Inspection Reports for Harmony at Martinsburg

Investigation of Complaint #39236 regarding the assisted living and memory care units at Harmony at Martinsburg.

The complaint was unsubstantiated, and no deficiencies were cited during the investigation.

Complaint #39236 was investigated and found to be unsubstantiated with no deficiencies cited.

Investigation of Complaint #39040 regarding the assisted living and memory care facility.

The complaint was unsubstantiated, and no deficiencies were cited during the investigation.

Complaint #39040 was investigated from 07/08/25 to 07/09/25. The complaint was found to be unsubstantiated with no deficiencies cited.

First follow-up visit to the annual survey to verify correction of previously identified deficiencies.

The deficiencies identified in the prior annual survey were corrected as of the follow-up visit on 02/11/2025.

Investigation of Complaint #35886 regarding facility conditions and care.

The complaint was unsubstantiated, and no deficiencies were cited during the investigation.

Complaint #35886 was investigated and found to be unsubstantiated with no deficiencies cited.

Annual survey conducted to assess compliance with regulations for assisted living and memory care units at Harmony at Martinsburg.

The facility was found deficient in multiple areas including staff training, medication order documentation, staffing levels, housekeeping and maintenance, resident assessments, and care planning. Several deficiencies related to staff training on Alzheimer's and dementia care, incomplete resident records, and inadequate night shift staffing were noted.

The document reports on an environmental survey conducted at Harmony at Martinsburg on December 2, 2024, to assess compliance with health and safety regulations.

No deficiencies were found during the environmental survey. The facility has a sprinkler system type 13, uses a public sewer, and had no recommendations from the fire marshal or sanitation reports.

Investigation of Complaint #34562 conducted from 2024-10-09 to 2024-10-10 at Harmony at Martinsburg assisted living and memory care facility.

The complaint was unsubstantiated, and no deficiencies were cited during the investigation.

Complaint #34562 was investigated and found to be unsubstantiated with no deficiencies cited.

Investigation of Complaint #33646 conducted from 09/17/24 to 09/18/24 at Harmony at Martinsburg, an assisted living and memory care facility.

The complaint was unsubstantiated, and no deficiencies were cited during the investigation.

Complaint #33646 was investigated and found to be unsubstantiated with no deficiencies cited.

This document is a first revisit to the annual survey of Harmony at Martinsburg, including the Assisted Living and Alzheimer's units, to verify correction of previously cited deficiencies.

All deficiencies identified in the prior annual survey were cleared as of the revisit on 04/29/2024.

Annual survey conducted to assess compliance with state regulations for assisted living and memory care units.

The facility was found deficient in multiple areas including staffing levels, employee training and orientation, documentation of resident assessments and care plans, notification procedures, housekeeping and maintenance, and regulatory compliance with tuberculosis screening and weight monitoring.

Annual environmental survey conducted to assess compliance with health, safety, housekeeping, laundry, maintenance, and emergency preparedness regulations.

The facility failed to ensure proper storage of soiled laundry, maintain a safe and sanitary living environment, and document evacuation procedures for new residents within 24 hours of admission. Observations included broken ceiling tiles, unsecured oxygen cylinders, damaged carpets, missing bathroom fixtures, and inadequate laundry practices.

Investigation of Complaint #28969 conducted from 08/29/23 to 08/30/23.

The complaint was unsubstantiated with no deficiencies cited during the investigation.

Complaint #28969 was investigated and found to be unsubstantiated with no deficiencies cited.

Follow-up to a Focus Survey conducted to verify correction of previously identified deficiencies.

The report documents a follow-up survey conducted on 07/19/2023 with a census of 77 assisted living and 35 Alzheimer’s residents. The survey aimed to assess compliance and corrective actions since the prior focus survey.

The inspection was conducted in response to Complaint ID 28741, to investigate allegations related to the facility.

The complaint allegations were found to be unsubstantiated. The census at the time was 35 Medicaid and 77 Assisted Living residents.

Complaint ID 28741 was investigated from 07/18/23 1:30 PM to 07/19/23 1:00 PM. Allegations were unsubstantiated.

Follow-up to complaint #28560 to verify compliance and address issues raised in the complaint.

The report documents a follow-up inspection conducted on 07/19/2023 with a census of 77 assisted living and 35 Alzheimer’s residents. The inspection was to assess compliance related to the complaint and included observations and interviews regarding safety and staffing.

Follow-up to complaint #28560; substantiation status not explicitly stated.

Revisit for Complaint #28560 to verify correction of previously cited deficiencies related to maintaining accurate resident records and reports.

