Berkeley Springs Center (SFF) Abuse and Neglect Attorneys

Berkeley SpringsBoth the State of West Virginia and Centers for Medicare and Medicaid Services (CMS) conduct routine investigations, surveys, and inspections of every nursing facility each year. The efforts of the inspectors and surveyors help to identify serious concerns and violations of nursing home law. When problems are detected, regulators provide the nursing home the opportunity to make prompt changes to their policies and procedures and improve the level of care every resident receives.

In egregious cases, regulators might designate the center as a Special Focus Facility (SFF). This undesirable designation notifies the public and alerts the facility that providing residents substandard care is never tolerated.

In 2017, Berkeley Springs Center was designated a Special Focus Facility and was added to the National Medicare watch list. The facility must now undergo additional unscheduled surveys and unannounced investigations annually until regulators are assured that any changes made to the level of care they provide their residents are permanent. Some major issues, health violations and deficiencies involving this facility are listed below.

Berkeley Springs Center (SFF)

This Long-Term Care Home is a 120-certified bed Center providing cares and services to residents of Berkeley Springs and Morgan County, West Virginia. The ‘for profit’ Facility is located at:

456 Autumn Acres Road
Berkeley Springs, WV 25411
(304) 258-3673

The facility provides short-term and long-term skilled nursing care and short-term rehabilitation.

More than $55,000 in Monetary Penalties

The state of West Virginia and the federal government had the legal authority to levy monetary penalties against any nursing home in the state identified to have violated nursing home regulations. These fines are meant to redirect the facility in improving the level of care provided to every resident.

Over the three years, Berkeley Springs Center received one monetary fine of $56,875 on 04/06/2016. On the same day, Medicare denied a request for payment by the facility. During this time, regulators followed up on two formally filed complaints that after investigations both resulted in citations.

Current Nursing Home Resident Safety Concerns

Families can visit the website to obtain a complete list of all dangerous hazards, filed complaints, safety concerns, health violations, opened investigations, and incident inquiries at nursing homes nationwide. The regularly updated information can be used to make a well-informed decision on which long-term care facilities in the community provide the highest level of care.

Currently, Berkeley Springs Center maintains an overall one out of five stars compared to all nursing homes nationwide. This ranking includes one out of five stars for health inspections, three out of five stars for staffing issues, and two stars for quality measures. Some violations, citations, deficiencies and health concerns involving this facility include:

  • Failure to Allow the Resident to Refuse Treatment or Take Part in an Experiment or Formulate Advance Directives
  • In a summary statement of deficiencies dated April 6, 2016, a state investigator identified failures. It was noted that the facility failed “to formulate a Plan of Care with written policies and procedures to provide cardiopulmonary resuscitation (CPR) to residents on the 500 Hall/Memory Care Unit; a separate unit isolated from other parts of the building.” The surveyor noted that the “staff was unaware of the location of emergency equipment and the planned procedure to call for additional staff in the event of a cardiac or respiratory emergency.” The deficiency by the nursing staff affected to residents “with advance directives for CPR residing on the memory care unit.”

    The state investigator reviewed a resident’s Care Plan noting that the resident “has multiple cardiac issues, hypertension, … and stenosis of [the] carotid artery. However, [the resident’s] Care Plan did not reflect the resident’s resuscitation status.” In a review of another resident’s medical record, surveyors found that the resident power of attorney and identify the resident “was to receive resuscitation with full interventions.” The surveyor noted that upon random observations of the unit it was revealed that there were no procedures for staff to follow in the event of a cardiopulmonary emergency.”

  • Failure to Notify the Resident’s Responsible Party Immediately of the Serious Decline in Their Medical Condition That Jeopardizes Their Health
  • In a summary statement of deficiencies dated April 6, 2016, a state investigator noted the facility failed “to properly notify a resident’s legal representative when there was a significant change in the resident’s condition [that] required medical interventions and treatment.” The deficiency by the nursing staff involved one resident who was “sent to an acute care hospital where she expired…”

    The surveyor documented that the resident’s “Progress Note did not contain documentation of notification of Power of Attorney/family member during this change in condition.” During an interview with the Registered Nurse/Infection Control Nurse (previous Director of Nursing), the nurse stated “I would hope my nurses notified the brother, but it is not here. Of course, if it is not written, it was not done.”

