Berkeley Springs Healthcare Center

In the surveyor’s words

From the most serious findings on record at Berkeley Springs Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF693Mar 29, 2023

  Based on observation, record review, and staff interview, the facility failed to ensure a resident who received enteral feeding was provided that feeding in accordance with professional standards of being in a semi-Fowler's position during the tube feeding administration. This deficient practice was identified in one (1) of one (1) resident reviewed who received enteral feedings. Resident identifier: Resident #41. Census: 102. On 03/28/23 at 5:26 PM, the State Agency determined these failures placed Resident #41 and six (6) other residents receiving enteral feeding in an immediate jeopardy situation due to potential complications from improper positioning. On 03/28/23 at 5:27 PM, the State Agency notified the Nursing Home Administrator of the immediate jeopardy. […]

• No harm, potential for more than minimal, patternF584Jul 8, 2026

  Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on the 300 hall. This was a random opportunity for discovery. Room Numbers: #307, #308, #309, and #312. Facility census: 101. Findings included: room [ROOM NUMBER]Upon survey entrance and resident interviews on 07/06/26 at 11:50AM, the following was observed in room [ROOM NUMBER]The window sills had dust and cobwebs in the corners with a buildup of blackish debris. a) room [ROOM NUMBER]-During resident interviews on 07/06/26 at approximately 12:10 PM, the following was observed in room [ROOM NUMBER]The window sill had dust and cobwebs with a buildup of blackish debris. […]

• No harm, potential for more than minimal, patternF645Jul 8, 2026

  Based on record review and staff interviews, the facility failed to include all the relevant diagnoses for residents on their Pre-admission Screen (PASARR). Out of the thirty four (34) residents in the initial pool, four (4) residents had incorrect or missing diagnoses. Resident identifiers #8, #11, #12 and #68. Facility census: 101. Findings include: a) Resident #8 On 07/06/26, during a record review of Resident #8's chart, their Pre-admission Screening (PAS) in section thirty (30) has option K (affective bipolar disorder) marked. […]

• No harm, potential for more than minimal, patternF657Jul 8, 2026

  Based on record review and staff interview, the facility failed to ensure resident care plans were revised for one (1) resident. The issues included the residents diet being changed twice and her weekly weight orders not being included. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #14. Facility Census: 101.a) CommuniCare policy titled Plan of Care Overview states: Plan of Care: for the purpose of this policy, the Plan of Care, also Care Plan is the written treatment provided for a resident that is resident focused and provides for optimal personalized care. It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. […]

• No harm, potential for more than minimal, patternF584Mar 27, 2025

  Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on the two (2) of four (4) hallways. Resident rooms affected were on the 100 and 300 halls. Room Numbers: #112, #114, #117, #301, #104, and #103. Resident identifier: #82. Facility census: 99. Findings included: a) room [ROOM NUMBER] Upon survey entrance on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]: -black scuff marks on right wall inside the door - window missing curtains, - broken blinds During a walk through with the Infection Prevention Manager, on 03/25/25 at 3:50 PM, she acknowledged the scuffs and black marks, missing curtains, and broken window blinds and stated she would make sure the room repair would be… […]