The licensee failed to maintain accurate resident rosters, listing a discharged resident as currently residing in the facility. The facility corrected the issue by updating the roster to reflect the resident's physical discharge. Additional findings from a prior behavioral health survey included safety and housekeeping deficiencies in the adolescent residence.

Revisit for Complaint #28560. The complaint was substantiated as the facility failed to maintain accurate resident records, listing a discharged resident as still residing in the facility.

The inspection was conducted as a complaint investigation related to failure to provide staff training on care for residents with prosthetic eyes.

The licensee failed to provide training for staff regarding care of residents with prosthetic eyes, affecting one resident. Interviews revealed staff were not trained and lacked a policy for prosthetic eye care. The facility developed and implemented a policy and training plan with completion by 07/18/2023.

Complaint ID: #28559. The investigation was conducted from 05/31/23 8:30 AM to 06/01/23 1:00 PM. Census at time of complaint was 35 residents.

The inspection was conducted as a complaint investigation following reports of failure to report major incidents and concerns about resident safety and housekeeping.

The facility failed to report major incidents to the Office of Health Facility Licensure and Certification within the required timeframe, specifically incidents involving Resident CR #01 and ALZ Resident #24. Additionally, the facility failed to maintain adequate housekeeping and maintenance, with issues such as damaged carpets, missing bathroom fixtures, and unclean sinks observed.

Complaint ID #28560. The complaint investigation started on 2023-05-30 and ended on 2023-06-01. The complaint involved failure to report major incidents and inadequate resident safety and housekeeping. The complaint was substantiated based on documentation review and interviews.

Revisit to Complaint ID: #28560 to verify correction of previously cited deficiencies.

The revisit inspection found that citations related to the complaint were corrected.

Complaint ID: #28560; citations corrected upon revisit.

Revisit to Complaint Investigation conducted from 05/30/23 to 06/01/23 to verify correction of previously cited deficiencies.

The deficiency cited in the prior complaint investigation was cleared during this revisit inspection.

This visit was a follow-up to a complaint investigation. The deficiency was cleared.

The inspection was a complaint survey revisit conducted to verify correction of previously cited deficiencies related to a complaint investigation.

The deficiencies identified during the prior complaint investigation were corrected as verified during the revisit inspection.

Complaint ID 26922 was investigated, and deficiencies were corrected as of the revisit on 05/08/2023.

This was a 1st follow-up/revisit to Complaint #27750 conducted to verify correction of previously cited deficiencies.

The citations related to the complaint were corrected as of the follow-up visit conducted from 02/27/23 to 03/01/23.

Follow-up visit related to Complaint #27750; citations were corrected.

The inspection was conducted as a complaint investigation (Complaint #28018) entered on 2023-02-27 and exited on 2023-03-01, related to staffing and care needs at the facility.

The facility failed to ensure adequate staffing levels on both day and night shifts to meet the needs of residents requiring two or more care needs. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.

Complaint #28018 was substantiated. The complaint was related to staffing shortages and care needs not being met. The investigation confirmed insufficient staffing on both day and night shifts to meet resident needs.

The inspection was conducted as a complaint investigation related to medication administration issues and overall facility compliance.

The facility failed to ensure that prescription or written orders were properly maintained and that PRN medications were available as prescribed, specifically for Resident #52 who went without her PRN albuterol for several days. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.

Complaint #28007 was unsubstantiated. The complaint involved Resident #52 not receiving PRN albuterol from 02/02/23 to 02/05/23. The pharmacy acknowledged an error. The complaint investigation occurred from 2023-02-27 to 2023-03-01.

This was a 2nd follow-up/revisit investigation survey related to Complaint #26922 conducted to verify compliance with assessment and care plan requirements for a resident admitted after the initial plan of correction date.

The facility failed to ensure that an interdisciplinary team completed an initial assessment within seven days of admission and developed a written individualized care plan within twenty-one days for one resident. The assessments and care plan were completed by an unlicensed professional rather than the required interdisciplinary team, and the facility's data system did not allow correction of this error.

This was a 2nd follow-up/revisit to Complaint #26922. The complaint investigation found deficiencies related to assessments and care planning for Resident #23 admitted after the initial plan of correction date.

The inspection was a routine special focus survey conducted on February 28, 2023, to assess compliance with medication administration and facility safety standards.

The facility failed to administer medications within the required time frame for two residents, with 8:00 AM medications given after 11:00 AM. Additionally, deficiencies in housekeeping and maintenance were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.

Annual survey conducted to assess compliance with state regulations for assisted living and memory care facility.

