Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkersburg Center during CMS and state inspections, most recent first.
A facility failed to ensure that two residents with dysphagia received beverages at the ordered consistency. One resident ordered honey-thick liquids and another ordered nectar-thick liquids were both observed with thin water at bedside, despite SLP involvement and documented swallowing impairment, including silent aspiration and ongoing aspiration of liquids. The surveyor confirmed the liquid inconsistency, and the issue was identified as an IJ.
Menus Not Followed as Posted: The facility failed to serve the posted lunch menu items as written. A posted menu and the weekly menu listed turkey, dressing, peas or broccoli, rolls, and pumpkin pie, but residents were served turkey, cauliflower, pumpkin cake, and cornbread instead. Staff confirmed several items were not served, and multiple residents stated they did not receive the posted foods.
Food served to residents was not palatable or attractive, with surveyors finding chewy scalloped potatoes, tough Salisbury steak, and overcooked vegetables with no seasoning. A resident reported meals were always lukewarm and awful, another did not eat dinner because a sandwich was burned black and too hard, and a third said food did not taste good at times.
Systemic administrative oversight failures were identified involving incident investigation and reporting, abuse and neglect, RN coverage, staffing postings, nurse aide training, hygiene and dignity, timely care, dietary safety, infection control, environmental safety, and activities. Findings included missing FRI documentation, residents not being toileted or changed, a resident with a fracture after a fall, incorrect thickened liquids for two residents, staff not wearing masks during a COVID outbreak, and a resident who could not receive a shower because the available equipment and shower room could not accommodate her needs.
Surveyors found that the facility failed to provide a safe, clean, and comfortable environment, with issues including broken window blinds, dirty privacy curtains, sticky and unclean floors, and missing or poorly maintained baseboards and paint in resident rooms and bathrooms. These deficiencies were confirmed by facility staff and reported by residents.
Multiple residents experienced neglect, including being told to soil briefs instead of being assisted to the toilet and a fall that was not documented or followed up by staff. These incidents were substantiated through interviews and record reviews, with failures to follow the facility's abuse and neglect policies.
The facility did not thoroughly investigate reportable incidents or submit required five-day follow-up investigation reports to the State Agency for multiple residents. Documentation was missing for staff and resident interviews, evidence of completed investigations, and staff education on emergency procedures. In cases of resident-to-resident abuse and reports of verbal threats, there was no documentation of investigation or follow-up, and required reports were not submitted.
The facility did not consistently provide dependent residents with required assistance for ADLs such as showers, oral care, and grooming. One resident with hemiplegia missed multiple scheduled oral care and bathing sessions, while another resident who preferred showers received only bed baths and was unable to access the shower room due to equipment and space limitations. A third resident, who is blind and requires extensive help, did not receive scheduled hygiene care on several occasions. These deficiencies were confirmed through documentation, resident interviews, and staff observations.
Surveyors observed significant ice and frost buildup on and around the freezer door and fan during a kitchen inspection. A dietary staff member confirmed the findings and indicated the frost developed during frequent access to the freezer. Facility policy requires proper maintenance of kitchen equipment, but this was not followed.
Failure to Coordinate PASARR Updates for New Mental Health Diagnoses: The facility did not coordinate PASARR assessments when residents developed new mental health diagnoses or had changes in condition. Four residents had diagnoses such as major depressive disorder, schizoaffective disorder, schizophrenia, anxiety, hallucinations, or mood disturbance documented in the chart or MDS that were not reflected on the PASARR, and new PASARRs were not initiated to notify the state-designated authority.
Inadequate Resident Activity Program: The facility did not provide an ongoing activity program that supported residents’ interests and psychosocial well-being. The activity calendar repeated the same events each week, with movies as the only evening activity and weekend activities ending at dinner time, while residents reported wanting more crafts, games, and evening options. Residents also stated the activity assistant was not completing assigned activities, and the AD said evening activities were movies because it was easier and could not explain the missed duties.
Failure to review and act on consultant pharmacist irregularities was identified for three residents. A resident with schizophrenia, anxiety, hallucinations, depression, and dementia had multiple psychotropic meds and repeated pharmacist irregularities that the facility could not produce or show action on. Another resident on apixaban for TIA history and a resident with DM2 on Lantus also had repeated pharmacist irregularities, but the facility could not locate the reports or document any response.
