Berkeley Springs Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. Safety is a primary concern for our residents, staff and visitors. [...]

Inspectors wroteBased on observation and staff interviews the facility failed to ensure Resident #71 had a dignified dining experience during the lunch meal on 07/06/26 and 07/07/26. The facility failed to serve Resident #71 at the time his roommate was served. Resident #71 was not served for 35 minutes after the roommate was served his meal. This failed practice was a random opportunity for discovery. Resident Identifiers: #45 and #71. Facility Census: 101. Findings Included: a) During an observation of the lunch meal at 12:10 PM on 07/06/26 Resident #45 was observed eating his meal while his roommate Resident #71 still had not received his tray. In an interview with Resident #45, about his lunch, he stated he was on vacation and was eating in his room this week. When asked of Resident #71 if he had already eaten his meal, he reported he had not received his tray yet. [...]

Inspectors wroteBased upon Record review and staff interviews, the facility failed to ensure that care plans were person centered and had measurable goals. Resident identifiers #8. Census: 101.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed in regards to G-tube (gastrostomy tube) placement and significant weight loss Resident #100 and #14. Facility census: 101. Findings Included: An observation on Medication administration for Resident #100 found Licensed Practical Nurse (LPN) # 74 administering medication and feeding through a G-tube. Eternal tube placement was not checked prior to administrating medications or feeding. During an interview on 07/08/26 at approximately 8:10 AM with LPN #74 she verified placement was not checked prior to medication administration and feeding. A medical record review found a physician orders: [...]

Inspectors wroteBased on record review, observations, and staff interview. The facility failed to ensure physician orders were being followed for treatment services to prevent pressure ulcers. This affected one(1) of three (3) residents reviewed. Resident identifier: #101. Facility census : 101.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible r/t med cart left unlocked and unattended. This failed practice was a random opportunity for discovery. Facility Census:101Findings Included: a) On 07/06/26 approximately 3:10 PM It was observed in the 200 hallway, the med-cart was found unattended and left unlocked. Employee #148 was also in the 200 hall at the time the med cart was found unattended and unlocked, confirmed she had witnessed surveyor able to walk up and pull open the top drawer of the med cart. She then closed it and locked it to ensure the safety of residents until the nurse returned. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident environment over which they had control was as free from accident hazards as possible in regards to bed safety. This was a random opportunity for discovery. Resident Identifiers: 101. Facility census: 101. Findings Include: a) Resident #101 During an initial tour of the facility an observation, completed on 07/06/26 at 1:16 PM, revealed Resident #101 was lying in bed with an approximate 12-inch gap between the mattress and foot rail. The bed was extended with a small suffer in place leaving about a 10 inch gap deep. During an interview on 07/06/26 at 1:20 PM, the Assistant Director of Nursing verified the gaps between the mattress and foot boards for Residents #101. He continued to say that he would have the maintenance director evaluate and fix the gap at this time.

Inspectors wroteBased 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.

Inspectors wroted) Resident #49 An observation of Resident #49 sitting in a resident sitting area 3/24/25 11:45 AM with disheveled oily hair. A second observation on 03/25/25 at 9:24 AM found Resident #49 with oily hair. Medical record review revealed, Resident #49 shower schedule and preference are two (2) times weekly. A continued review of Resident #49s ADL documentation found: Two (2) showers given, one (1) bed bath, and no refusals documented in 30 days. On 03/27/25 at 12:30 PM the Regional Director of Operations verified the facility could not provide any other documentation for Resident #49's showers. Based on interviews, observation and review of documentation the facility failed to provide Activities of Daily Living (ADL) care for dependent residents in the area of bathing. This was true for four (4) of four (4) residents reviewed in this area. Resident identifiers: #66, #94, and #49. [...]

Inspectors wroteBased on resident interview and observation the facility failed to provide palatable, attractive, and appetizing food. This practice had the potential to affect more than an isolated number of residents who received their nutrition from the facility dietary department. Facility Census 99.