The facility was found deficient in multiple areas including staff qualifications, training, housekeeping and maintenance, medication administration, resident assessments, and documentation. Several employees lacked required training and qualifications, resident health assessments were incomplete or outdated, and policies for medication administration were contradictory and not properly approved.

Follow-up to a complaint survey conducted to verify correction of previously cited deficiencies related to individualized care plans and facility conditions.

One deficiency remains regarding the development and signing of individualized care plans by the interdisciplinary team and resident or representative. The facility has implemented a plan of correction to review and sign care plans at specified intervals. Observations from prior surveys noted issues with housekeeping and maintenance, but these are addressed through supervisory monitoring and maintenance work orders.

Follow-up to Complaint Survey 1st Visit. Ombudsman notified via e-mail. Census 76 Assisted Living and 33 Memory Care. One deficiency remains (Plan of correction date 01/28/23).

Annual environmental inspection of Harmony At Martinsburg facility conducted on January 17, 2023.

No deficiencies were cited during the annual environmental inspection. The facility census was 111 at the time of the visit.

The inspection was conducted as a complaint investigation from 12/02/22 to 12/05/22 regarding concerns at Harmony at Martinsburg (ALR/ALZ).

The complaint investigation was completed and found to be unsubstantiated. The census at the time was 70 assisted living residents and 35 Alzheimer’s residents.

Complaint ID 27568 was investigated and found to be unsubstantiated.

Complaint investigation conducted due to concerns about staffing, activities, and safety in the Memory Care Unit at Harmony at Martinsburg.

The facility failed to provide adequate staffing levels and appropriate activities for Memory Care residents, especially on weekends. Numerous incidents of resident aggression and safety concerns were documented. Housekeeping and maintenance issues were also noted, including damaged carpets and missing bathroom fixtures. Staff shortages led to lack of engagement and supervision of residents, contributing to unsafe conditions.

Complaint investigation #27750 focused on staffing shortages, lack of activities, and safety concerns in the Memory Care Unit. Multiple staff and former employees reported inadequate staffing, especially on weekends, lack of management presence, and insufficient activities leading to resident agitation and aggression. Several incidents of resident altercations and unsafe behaviors were documented.

The inspection was conducted as a complaint investigation from 08/17/22 to 08/18/22 regarding concerns at Harmony at Martinsburg, an assisted living and Alzheimer's/dementia care facility.

The facility was found deficient in multiple areas including failure to develop individualized care plans within 21 days of admission, inadequate behavior management documentation, failure to report major incidents timely, lack of immediate RN notification for nursing care needs, medication administration by unlicensed personnel without an AMAP RN, and inadequate housekeeping and maintenance.

Complaint ID 26922 was substantiated. The investigation revealed multiple deficiencies including failure to develop care plans, inadequate behavior management documentation, failure to report major incidents timely, lack of RN notification, medication administration violations, and housekeeping deficiencies.

This was a 1st follow-up/revisit to a complaint investigation survey related to complaint #26416 conducted to verify correction of previously identified deficiencies.

The deficiencies identified during the complaint investigation were corrected and cleared as of the revisit date.

Complaint #26416 was investigated, and deficiencies were found and subsequently corrected as confirmed during the follow-up visit.

Complaint survey conducted to investigate allegations related to staffing, medication monitoring, nursing notifications, and discharge procedures at Harmony at Martinsburg.

The facility failed to provide adequate staffing hours in the Alzheimer's/Dementia Special Care Unit, did not ensure daily monitoring of residents on psychotropic medications, failed to have monthly evaluations by a registered nurse for residents on behavioral medications, did not notify the registered nurse immediately of new or changed nursing care needs for several residents, and failed to assist a resident's family in finding alternative placement upon discharge.

Complaint ID 26416 triggered the survey conducted from 04/26/22 to 04/27/22 regarding staffing shortages, medication monitoring failures, nursing notification lapses, and discharge assistance deficiencies.

Follow-up to a complaint investigation identified as Complaint 26138 conducted from 04/25/22 to 04/26/22.

The deficiency identified during the complaint investigation was corrected by the time of this follow-up visit.

Follow-up to Complaint 26138; deficiency corrected.

Follow-up to a complaint survey (CI #26354) to verify correction of previously identified deficiencies.

The deficiency identified in the prior complaint survey was corrected. The census included 68 Assisted Living and 32 Memory Care residents.

Complaint Investigation #26354; deficiency was corrected as of this follow-up visit.

Complaint investigation survey conducted from 01/05/22 to 01/10/22 due to concerns about staffing and care at the assisted living and memory care facility.

The facility failed to ensure adequate direct care staffing on the night shift to meet the needs of residents with two or more special care needs, resulting in delayed responses to call bells and resident falls. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.