Food Storage and Serving Practices Not Followed: Surveyors found multiple food safety lapses in kitchen storage areas, including unlabeled and undated milk, tea, fruit punch, and other items; opened foods without use-by dates; expired dressing; and food containers with dried residue. A beverage cart was also stored in the dry storage area with improperly labeled items, and serving utensils were not stored with handles in the same direction in two drawers.
Blocked Trash Can in Kitchen: Garbage and refuse were not disposed of properly because empty boxes were placed on the floor under the handwashing sink and covered the trash can. A dietary staff member confirmed the boxes were blocking disposal of paper towels after hand hygiene, and a plunger was also found under the boxes.
Infection control was deficient when staff were observed without masks at the nurse's station during a COVID outbreak, despite policy requiring masks for all staff inside the facility. Surveyors also observed ice scoops left in the ice buckets during drink passes on two halls, and NAs confirmed there was no separate container for the scoops. The same ice scoop practice was observed again on both halls on later dates.
Nurse aides did not receive required in-service education in dementia care and abuse prevention, and competencies were not completed before direct resident care began. One aide had far less than the required annual dementia training, while two newly hired aides had little or no dementia training and lacked education on abuse prevention, resident rights, and competency validation before working with residents.
The facility did not ensure that an allegation of verbal abuse involving a resident was reported immediately or within the required two-hour timeframe. Documentation lacked confirmation of when the incident was reported, and some witness statements were collected several days after the event. Staff confirmed the absence of required reporting documentation.
Surveyors identified that two residents did not receive appropriate care: one resident's fall was not documented or treated, and another resident missed multiple physician-ordered medications and essential care tasks over an extended period. These failures were confirmed by staff and had the potential to affect other residents.
Staff failed to use a proper carrier when transporting a full oxygen cylinder, and a resident's fall resulting in injury was not documented or treated at the time of occurrence. The resident, who has Alzheimer's disease and osteoporosis, later returned with a spinal brace and was receiving IV antibiotics for a hip infection.
A resident did not receive their meal in bowls as specified by their dietary order and tray card, with only dessert served in a bowl. This was confirmed by a nursing assistant, despite facility policy requiring assistive devices and utensils to be provided according to the care plan.
Two residents did not have their bathing preferences honored. One resident repeatedly requested showers but was often given bed baths or had no bathing documented, and his appearance showed oily, uncombed hair and beard growth. Another resident who stated showers were very important to her also reported receiving mostly bed or sponge baths, with records showing long gaps in bathing documentation and only one shower over the review period; she was observed with uncombed hair and facial hair.
The facility failed to provide required transfer and bed-hold documentation for a resident who was sent to the hospital multiple times. Record review showed missing bed-hold paperwork for two transfers and missing transfer documentation for one transfer, and the facility policy required written transfer notices, transfer forms, med lists, advance directives, and related documents to accompany hospital transfers.
The facility failed to keep care plans consistent with current orders and resident status. One resident’s plan still listed a pressure ulcer, Foley catheter, and PICC line that were not present and had the wrong tube-feeding downtime, while another resident’s plan contained conflicting directions about straw use despite the diet order and tray card stating no straws and staff observing straws in use.
A resident dependent on tube feeding was observed with no formula or water infusing even though the enteral feeding was scheduled to be running. An LPN confirmed the feeding should have started earlier and stated she would start it immediately, and the Administrator later confirmed the feeding was late being started.
A resident receiving tube feeding had a syringe used during administration that was observed without the current date on it. The facility procedure required the syringe and administration connector cover to be stored in a labeled and dated container, and the Administrator confirmed the syringe should have the current date and be used only daily.
Inaccurate daily nurse staffing information was posted in a prominent location and did not match the facility’s timekeeping records. The posted schedule showed an incorrect date at survey entrance, and the RN, LPN, and CNA/CN hours on the staffing form did not align with the time detail reports for multiple days. The issue was reviewed with the Infection Control RN in charge and the Regional Compliance Advisor, and neither had comments.
Inaccurate order and care plan for straw use with thin liquids. A resident was observed using a straw in a cup and at bedside even though the tray card listed no straws. The resident’s diet order and care plan included no straws, but the care plan also stated to use straws and handled cups. An SLP message and eval indicated thin liquids via straw, creating conflicting documentation about straw use.