Inspectors wroteBased on observation, staff interview and policy review the facility failed store food and wear hair net in accordance with professional standards for food service. This practice had the potential to affect more than an isolated number of residents. Facility census: 99.

Inspectors wroteBased on staff interview and documentation review the facility failed to implement the Abuse / Neglect policy of reported incidents of abuse to the appropriate agencies. Resident identifier: #31. Facility census: 99.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's newly mental disorder was referred to the appropriate state-designated authority for review or one (1) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier: #49. Facility census: 99.

Inspectors wroteBased on record review and staff interview, the facility failed to have a comprehensive and individualized care plan in discharge planning for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident identifier: 98. Facility census: 99.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Professional standards care and services were provided according to accepted standards of clinical practice in regard to medications left at bedside. This practice has the potential to affect a limited number of residents. Resident identifier: #79. Facility census: 99. An observation on 03/26/25 at 8:08 AM found, Resident #79 taking medications from a medication cup, unattended. During an interview on 03/26/25 at 8:10 AM, Licensed Practical Nurse (LPN) #59 verified, she should not have left the room before Resident 49 took her medication. Medical record review revealed Resident #49 did not have physician's order for medication self-administration.

Inspectors wroteBased on record review and staff interview, the facility failed to follow a physician's order for administration of an antibiotic. This was true for one (1) of five (5) residents reviewed under the unnecessary medications pathway. Resident identifier: #32. Facility census: 99.

Inspectors wroteBased on observation and staff interview, the facility failed to post an updated staffing report sheet for 03/24/25. This was a random opportunity for discovery. Facility census: 99.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to accommodate resident food preferences. This was true for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident identifier: 19. Facility census: 99.

Inspectors wroteBased on observation and staff interview the facility failed to store garbage and kitchen refuse in a proper manner. Facility Census 99.

Inspectors wroteBased on observation 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 the resident's personal products and unsanitary practices. This failed practice was a random opportunity of discovery. Resident identifier: #82. Facility census: 99.

Inspectors wroteBased 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. The facility submitted a Plan of Correction (POC) on 03/28/23 at 6:51 PM. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure each resident had the right to personal privacy during treatments and confidentiality of personal health information for three (3) of three (3) residents whose treatments were observed. This was found true for Residents #41, #20 and #1 who was not provided privacy during a treatment and Residents #41, and #1 had personal medical care instructions displayed above the beds in the room. Resident identifiers: #41, #20 and #1. Facility census: 101.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessments for three (3) of 26 residents reviewed during the long-term care survey process. Resident identifiers: #49, #76, #93. Facility census: 102.

Inspectors wroteb) Resident #93 A record review on 03/28/23 at 8:30 AM, revealed a physician order dated 02/28/23 - Ipratroplum-Albuterol Aerosol Solution 20-100MCG/ACT 1 inhalation inhale orally every 8 hours for cough congestion wheezing URI. A record review on 03/28/23 at 8:32 AM, found Resident #93's comprehensive care plan did not include the Nebulizer treatment. During an interview on 3/28/23 at 10:45 AM, the MDS Coordinator #89 acknowledged the care plan did not reflect the Nebulizer treatment. During an interview on 03/28/23 at 2:50 PM the DON acknowledged the care plan was incomplete. c) Resident #99 During a confidential interview on 03/27/23 at 12:12 PM, a resident reported Resident #99 sometimes enters the resident's room. The resident reported he was concerned Resident #99 might remove or destroy his personal property. [...]

Inspectors wroteBased on facility record review and staff interview the facility failed to ensure the Director of Nursing was not working dual roles and a Registered Nurse was in the facility at least eight (8) hours every day. This failed practice had the potential to affect more than a limited number of residents. Facility census 102.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications, used in the facility, were stored, in accordance with current accepted professional practices. This was true for medications stored in two (2) of two (2) medication storage rooms. The facility failed to ensure the temperature of the refrigerator was monitored in both medication storage rooms to ensure medications stored in the medication room refrigerator were maintained at the manufacturer's acceptable temperature range for storage. This practice had the potential to effect more than a minimum number of residents. Facility census:

Inspectors wroteBased on observations, resident interviews, resident council meetings, and staff interview, the facility failed to provide notification of changes of the menu by not updating the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 102 Findings Included: a) Confidential Interviews During an initial interview on 03/27/23 Confidential Resident stated the food is awful, we never get what the menu says or the meal tray ticket. The meal is always different from what they say. When you look forward to getting something and they don't have it on your tray its disappointing. During an initial interview on 03/27/23 Confidential Resident stated the menus are not being followed, the new company is trying to save money. [...]

Inspectors wroteBased on observation, facility policy review and staff interview, the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to complete the daily refrigerator and freezer temperature log. In addition, the facility also documented food and drink temperatures prior to the meal being prepared. This has a potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 102 Findings Included: A review of a facility policy titled Food Preparation with a revision date 09/2017 revealed the following. Procedures .14. Temperature for TCS foods will be recorded at time of service, and monitored periodically during meal service periods. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure garbage and refuse containers were in good condition. This deficient practice has the potential to affect more than a limited number of residents that reside in the facility. Facility Census: 102. Findings Included: a) Outside garbage receptacle An observation on 03/28/23 at 10:26 AM, found two (2) of the facility's outside garbage receptacle were full of bagged trash reaching the top, one of them was missing a closure lid. Another garbage receptacle was full of bagged trash with a bent lid which was unable to close properly. During an interview on 03/28/23 at 10:27 AM, Maintenance Assistance (MA) #1 acknowledge the missing closure lid and bend lid. The MA #1 stated I have called the (local Sanitary office name)several times to bring new lids, they have never brought them. I will call them again today. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for five (5) of 26 records reviewed in the long-term care survey sample. Resident identifiers: #59, #60, #5, #27, and #96. Facility census: 102.

Inspectors wroteBased on facility document review and staff interview the facility failed have all required members of the Quality Assessment and Assurance (QAA) attended at least one meeting every quarter. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 102.

Inspectors wroted) Hand Hygiene A dining observation on 03/28/23 beginning at 11:55 AM found the lunch meal trays arrived in the 200 Hall at 12:03 PM. Nurse Aide (NA) # 107 was observed passing three (3) lunch trays. During the observations hand hygiene was not offered to the residents prior to receiving their lunch trays. This surveyor intervened and inquired about hand hygiene. Hand sanitizer wipes were not placed on the meal trays . There were no hand sanitizer bottles observed near the serving areas. During an interview on 03/28/23 at 12:07 PM, NA #107 stated I just got here, I did not give any hand hygiene. No, I did not offer the Residents hand hygiene. During an interview on 03/28/23 at 12:07 PM, Registered Nurse (RN) #104 acknowledged no hand hygiene was provided. RN #104 stated this hand hygiene is being cited at every facility I have been working at. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to follow the current recommendation from the Center for Disease Prevention and Control (CDC) guidance for the Pneumococcal vaccine. One (1) resident received the vaccine to soon, two (2) residents were not offered a pneumococcal immunization. This was true for three (3) out of five (5) residents reviewed for immunizations. Resident Identifiers: #44, #5, and #77. Facility census 102.

Inspectors wroteBased on observation and staff interview, the facility failed to equip corridors with firmly secured handrails on each side. This was a random opportunity for discovery and the potential to affect a limited number of residents who reside in the facility. Facility census 102.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure meal trays were delivered in a manner to protect and promote the rights of resident dignity by failing to serve roommates a meal tray at the same time. This was based on a random opportunity for discovery and had the potential to affect a limited number of residents. Census: 102.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's representative was notified when the resident had a change in condition. The resident representative was not notified when the resident experienced weight loss for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #85. Facility census: 102.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a notice of discharge to resident/representative and/or ombudsman for two (2) of two (2) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifiers: #30 and #41. Facility census 102. Findings Included: a) Resident #30 On 03/28/2023 at 9:51 AM, discharge /transfer documentation was requested from the Administrator for resident #30 regarding recent hospitalization. On 03/28/2023 at 12:22 PM, the administrator stated, I do not think anything was sent with the resident, in regards to discharge paperwork. He stated that they are still looking. On 03/28/2023 at 12:50 PM, the Director of Nursing (DON) reviewed the medical record with the surveyor. The DON confirmed Resident #30 lacks capacity per capacity form dated 02/13/2023. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to the resident/represenative of their bed hold policy for two (2) of two (2) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifiers: #30 and #41. Census 102. Findings Included: a) Resident #30 On 03/28/2023 at 9:51 AM discharge /transfer documentation was requested from the Administrator for resident #30 regarding recent hospitalization. On 03/28/2023 at 12:22 PM, the administrator stated, I do not think anything was sent with the resident. He stated that they are still looking. Record review also indicates that the residents most recent Brief Interview for Mental Status (BIMS) score was a five (5), indicating severe impairment. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's comprehensive care plan was revised when the resident experienced weight loss. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #85. Facility census: 102.

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to provide care required to maintain proper hygiene to a female resident who was dependent for Activities Of Daily Living (ADL) care. This is true for one (1) of four (4) residents reviewed for ADL's care area during the Long-Term Care Survey Process. Resident Identifier: Resident #27. Facility Census: 102 Findings Included: a) Resident #27 During the initial interview on 03/27/23 at 1:17 PM, Resident #27 was unable to answer questions appropriately. Observation of Resident # 27 found she had facial hair under her chin and on her upper lip. Resident #27 was rubbing her chin and pulling her untrimmed hair during the interview. During an interview on 03/28/23 at 10:18 AM Hospitality aide (HA) #10 stated, I shave the men and women, everyone gets checked daily and most men get shaved daily. [...]

Inspectors wroteBased on record review and staff interview the facility failed to follow a physician's order to notify the physician when blood sugar is above 400. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: Resident #5. Facility census 102.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the environment is free from accident hazards over which it has control. This was a random opportunity for discovery. Resident Identifier: Resident # 56. Facility Census: 102 Findings Included: a) Resident #56 During the initial interview on 03/27/23 at 10:22 AM, Resident # 56 stated they were supposed to fix my lift chair. Resident # 56 showed this surveyor the wired remote to her recliner. The wires were exposed and bare with an attempt of a repair with electrical tape peeling away. Resident # 56 stated they were supposed to order me a new cord but never did they just taped this one. During an interview on 03/27/23 at 11:56 AM, the administrator acknowledged the recliner was an accident hazard and needed to be replaced. .

Inspectors wroteBased on record review and staff interview, the facility failed to monitor residents who experienced weight loss in accordance with accepted standards of care. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of nutrition. Resident identifiers: #85 and #91. Facility census: 102.

Inspectors wroteBased on observation and staff interview, the facility failed to provide necessary respiratory care consistent with professional standard practice. Resident #93 and Resident #90's nebulizer masks were on their bedside tables with no protective covering. This was a random opportunity for discovery. Resident identifier: Resident #93 and Resident #90. Facility census: 102. Findings Included: a) Resident #93 During the initial tour on 03/27/23 at 11:36 AM, Resident # 93's nebulizer mask was on the bedside table without a protective covering. During an interview on 03/27/23 at 11:38 AM, RN #9 acknowledged the mask was not stored appropriately. b) Resident #90 During the initial tour on 03/27/23 at 11:36 AM, Resident # 90's nebulizer mask was on the bedside table without a protective covering. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure staff had the appropriate competencies and skill sets to care for a resident receiving enteral (tube) feeding. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of tube feeding. Resident identifier: #41. Facility census: 102.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the attending physician provided a rationale as to why a Gradual Drug Reduction (GDR) suggested by the facility Pharmacist was not acted upon. This was true for one (1) out of five (5) residents reviewed for unnecessary medication. Facility census 102.