  • Failure to Report and Investigate Acts or Allegations of Abuse, Neglect or Mistreatment of Residents
  • In a summary statement of deficiencies dated April 6, 2016, the state investigator noted the facility had “failed to thoroughly investigate or immediately report allegations of abuse or neglect, including injuries of unknown origin.” The surveyor said that while the deficiency directly involved four residents it “had the potential to affect more than a limited number of residents.”

    One incident involved a resident “moved to the 500 Wing, the former Assisted Living Unit of the facility, in preparation for conversion of the unit to an Alzheimer’s memory care unit.” The resident’s progress notes revealed that the resident had “falls and [was] sent for x-rays. The facility sent the resident to a hospital emergency room” where she returned with diagnoses of “fractures to her hip and pelvis.”

    A review of the facility’s Clinical Meeting Note: Reason for Review revealed “three falls over the past week.” However, the summary of the resident’s status in the Clinical Meeting Note lists “no injuries with fall, except a bruise on the shoulder and hands, x-rays negative…” The outcome of the interdisciplinary team review involving new interventions documented that the staff “will continue to maintain a safe environment for the resident, plan to move to the member to the unit/skilled nursing facility.”

    Other notes involving the resident documents “up wandering the halls. Pleasant. Confused. Assisted to bed several times. Restless.” An additional Nursing Note revealed that “resident had refused meds earlier. When CNA was doing morning care, the resident screamed that her hip/back was hurting and cried in pain.” One hour later, the nurse's note reveals that the “resident [got] up, dressed and walked to the dining room with no issues. Asked the resident about any pain, she denied having any. No signs of discomfort noted. Pleasant and cooperative.

    The Order Note for the X-Ray revealed “right femur and right hip via quality mobile imaging… Resident pain level increased upon supine position; there is a 4 cm lump on top of the right femur.” “Further review of incidents the facility had reported to state agencies did not find evidence the facility reported the resident’s injury, which was unwitnessed, as an injury of unknown origin to appropriate State Agencies. Also, there was no evidence of any investigation regarding the incident.”

    The state investigator interviewed the facility’s Social Worker who stated “yes I would have reported this because of the unusual location and an injury of unknown origin. I was not aware of this incident, but it should have been reported and investigated.”

  • Failure to Develop, Implement and Enforce Policies that Forbid Mistreatment, Neglect or Abuse of Residents
  • In a summary statement of deficiencies dated April 6, 2016, the state investigator documented that the facility had failed to “implement and operationalize its policies regarding abuse/neglect, including injuries of unknown origin. The facility failed to investigate and report occurrences of possible neglect or injuries of unknown origin for [4 residents].” The deficient practice by the nursing staff “had the potential to affect all residents.” One incident involved a resident who suffered an injury of unknown origin and was diagnosed with hip and pelvic fractures.

  • Failure to Provide Housekeeping and Maintenance Services at a Professional Level
  • In a summary statement of deficiencies dated April 6, 2016, the state investigator documented that the facility “had failed to provide effective housekeeping and maintenance services necessary to ensure an environment was sanitary, orderly and comfortable for residents.” Upon observation of the facility, the surveyor documented “numerous cosmetic imperfections. Concerns included stain discolored tile and caulking around toilet bases and doorframes, rusted stained drains, and stained sink basins. In addition, the baseboard heaters on either side of the 200 Hall had large scratches and dents with missing paint. This [lack of maintenance] had the potential to affect more than a limited number of residents.”

  • Failure to Ensure That Every Resident Receives an Accurate Assessment by a Qualified Health Professional
  • In a summary statement of deficiencies dated April 6, 2016, the state surveyor documented that the facility failed to “ensure that the assessment was accurate regarding prognosis and hospice services.” The deficient practice by the nursing staff effected one hospice resident.” The state investigator reviewed the resident’s Quarterly Minimum Data Set (MDS) that asked, “does the resident have a condition or chronic disease that may result in a life expectancy of less than six months?” The response on the form stated “No.”