A resident who preferred to smoke outside complained that the facility changed the smoking schedule and required staff accompaniment and a smoking apron. The resident’s record showed the last smoking assessment was completed in August 2025, but the required quarterly reassessment was not done until after survey staff asked about it, despite the facility’s policy requiring quarterly smoking assessments.
Incorrect Thickened Liquids Served to Residents with Dysphagia
Penalty
Summary
The facility failed to ensure that residents with orders for thickened liquids received beverages at the correct consistency. During observation, one resident who was ordered honey-thick liquids was found eating lunch with a bottle of water and a facility pitcher of thin water at bedside, and she was able to reach and drink the liquids provided. Record review showed diagnoses of oral phase dysphagia and pharyngeal phase dysphagia, with current orders for a regular/liberalized diet, puree texture, and honey-thick liquids. The Speech Language Therapist had evaluated the resident after a Modified Barium Swallow and determined that honey-thick liquids were safest because of silent aspiration. A second resident who had an order for a regular liberalized dysphagia advance texture diet with nectar-thick liquids and a two-handled cup with inset lid was observed with a facility pitcher of water at bedside containing thin liquids. The facility’s food and nutrition policies identified nectar, honey, and spoon-thick liquid modifications for individuals having difficulty swallowing thin liquids. The surveyor, who was licensed as an SLP, confirmed by spoon test that the water in the pitcher was not the correct consistency. During interview, the SLP stated the purpose of thickened liquids was to avoid aspiration pneumonia and noted that the resident continued to aspirate liquids. She also stated she expected staff to know exactly which residents were on thickened liquids because only four residents out of the census required them, and that staff had been educated several times. The report identified the deficiency as an Immediate Jeopardy situation involving the two residents who received liquids that did not match their ordered consistencies.
Menus Not Followed as Posted
Penalty
Summary
The facility failed to ensure menus were followed and met the nutritional needs of residents. The facility policy stated menus would be planned in advance, served as written unless a substitution was needed, and posted. However, the posted dining menu listed turkey, cornbread, dressing, broccoli, rolls, pumpkin pie, and whipped topping, while the Week at a Glance menu listed maple sage turkey, dinner roll, homemade pumpkin pie with whipped topping, seasoned peas, and cornbread dressing. The lunch meal that was actually served included turkey, cauliflower, pumpkin cake, and cornbread instead of the posted items. On 12/07/2025 at 1:20 PM, Recreation Assistant #6 confirmed that rolls, peas, and broccoli were not served and that cauliflower was served, stating, "If they can't prepare it, they change the menu." The assistant also confirmed cornbread, cauliflower, and cake were served. Residents observed by the surveyor did not receive the posted lunch menu items, including Residents #11, #56, #24, #35, and #58. Resident #58 stated they liked broccoli if it was done right and received cake instead of pie and cauliflower instead of peas or broccoli. Resident #16 stated, "Looks like cake," and did not receive peas or broccoli, which was confirmed by Nursing Assistant #42. Resident #36 reported lunch was awful and said they only received bits of turkey, cauliflower, and cornbread, and did not receive pumpkin pie.
Food Served Was Not Palatable or Properly Prepared
Penalty
Summary
The facility failed to ensure food served to residents was palatable, attractive, and prepared by methods that conserved nutritive value, flavor, and appearance. During a lunch tray test on 12/08/2025, surveyors found the scalloped potatoes had chewy edges and an inconsistent consistency, the Salisbury steak was tough, hard to cut, and had crunchy edges, and the vegetables were too soft, especially the broccoli, with no seasoning; these findings were confirmed by the Regulatory Compliance Officer. Resident #36 reported that the food was awful and never hot, describing it as always lukewarm, and later stated at lunch that the potatoes and roll were the only items eaten. Resident #14 did not eat dinner because the sandwich was excessively toasted, burned black, too hard, and tasted unpleasant. Resident #40 stated that food did not taste good at times and surveyors documented the same tray quality concerns during the meal observation.
Systemic Administrative Oversight Failures Affecting Resident Care and Safety
Penalty
Summary
The facility failed to provide effective administrative oversight related to reportable incidents, abuse and neglect, staffing, infection control, dietary services, resident hygiene, timely care, and environmental safety. Review of facility records showed that reportable incidents were not thoroughly investigated and were not always reported to the State Agency within five working days, with missing documentation of staff interviews and follow-up reports for some residents. The report also identified failures related to resident abuse and neglect, including refusal to toilet or change residents and failure to appropriately treat a resident who sustained a fall resulting in a fracture. Additional deficiencies included failure to provide an RN for at least 8 hours per day, 7 days per week, inaccurate daily staffing postings, and incomplete nurse aide annual in-service training, including dementia management and abuse prevention. The facility also failed to maintain resident hygiene and dignity, as one resident was observed with uncombed hair and visible facial hair, and another resident reported distress about not recalling the last shower received and stated only bed baths were being provided. The Administrator stated the resident could not fit through the shower room doors, and therapy staff confirmed the resident exceeded the weight limit of the available shower chair, preventing a shower at the facility. Other findings included failure to treat a fall for one resident, failure to administer medications as ordered for another resident, dietary safety failures involving incorrect thickened liquid consistencies for two residents and unsafe freezer maintenance, infection control lapses during a COVID outbreak, hot water temperatures above 110 degrees Fahrenheit, and failure to provide an ongoing activity program. The report states that these deficiencies reflected a systemic failure of administrative oversight.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment for its residents. In one room, window blinds were found to be broken and missing. In another, a privacy curtain was observed to be dirty with a dark brown substance. Additionally, the floor at the head of a resident's bed, under the tube feeding pole, was dirty and sticky, with evidence of spilled feeding solution and an overall unclean surface. These findings were confirmed by both the Environmental Services Manager and the Administrator, who acknowledged that the issues required attention. A resident reported that her floor and the wall behind her bed were dirty and in need of painting, and that the baseboard in her bathroom was missing, with a poor paint job observed. The state surveyor confirmed the presence of dirty walls, a dirty floor, and missing baseboard in the bathroom. The Regulatory Compliance Officer later verified the dirty wall, scuffmarks, missing paint, and missing baseboard. Documentation reviewed indicated a work order for baseboard replacement had been created, but the baseboard remained missing at the time of the survey.
Failure to Prevent and Document Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect and ensure proper care, as evidenced by multiple substantiated incidents. One resident, who was alert and oriented but lacked capacity for medical decisions, reported that CNAs instructed her to soil her brief instead of assisting her to the toilet, despite her ability to walk to the bathroom with assistance. This allegation was substantiated through resident interviews, although the specific staff member involved could not be identified due to lack of recall by the resident. Another incident involved a resident with Alzheimer's disease and dementia who sustained a fall that was not documented in the medical record. There was no evidence of neuro-checks, treatment, or follow-up after the fall, and the nurse on duty at the time resigned and did not provide a statement. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection. The fall and lack of documentation were confirmed by both a CNA and the resident's roommate, who is alert and oriented. A third resident was also found to have experienced neglect, as verified by the facility's investigation. The facility's own Abuse Prohibition Policy requires immediate reporting and thorough documentation of suspected abuse or neglect, but these procedures were not followed in the cases described. The deficiencies were substantiated through interviews, record reviews, and facility investigations.
Failure to Investigate and Report Incidents as Required
Penalty
Summary
The facility failed to thoroughly investigate reportable incidents and submit the required five-day follow-up investigation reports to the State Agency for multiple residents. In several cases, documentation was missing regarding staff and resident interviews, as well as evidence of completed investigations. For example, incident records for one resident did not include documentation of staff interviews or submission of the five-day follow-up report. Another resident's incident file lacked documentation of both staff and resident interviews. Additionally, there was no documentation showing that staff had completed education on handling emergency situations for another resident's incident. Further review revealed that when residents reported experiences of verbal threats or derogatory remarks from other residents, there was no documentation to demonstrate that these responses were investigated or that any follow-up actions were taken. In an incident involving resident-to-resident abuse, while the initial incident was reported to the appropriate agencies and immediate actions were taken, the required five-day follow-up report outlining the investigation, findings, and actions taken was not submitted. These deficiencies were confirmed through interviews with facility leadership and review of facility records.
Failure to Provide ADL Assistance and Honor Resident Preferences for Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including showers, oral care, and grooming, to residents who were dependent on staff for these tasks. For one resident with hemiplegia and hemiparesis, documentation showed that oral care was not provided twice daily as required by facility policy on multiple occasions, and no showers or bed baths were documented on several scheduled days over a 30-day period. There was no documentation of refusals for showers or bed baths, despite the resident's care plan indicating a history of refusal for oral and hair care. Another resident, who required assistance from one to two staff for bathing and a mechanical lift, expressed dissatisfaction with only receiving bed or sponge baths instead of showers, which was her stated preference. Documentation revealed significant gaps in bathing and showering, with extended periods where no hygiene care was recorded. Observations confirmed the resident's hair was uncombed and facial hair was not removed, despite her preference for grooming. Staff interviews revealed that the resident could not access the shower room due to physical limitations and equipment constraints, and her preferences were not honored. A third resident, who was blind and required extensive assistance for ADLs, did not receive scheduled showers or baths on several occasions within a 30-day period. The resident reported not receiving showers or baths as scheduled, and records confirmed that only four out of nine scheduled hygiene sessions were provided. The administrator acknowledged that the frequency of showers and baths was insufficient for this resident.
Failure to Maintain Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition, specifically regarding the freezer. During an inspection, a state surveyor observed ice and significant frost accumulation on the right side of the freezer door, as well as small ice drips frozen on the freezer's fan and a large block of ice formed under the freezer fan. A dietary staff member confirmed these findings and stated that there was no frost earlier in the day, suggesting the issue developed during frequent access to the freezer by staff. The facility's policy requires that all kitchen equipment be properly maintained and in safe working order, with the Dining Service Director responsible for ensuring compliance.
Failure to Coordinate PASARR Updates for New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program when residents had new mental health diagnoses or changes in condition. Record review showed that four of five residents reviewed had mental health diagnoses documented in their medical records or MDS assessments that were not reflected on their PASARRs, and the facility did not initiate new PASARRs to notify the state-designated mental health or intellectual disability authority. The deficiency was identified for residents #56, #59, #44, and #5 during the survey process. Resident #56 had a PASARR completed at another facility that listed bipolar disorder and depression, unspecified, and later received a diagnosis of major depressive disorder, recurrent, mild while in the facility. Resident #59 had a PASARR completed at the facility that listed unspecified dementia with psychotic disturbance, mood disturbance, and anxiety, but later had major depressive disorder, recurrent, mild documented in the medical record and not found on the MDS. Resident #44’s PASARR listed only schizophrenic disorder, while the medical record and MDS documented schizophrenia, anxiety disorder, hallucinations, and major depressive disorder, single episode. Resident #5’s chart listed major depressive disorder, recurrent, mild and schizoaffective disorder, but these were not marked as active diagnoses on the PASARR; the Administrator confirmed the PASARR was not coded correctly.
Inadequate Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices through facility-sponsored group activities designed to meet residents’ interests and support their physical, mental, and psychosocial well-being. An observation of the posted monthly activity calendar showed the same activities repeated each week except for a few volunteer days, with the last weekday activity being a movie at 4:30 PM and the last weekend activity being dinner and a movie at 5:00 PM. The calendar also did not show where the activities would be held. Record review of the monthly activity calendars for August, September, and October showed the same activities repeated each week unless there was a volunteer or holiday event, and the only evening activity was a movie. Review of Resident Council meetings showed repeated concerns that the activity assistant did not provide entertaining activities, residents wanted more evening activities, more crafts, more games such as volleyball, horseshoes, badminton, and golf, and that weekends were boring with no crafting when scheduled. During the resident council meeting, residents stated the activity assistant was not doing the activities they were supposed to do and that the activity director was doing everything. The activity director stated she only had one other assistant and that evening activities were movies because it was easier, and she could not provide education regarding not completing activity duties, confirming evening and weekend activities were not being completed correctly.
