Berkeley Springs, WV

War Memorial Hospital

5-star overall rating with 5-star inspections with 1 recent health deficiencies

1 Healthy Way, Berkeley Springs, WV

(304) 258-6502

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

16

Certified beds

Average residents

14

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1990-01-15

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

1.33

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

1.08

Licensed practical nurse staffing · state 0.92 · national 0.87

Aide hours / resident day

3.52

Nurse aide staffing · state 2.07 · national 2.35

Total nurse hours

5.93

All reported nurse hours · state 3.69 · national 3.89

Licensed hours

2.41

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

5.06

Weekend nurse staffing · state 3.18 · national 3.43

Weekend RN hours

0.94

Weekend registered nurse coverage · state 0.39 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

1.41

CMS adjusted RN staffing hours

Adjusted total hours

6.27

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

27%

Annual nurse turnover · state 43% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	91.7%	96.7% 5 pts worse	93.4% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 91.7%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	4.5% 4.5 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	6.8% 6.8 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	5.0%	6.6% 1.6 pts better	5.4% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.3%	27.0% 18.7 pts better	19.6% 11.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3%
Percentage of long-stay residents who received an antipsychotic medication	12.5%	15.5% 3 pts better	16.7% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	8.3%	19.5% 11.2 pts better	16.3% 8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.0%	17.6% 7.6 pts better	14.9% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.8% 1.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.4%	22.4% 4 pts worse	19.8% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 26.4%
Percentage of long-stay residents with pressure ulcers	10.5%	4.7% 5.8 pts worse	5.1% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-16 · Fire 2024-10-16

1 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-11-02 · Fire 2022-11-02

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-07-28 · Fire 2021-07-28

2 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

C · Minimal harm 2021-07-28

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2021-07-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-10-16

F710 · Nursing and Physician Services Deficiencies

Health

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Corrected 2024-11-04

E · Potential for more than minimal harm 2022-11-02

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-11-30

E · Potential for more than minimal harm 2022-11-02

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2022-11-30

D · Potential for more than minimal harm 2022-11-02

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-11-30

D · Potential for more than minimal harm 2022-11-02

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-11-30

D · Potential for more than minimal harm 2021-07-28

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2021-08-20

D · Potential for more than minimal harm 2021-07-28

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2021-08-20

Penalties and ownership