  • Failure to Provide Necessary Care and Services to Ensure the Resident Maintains Their Highest Well-Being
  • In a summary statement of deficiencies dated April 6, 2016, the state investigator documented that the facility had “failed to ensure that a resident was provided with the assistance she required as identified in her Comprehensive Plan of Care.” The resident “experienced pain and anxiety after falling out of bed when a staff member failed to provide care in accordance with the resident’s assessed needs. This avoidable incident resulted in the actual harm to the resident.”

    Medical records revealed that following the incident, a Registered Nurse Aide “came out of the resident’s room to get [a] nurse. She stated the resident rolled out of bed was on the floor. The resident [was] assessed and noted to have complaints of pain in the left shoulder, wrist, knee, and hip. She had a slight nosebleed to the left nares [nostrils]. The resident was urgently transferred to the hospital for evaluation.” The document also revealed that the resident “is terrified whenever staff [performs] personal care, and when repositioned. The resident was reassured by having several staff members present during care.”

    Since the incident, the resident “is now scared to death of falling. The facility provided the resident with a wider bed to assist with her anxiety related to falling out of bed during care. This avoidable incident resulted in actual harm to the resident as she experienced pain, had been sent to a hospital and had persisting anxiety about falling out of bed.”

  • Failure to Provide an Environment Free of Accident Hazards
  • In a summary statement of deficiencies dated April 6, 2016, the state investigator documented that the facility had failed to “ensure that the resident environment remained as free from accident hazards as possible and that each resident received adequate supervision to prevent accidents.” These hazards involved seven residents who “resided in the 500 Hall/Memory Care Unit… The T-shaped department was staffed every shift by two people, a Nurse, and Nurse Aide, and contained multiple unsecured, of site areas for residents to wander into unobserved.”

    The surveyor documented that there were three out of seven residents with who “had care plans for wandering. The front door and alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if sounded.” Additionally, it was documented that the “staff had difficulty hearing the alarm.”

    During the tour, the facility, the surveyor documented their observations and found “the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it open. A faint alarm sounded, but no staff approached in response.” The investigator interviewed the facility’s Unit Director Registered Nurse who “acknowledge the front door had been an issue since the residents were moved to the unit. The staff could not hear the alarm, and they had been asking for it to be repaired.” It was documented that the facility had an Immediate Jeopardy that existed for the seven residents residing in the 500 Hall.

  • Failure to Follow Protocols and Procedures to Prevent the Spread of Infection throughout the Facility
  • In a summary statement of deficiencies dated April 6, 2016, the state investigator documented that the facility “failed to maintain an effective infection control program to prevent and control to the extent possible, the onset and spread of infection within the facility.” Surveyors noted that “a urinal and urine container were stored improperly in a resident bathroom.” A surveyor noted that upon observation of a bathroom shared by two residents there was a “urinal in urine collection container uncovered and not labeled with the name of the resident to whom it belonged.”

    During an interview with the Director of Nursing, it was revealed that the Director “viewed the uncovered and unlabeled urinal and urine collection container in the bathroom” and stated “I will toss them and get new ones because I do not know who they belong to. They should be bag and labeled because of infection control.”

  • Failure to Ensure There Is a Pest Control Program That Prevents Dealing with Mice, Insects or Other Pests
  • In a summary statement of deficiencies dated April 6, 2016, the state investigator documented that the facility “failed to maintain an effective pest control program so that the facility is free of pests and insects. Numerous ants were located on the same countertop in the resident’s room.” The deficient practice by the maintenance department “had the potential to affect more than an isolated number of residents.”

Were You Abused or Neglected in a Nursing Home?

If your loved one suffered injuries while residing at Berkeley Springs Center, or any nursing home, consider hiring a personal injury lawyer to resolve your case. Working on your behalf, your attorney can issue a complaint, file your compensation claim, gather evidence, build your case, and negotiate an out of court settlement or take your lawsuit to trial.

No upfront retainers or fees are required because personal injury attorneys accept every nursing home abuse claim for compensation through contingency fee arrangements. This agreement provides immediate legal representation while postponing payment for services until after the case is resolved at trial or through a negotiated settlement.


Client Reviews

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric