Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berkeley Springs Healthcare Center during CMS and state inspections, most recent first.
Dirty window sills and bathroom soil were observed on the 300 hall. Rooms 307, 308, 309, and 312 had dust, cobwebs, and blackish debris on the window sills, and room 312 also had a brownish smeared substance on the bathroom floor in front of the toilet that remained on recheck. The ADM confirmed the findings during the walk-through.
PASARR screening was incomplete for four residents when the PAS forms did not match active chart diagnoses or omitted required mental health diagnoses. The records showed missing or incorrect entries for bipolar disorder, dementia, schizophrenia, depression, and anxiety, and the DON and Corporate RN confirmed the discrepancies during record review.
Failure to revise a resident’s care plan after multiple nutrition-related order changes. A resident’s diet was changed from a therapeutic diet to a regular diet, weekly wt orders were added due to wt loss, and finger foods were later discontinued, but the care plan was not updated to reflect any of these changes. During survey review, the RDCO acknowledged the missed revisions.
Delayed Meal Service for Roommate: A resident was served lunch in his room while his roommate waited 35 minutes for his tray on two consecutive days. Staff confirmed one resident preferred room service and had explosive disorder, while the other also preferred in-room meals, but trays were delivered after dining room service, resulting in the roommate receiving meals later than the other resident.
Care plan documentation for a resident was not person centered and did not include measurable goals. The plan used broad statements about mood disturbance and behaviors, but it did not identify the resident’s specific symptoms, current episode frequency, preferred choices, or the exact signs, symptoms, and side effects staff were to monitor and document.
An LPN administered meds and tube feeding through a resident’s G-tube without verifying tube placement first, despite an order to check placement before feedings, flushes, and med passes. The report also references a second resident in connection with significant weight loss and the facility’s weight-monitoring policy, but provides no further event details.
Failure to follow physician orders for heel protectors led to a deficiency for pressure ulcer prevention. A resident at risk for pressure ulcers due to decreased mobility, poor nutritional intake, and favoring the right side was observed multiple times lying on the right side without the ordered heel boots in place, with the devices left in a chair and once on the floor. Nursing staff confirmed the heel protectors were supposed to be on while the resident was in bed.
An LPN left a med cart unattended and unlocked in the 200 hall while getting ice for the cart. A surveyor was able to open the top drawer, and another employee then closed and locked the cart until the nurse returned. The Facility Administrator acknowledged the cart had been left unlocked.
A resident was observed lying in bed with an approximate 12-inch gap between the mattress and the foot rail, and the bed was extended with a small support in place leaving about a 10-inch deep gap. The ADON verified the gap between the mattress and foot boards and stated that maintenance would evaluate and fix it.
Dirty Window Sills and Bathroom Floor Soil on 300 Hall
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the 300 hall. During observations and resident interviews, window sills in rooms 307, 308, 309, and 312 were found to have dust and cobwebs in the corners with a buildup of blackish debris. In room 312, surveyors also observed a brownish smeared substance on the bathroom floor in front of the toilet, and a recheck the next day found the substance was still present. During a facility walk-through, the administrator confirmed the black debris buildup and dusty cobwebs on the listed window sills, as well as the brown smears on the bathroom floor in front of the toilet base in room 312.
PASARR Screening Missing or Incorrect Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was incomplete and inaccurate for four residents reviewed out of an initial pool of 34. For Resident #8, the Pre-admission Screening marked option K for affective bipolar disorder, but the chart listed Bipolar disorder, unspecified (F31.9) and also included Unspecified dementia, unspecified severity without behavioral disturbances (F03.90), which was not reflected on the PAS. For Resident #12, the PAS marked option A for none and did not include any entry in section N for other diagnoses, despite active diagnoses of Bipolar II disorder (F31.81), Major depressive disorder (F33.1), and Generalized anxiety disorder (F41.1) in the chart. For Resident #11, the PAS marked option K as none even though the chart listed Schizophrenic disorder, Vascular dementia with anxiety (F01.B4), and Major depressive disorder recurrent, moderate. For Resident #68, the PAS also marked option K as none, while the chart listed Bipolar disorder, unspecified and Generalized anxiety disorder recurrent, mild (F41.1). The record review and staff interviews confirmed that these diagnoses were missing or not matched on the PAS forms for the affected residents.
Failure to Revise Care Plan for Changed Diet and Weight Orders
Penalty
Summary
The facility failed to ensure that Resident #14’s care plan was revised when her diet and nutrition-related orders changed. Her diet was changed from a therapeutic diet to a regular diet on 03/31/26, but the care plan was not updated to reflect that change. Her order for weekly weights every Thursday was also not included in the care plan after it was changed on 06/18/26 due to weight loss. In addition, her order for finger foods with meals as available was discontinued on 06/29/26, and the care plan was not revised for that change either. During record review and staff interview, the surveyor identified that these three separate changes had not been incorporated into Resident #14’s care plan. On 07/07/26 at 1:35 PM, the Regional Director of Clinical Operations acknowledged that the revisions had been missed and stated that the Registered Dietitian would be contacted and an audit for care plan revision would be started.
