10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Martinsburg, PA
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
429 South Market Street, Martinsburg, PA
(814) 793-2104
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
114
Certified beds
Average residents
64
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.80
Registered nurse staffing
LPN hours / resident day
0.98
Licensed practical nurse staffing
Aide hours / resident day
2.57
Nurse aide staffing
Weekend hours
3.85
Weekend nurse staffing
RN turnover
62%
Annual RN turnover
Total nurse turnover
64%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.2
1.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
86.9%
12.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.2%
2.4 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.3% |
6.5%
0.2 pts better
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
19.9%
0.6 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
18.7%
6.5 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.4% |
19.6%
5.8 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
18.3%
0.6 pts better
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.7% |
26.4%
5.3 pts worse
|
19.8%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.3%
2.6 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
68.9%
26 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.4% |
9.8%
15.6 pts worse
|
12.0%
13.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.5%
1.6 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
68.7%
31.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.3% |
23.1%
7.8 pts better
|
23.9%
8.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-04
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-01
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-01
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-03-01
Fire Safety
Meet other general requirements.
Corrected 2024-03-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-01
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-07
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-07
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-04-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-07
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-04-07
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-04-07
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-04-07
Inspection history
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-19
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-19
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-19
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-19
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-03-19
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-03-19
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-19
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-03-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-08
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-02-23
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-23
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-02-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-23
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-23
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-23
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-23
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-23
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-03-31
Health
Report COVID19 data to residents and families.
Corrected 2023-03-31
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-31
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-31
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-31
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-03-31
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-03-31
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-31
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-31
Penalties and ownership
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
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