Complaint Investigation Survey from 01/05/22 10:30 p.m. to 01/10/22 3:00 p.m. Census: Assisted Living 70, Memory Care 31. Complaint ID: 26354. Substantiation status not explicitly stated.

The inspection was conducted as a complaint investigation survey from November 15 to November 16, 2021, in response to Complaint ID 26203.

The complaint investigation was completed and the complaint was found to be unsubstantiated. The census at the time was 66 assisted living residents and 31 Alzheimer’s residents.

Complaint ID 26203 was investigated and found to be unsubstantiated.

The inspection was conducted as a complaint investigation triggered by a complaint received regarding the facility.

The complaint investigation was completed and the complaint was found to be unsubstantiated.

Complaint investigation conducted from 10/24/21 to 10/27/21. Complaint was unsubstantiated.

The inspection was conducted as a complaint investigation from 10/24/21 to 10/27/21 regarding concerns about the adequacy of activities programming and engagement in the Memory Care Unit.

The facility failed to maintain accurate records and reports of activities and did not ensure that scheduled activities were implemented to enhance the wellbeing of Memory Care Unit residents. Observations and interviews revealed that residents were often not engaged in activities, and the designated Activities Assistant did not fulfill job duties, leading to substantiated complaints.

Complaint number 26138 was substantiated. The investigation found that the Memory Care Unit residents' needs were not being fulfilled, activities were not completed during weekends, and staff felt overwhelmed with care responsibilities.

Follow-up visit to verify correction of deficiencies identified in complaint investigation #25260.

The deficiencies cited in the previous complaint investigation were corrected as of the follow-up visit on 10/12/2021.

Follow-up to complaint investigation #25260; deficiencies were corrected.

Follow-up visit to verify correction of previous deficiencies during the annual survey.

Deficiencies identified in prior inspections were corrected as of this follow-up visit. The census included 68 assisted living and 28 memory care residents.

The inspection was a revisit and complaint survey conducted due to a complaint identified by Complaint ID WV00025602.

The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.

Complaint ID WV00025602 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation (Complaint 25119) from August 26 to August 27, 2021, to address concerns raised about the facility.

The revisit inspection found deficiencies which were cleared on August 27, 2021, with no additional deficiencies cited.

Complaint 25119 was investigated during the visit from 08/26/21 to 08/27/21. Deficiencies identified during the revisit were cleared on 08/27/21 with no additional deficiencies cited.

The inspection was conducted as a complaint investigation related to Complaint #25523.

The inspection found deficiencies that were corrected during the visit. The census included 52 residents on the Assisted Living side and 23 on the Alzheimer's side.

Complaint #25523 was investigated and the deficiency was corrected during the inspection.

The inspection was conducted as a routine environmental survey of the facility to assess compliance with health, safety, and physical environment regulations.

The inspection identified deficiencies related to the physical environment, including improper installation of keypad locks without posted directions, inadequate laundry storage practices, inaccessible call systems from resident beds, and incomplete documentation of disaster and emergency preparedness rehearsals.

The inspection was conducted as an environmental survey of the facility.

The facility had deficiencies identified during the environmental survey, with a total of 154 deficiencies noted.

Complaint survey conducted from 04/19/21 to 04/28/21 to investigate allegations of neglect, abuse, and failure to report incidents at Harmony at Martinsburg assisted living facility.

The facility failed to notify responsible parties after major incidents, failed to monitor and document resident conditions post-incident, failed to report abuse to adult protective services timely, allowed alleged abuse by staff with inadequate investigation and response, failed to ensure adequate housekeeping and maintenance, and failed to provide appropriate activity programming for residents with dementia.

Substantiated complaint survey #25260 conducted 04/19/21 to 04/28/21. Allegations included failure to notify families of incidents, failure to monitor residents post-fall, failure to report abuse, and inadequate activity programming. Resident #37 and Resident #44 were specifically involved in findings.

Annual survey conducted to assess compliance with regulations for assisted living and memory care facility.

The facility was found deficient in multiple areas including staff training on Alzheimer's care, housekeeping and maintenance issues, incomplete interdisciplinary care plans, missing social assessments, incomplete personnel records, medication administration errors, incomplete nursing documentation, and inaccurate resident records.

Complaint Survey #25119 was conducted from 04/19/21 to 04/28/21 to investigate allegations related to staff entering a resident's room without identifying themselves and taking medications without permission.

The licensee failed to ensure that no staff entered a resident's room without identifying themselves and receiving permission. Specifically, Resident #80 reported staff entered her room unannounced and took her medications, including her emergency inhaler. Interviews confirmed that previous staff were instructed to enter rooms unannounced and take medications, overriding physician orders.