Delayed Meal Service for Roommate
Penalty
Summary
The facility failed to ensure Resident #71 had a dignified dining experience during lunch on 07/06/26 and 07/07/26. During observation on 07/06/26 at 12:10 PM, Resident #45 was eating in his room while his roommate, Resident #71, had not yet received his tray. Resident #45 stated he was on vacation and eating in his room that week, and Resident #71 stated he had not received his tray yet and that his tray always came after the dining room residents were served. Resident #71’s meal arrived at 12:35 PM. On 07/07/26 at 12:15 PM, Resident #45 again received his tray in his room while Resident #71 did not receive his noon meal until 12:40 PM. During interview, the LPN confirmed she was aware Resident #45 was eating in his room that week and that his meals arrived before his roommate’s. She also stated Resident #71 preferred to receive meals in his room and was served after the dining room, while Resident #45 usually preferred the dining room. The LPN reported Resident #45 had explosive disorder and would become upset if his food was not where he expected it at mealtime, and she could not see a way to accommodate both residents to receive meals at the same time. The Administrator later acknowledged that trays were delivered to the floors after dining room meals, causing conflicts in tray arrival times when a resident chose to eat in his room, and stated this was unacceptable.
Care Plan Lacked Person-Centered, Measurable Goals
Penalty
Summary
The facility failed to ensure that Resident #8’s care plan was person centered and included measurable goals. During a routine chart review, the resident’s care plan was found to contain broad statements such as the resident will not experience any increase in signs and symptoms of mood disturbance through the review period, but it did not identify what mood disturbances or behaviors the resident had experienced or what staff should monitor for. The intervention section stated to observe and document signs and symptoms of effectiveness and side effects, but it did not specify which signs, symptoms, or side effects to observe. It also stated to honor the resident’s preferred choices, but the choices were not listed. Another goal stated the resident would have fewer episodes of behaviors through the review date, but it did not identify how many episodes were occurring or include the signs and symptoms related to the medications staff were to observe and document.
Failure to Follow G-tube Orders and Weight Monitoring Requirements
Penalty
Summary
Physician orders were not followed for Resident #100 during medication administration and tube feeding. During observation, an LPN administered medication and feeding through the resident’s G-tube without checking tube placement first. When interviewed, the LPN verified that placement had not been checked before giving the medication and feeding. The medical record showed orders to verify enteral tube placement before feedings, flushes, and medication passes by checking that gastric contents were not visualized, and to check residual every shift with instructions to hold feeding and notify the physician if residual remained greater than 100 mL. The facility also had a policy stating that weights are to be obtained monthly or as ordered, compared to the previous weight, and that a variance of five pounds or more requires a reweigh to verify the weight. The report identifies Resident #14 in connection with significant weight loss, but the narrative provided does not include the specific observations or events for that resident beyond the policy reference and the resident identifier.
Failure to Follow Heel Protector Orders
Penalty
Summary
Failure to follow physician orders for heel protectors led to a deficiency for pressure ulcer care and prevention of new ulcers. Resident #101 was identified as at risk for pressure ulcers/injuries related to decreased mobility, poor nutritional intake, and favoring the right side, and the care plan and physician order both directed that heel boots/protectors be on the right and left heels at all times except during bathing or showers. During multiple observations on 07/06/26 and 07/07/26, the resident was lying on the right side while both heel protectors were not in place, with the devices found in a chair and, at one point, one in the chair and one on the floor. Nursing staff confirmed the heel protectors were supposed to be on when the resident was in bed and that they were not in place as ordered.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible when a med cart in the 200 hallway was found unattended and left unlocked. During observation on 07/06/26 at approximately 3:10 PM, the med cart was seen unattended, and Employee #148 confirmed witnessing the surveyor walk up and pull open the top drawer of the cart. She then closed it and locked it until the nurse returned. In an interview at 3:15 PM, the LPN, Employee #140, confirmed the med cart had been left unlocked while she went to get ice for the cart and stated she did not realize it was unlocked. The Facility Administrator later acknowledged that the med cart had been left unlocked.
Bed Gap Found Between Mattress and Foot Rail
Penalty
Summary
Bed safety was not maintained for Resident #101 when an initial tour on 07/06/26 at 1:16 PM found the resident lying in bed with an approximate 12-inch gap between the mattress and the foot rail. The bed was extended with a small support in place, leaving about a 10-inch deep gap. During an interview at 1:20 PM, the Assistant Director of Nursing verified the gaps between the mattress and foot boards for Resident #101 and stated that the maintenance director would evaluate and fix the gap at that time.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Berkeley Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| War Memorial Hospital | 2.4 mi | ★★★★★ | 3 | 0 |
| Martinsburg Healthcare Center | 15.6 mi | ★★★★★ | 0 | 0 |
| Care Haven Center | 18.2 mi | ★★★★★ | 7 | 0 |
| Williamsport Health And Rehabilitation Center | 21.6 mi | ★★★★★ | 11 | 1 |
| Homewood Living Williamsport | 22.7 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.