census: 115.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to honor a resident's right to privacy and confidentiality for all aspects of care and services. This was a random opportunity for discovery. Resident identifier: #50. Facility census:

Inspectors wroteBased on resident interview, observation and staff interview, the facility failed to maintain the walls of a resident's room and keep a resident's wheel chair clean and odor free. These were random opportunity for discovery. Resident identifiers: #53 and room [ROOM NUMBER]. Facility census: 115.

Inspectors wroteBased on observation, staff interview, electronic medical record review and Operation Policy, the facility failed to follow written policy, thoroughly investigating and reporting to the proper agencies of an allegation of neglect. This has the potential to affect all residents that reside in the facility. Resident identifier: #4. Facility census: 115. Findings Included: A record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed: --Training 1) Provide education and training upon hire, annually and as needed for re-training to include not limited to: [...]

Inspectors wroteBased on observation, staff interview, and operation policy the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This has the potential to affect all residents that reside in the facility. Facility census: 115. Findings Include: Record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed: --Training 1) Provide education and training upon hire, annually and as needed for re-training to include not limited to: [...]

Inspectors wroteBased on observation, staff interview, and operation policy the facility failed to take actions to investigate an alleged violation related to, neglect and failed to take corrective actions following an investigation to re-educate staff after a resident injury. This has the potential to affect all residents that reside in the facility. Resident identifiers: #4, #13, #10. Facility census: 115. Findings Included: Record review of the facility's policy titled, West Virginia Abuse, Neglect & Misappropriation, showed: --Training 1) Provide education and training upon hire, annually and as needed for re-training to include not limited to: [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence the long-term care Ombudsman was provided a copy of the written Notice of Transfer for two (2) acute hospital transfer/discharges for Resident #92. This was true for one (1) of two (2) residents reviewed for hospitalizations. Resident identifier: #92. Facility census: 115.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the resident/resident representative of the facility bed hold when transferred. This was true for one (1) of two (2) residents reviewed for hospitalizations. Resident identifier: #92. Facility census: 115.

Inspectors wroteBased on observation, policy review and staff interview, the facility failed to develop a comprehensive care plan for Aerosol droplet precautions. This was true for two (2) of thirty two (32) care plan records reviewed. Resident identifiers: #88 and #91. Facility Census: #115.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to revise care plans for two (2) of 32 resident's care plans during the Long Term Care Survey Process. Resident #3's had not been revised for a nutritional intervention and Resident #421 had not been revised for hospice services. Resident identifiers: #3 and #42. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to follow a physician's orders for weekly weights and the administration of pain medication for a Hospice resident was not followed. These were random opportunities for discovery with the potential to affect a limited number of residents. Resident identifiers: #424 and #57. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to provide care and treatment, based on the comprehensive assessment of the resident, to ensure a resident received care, consistent with professional standards of practice, for pressure ulcer care. This was found true for one (1) of five (5) residents reviewed for pressure ulcer care. Resident #10 developed a facility acquired pressure ulcer, however, there were inconsistencies with the identification and time treatment was started to ensure monitoring of the healing process for the pressure ulcer. Resident Identifier: Resident identifier: #10. Facility census: 115.

Inspectors wroteBased on employee record review and staff interview, the facility failed to ensure Employee #44 and #148 had completed the required annual 12 hours of in-services for dementia and abuse prevention. This deficient practice was found true for two (2) of five (5) employee records reviewed for staffing. Employee identifiers: #44 and #148. Facility Census: 115.

Inspectors wroteBased on a review of staff postings and staff interview, the facility failed to display the required data on the daily Staff Postings. This was a random opportunity for discovery and affected a limited number of residents and visitors. Facility census: 115.

Inspectors wroteBased on medical record review and staff and interview, the facility failed to ensure each resident and/or representative is educated on the risks and benefits and given the opportunity to accept or decline the pneumonia vaccine prior to administration. This is true for one (1) of five (5) residents reviewed for immunizations. Resident identifier: #40 Facility census: 115.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food to residents at the same table in the north dining room as well as in resident rooms. Resident #1 was put to bed without sheets. Resident identifiers #1. North Dining room and north hall rooms 105, 112 and 115. Facility Census 111.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with contractures had interventions in place to prevent further decline. This was true for three (3) of five (5) resident reviewed for the care area of limited range of motion (ROM) during the long-term care survey process. Resident identifiers: #26, #65, and #73. Facility census: 111.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure a drug regimen of each resident was completed at least once a month by a licensed pharmacist. This was true for four (4) of six (6) residents reviewed for unnecessary medication reviews during the annual long-term care process. Resident identifiers: #93, #75, #59, #73. Facility census: 111. Review of the facility's policy entitled Medication Regimen Review (MRR) Time Frame, with a revision date of 05/03/21, found the following guidance, The medication regimen of each patient is reviewed at least once a month by a licensed Consultant Pharmacist.

Inspectors wroteBased on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for one (1) of four (4) reviewed for grievances during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #19. Facility census: 111.

Inspectors wroteBased on observation, resident interview, family interview, record review and staff interview the facility failed to ensure residents were free from abuse in the form of mental anguish. The failed practices were random opportunities for discovery. Resident identifiers: #62. Facility census: 111.

Inspectors wroteBased on resident interview, observation, record review and staff interview facility failed to thoroughly investigate a resident to resident altercation to prevent and take corrective action as a result of the investigative findings. The failed practice was a random opportunity for discovery. Resident identifier: #62. Facility census 111.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence that a copy of the Notice of Transfer was sent to the Ombudsman. This was true for one (1) of four (4) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #12. Facility census: 111.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for one (1) of four (4) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #12. Facility census: 111.

Inspectors wroteBased on record review, and staff interview, the facility failed to follow physician orders related to insulin. This was true for one (1) of six (6) residents reviewed for drug regimen review during the annual long-term care survey process. Resident identifier: #93. Facility census: 111.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This was a random opportunity for discovery, during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #70. Facility Census: 111.

Inspectors wroteBased on resident interview, observation, record review and staff interview the facility failed to assess for the indications required for the use an antianxiety medication and adequately monitor the medication side effects. This was a random opportunity for discovery. Resident identifier: #62. Facility census: 111.

Inspectors wroteBased on resident interview, observation, record review and staff interview the facility failed to accurately document pain levels for pain management and did not documented the administration of an anxiety medication or the side effects of the medication after administration. The failed practice was true for two (2) of 32 sampled residents. Resident identifiers: #13 and #62.