Complaint Survey #25119 was substantiated. The complaint involved staff entering Resident #80's room unannounced and taking medications without permission, including the emergency inhaler. Multiple employees verified these practices were directed by the previous Health Care Director.

This was a second revisit inspection conducted to verify correction of previous deficiencies.

The revisit inspection found no deficiencies at the facility.

The inspection was conducted as an Infection Control Survey at Harmony at Martinsburg.

No related or unrelated citations were written during the infection control survey conducted from January 4 to January 5, 2021.

The inspection was a revisit to evaluate compliance with previously cited deficiencies related to nursing care oversight, medication administration, housekeeping, and staff training at Harmony at Martinsburg assisted living and memory care facility.

The facility was found to have operated without a full-time registered nurse for 42 days, with interim AMAP RN coverage limited to medication-related duties and no full nursing oversight. Deficiencies included failure to notify RN immediately of nursing care needs, inadequate housekeeping and maintenance, incomplete staff training records, failure to maintain proper nursing documentation and service plans, and incomplete transfer summaries. The facility implemented a plan of correction including hiring a new RN, providing interim AMAP RN coverage, staff training, and maintenance repairs.

Annual survey of Harmony at Martinsburg Assisted Living and Alzheimer's Unit to assess compliance with regulatory requirements.

The facility was cited for failure to maintain a resident admission register in order, inadequate medication administration oversight including unauthorized verbal orders by LPNs and AMAPs, lack of annual in-service training documentation for some employees, and failure to prepare complete transfer/discharge summaries for residents.

The visit was a follow-up complaint investigation at Harmony at Martinsburg to verify correction of previously cited deficiencies.

The follow-up inspection cleared two citations related to the prior complaint investigation.

Complaint Investigation Follow Up with two citations cleared.

The inspection was conducted as a substantiated complaint investigation at Harmony at Martinsburg.

The complaint investigation found no citations. The report notes a previous behavioral health survey from 2004 with deficiencies related to safety and supervision, but no current deficiencies were cited in this 2020 investigation.

Substantiated Complaint entered on 03/02/20 and exited on 03/04/20 with no citations.

The inspection was conducted as a substantiated complaint investigation regarding medication errors and compliance with medication administration regulations.

The facility failed to report a medication error involving a resident receiving two doses of insulin within two hours and failed to ensure that Approved Medication Assistive Personnel (AMAP) received required quarterly observations and retraining every two years. Additionally, housekeeping and maintenance deficiencies were noted in the adolescent consumer residence.

Substantiated complaint. The complaint investigation was entered and exited on 03/03/20. Census at the time was Assisted Living - 45, Memory Care - 14.

The inspection was an annual environmental survey conducted to assess the facility's compliance with health, safety, and maintenance regulations.

The facility was found deficient in maintaining a safe environment for residents, specifically failing to rehearse the disaster and emergency preparedness plan annually with all staff and maintain proper documentation. Additionally, housekeeping and maintenance issues were noted, including damaged carpets, missing bathroom fixtures, and general cleanliness concerns.

The inspection was an annual environmental survey conducted to assess compliance with health and safety regulations at the facility.

The survey found concerns related to tag 0455, but no complaints were substantiated. The inspection included a full sample size of 100%.

The inspection was conducted as an annual licensure survey to assess compliance with state regulations regarding assessments and plans of care for residents.

The facility failed to ensure that within seven days of admission, an interdisciplinary team completed initial assessments for new residents, and within twenty-one days, developed individualized care plans signed by all required parties for four residents. Deficiencies were noted in documentation and interdisciplinary team involvement.

The inspection was conducted as a complaint investigation from February 25-27, 2019, related to complaint ID WV00021862.

No deficiencies were cited during this complaint investigation.

Complaint ID WV00021862 was investigated with no deficiencies cited.

The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements for the facility.

The report documents the annual licensure survey conducted on February 26-27, 2019, with a census of 56 residents. A follow-up survey on March 27, 2019, confirmed that previously identified deficiencies were corrected.

The visit was conducted as an annual licensure survey including an annual environmental inspection of the facility.

No deficiencies were cited during this annual licensure and environmental survey.

Initial licensure survey conducted to assess compliance for facility licensing.

No deficiencies were cited during the initial licensure survey conducted May 14-16, 2018.

The inspection was conducted as an initial licensure survey to evaluate the environmental conditions and compliance of the facility.

The survey found no deficiencies related to environmental conditions, fire marshal, or sanitation reports. The facility had a sprinkler system type 13 and public sewer type, with no recommendations noted.