Failure to Review Consultant Pharmacist Medication Regimen Irregularities
Penalty
Summary
The facility failed to review and act on the consultant pharmacist’s monthly medication regimen review recommendations for irregularities found in residents’ drug regimens. This was identified for three of five residents reviewed during the survey. The surveyor requested the pharmacist reports showing the irregularities and the facility’s actions taken in response, but the records could not be found by the NHA or other facility leadership when requested. For Resident #44, the record showed diagnoses including schizophrenia, anxiety disorder, auditory and visual hallucinations, major depressive disorder, generalized anxiety disorder, and unspecified dementia, with orders for duloxetine, mirtazapine, loxapine, and buspirone. The consultant pharmacist’s monthly reviews documented irregularities on multiple dates, but the facility could not produce the reports or show what action was taken. For Resident #59, who was receiving apixaban for a history of TIA, the pharmacist documented irregularities on several monthly reviews, and the facility again could not locate the irregularity reports or related actions. For Resident #14, who had type 2 diabetes mellitus with diabetic neuropathy and was ordered Lantus insulin, the pharmacist documented irregularities on multiple monthly reviews, but the facility could not find the irregularities or any action taken in response.
Food Storage and Serving Practices Not Followed
Penalty
Summary
The facility failed to ensure food was stored and served in accordance with professional standards for food service safety. During the kitchen investigation, a beverage cart was found sitting in the dry food storage area for lunch with milk that was not labeled or dated, a carafe of hot water that was not labeled or dated, and an ice scoop in a serving container with a small amount of water. Dietary Aide #76 confirmed the cart was in the storage area and stated it goes out first to the dining room. Additional dry storage items were found improperly stored, including opened ripple potato chips that were not dated or sealed, House Recipe Saltines with a stored date of 10/23 and no use-by date, and bananas that were not labeled with a received or use-by date. In cold storage, surveyors found four pitchers of tea not labeled or dated, three gallons of milk opened with no open or use-by date, mayonnaise with a use-by date of 12/02/25, mustard and ketchup with dried drips on the outside of the containers, raw hamburger patties dated 12/02/25-12/06/25, opened margarine with no use-by date, opened Italian dressing with an opened date of 08/02/25 and use-by date of 12/02/25, a large container of fruit punch not labeled or dated, a bowl of Cheerios not labeled or dated, angel food cake labeled 3/10-4/10, salami dated 4/12-5/17, and a box of frozen biscuits that was not sealed and not dated. At the Nourishment Center, an opened bottle of creamy French dressing was found with a manufacturer expiration date of 10/07/2024. During follow-up in the kitchen, serving utensils were also found not stored with the handles in the same direction in two investigated drawers.
Blocked Trash Can in Kitchen
Penalty
Summary
Garbage and refuse were not disposed of properly because trash cans in the kitchen area were blocked. During the initial kitchen observation on 12/07/2025 at 11:35 AM, five empty and opened boxes were found on the floor under the handwashing sink and were covering the trash can, with a plunger also under the boxes. The boxes had to be moved in order to dispose of paper towels after hand hygiene was completed. Dietary staff member #62 confirmed the boxes were on the floor and that there was difficulty disposing of paper towels after hand hygiene.
Infection Control Lapses During COVID Outbreak and Ice Scoop Handling
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because staff did not follow infection control practices during a COVID outbreak and ice scoops were not kept in separate containers during drink passes. On 12/07/25 at approximately 11:30 a.m., the facility was observed to be under a COVID outbreak, and Employee #18 and Employee #42 were sitting at the nurse's station without masks on, despite the facility's COVID outbreak policy requiring all staff to wear masks during an outbreak. Employee #20 later verified that all staff were required to wear masks inside the facility during a COVID outbreak. In addition, during drink passes on the 200 Hall and 100 Hall, surveyors observed that ice scoops were placed in the ice buckets rather than in a separate container; Nurse Aide #24 and Nurse Aide #9 confirmed the scoops were in the ice containers. The same practice was observed again on 12/08/25 and 12/09/25 on both halls, and the observation was reviewed and verified with the Regulatory Compliance Officer on 12/09/25.
Nurse Aide Training and Competency Deficiencies
Penalty
Summary
The facility failed to ensure nurse aides received the required in-service education, including dementia management training and resident abuse prevention training, and failed to ensure competencies were completed before nurse aides began providing direct care. During record review, three of five nurse aide personnel reviewed were found to be out of compliance. Nurse Aide #9 had only 16 minutes of dementia management training during the annual review period, which was below the required 2 hours. Nurse Aide #43, hired on 09/17/25, had only 24 minutes of dementia management training during the period reviewed, had not been educated on resident abuse prevention or resident rights, and had no competencies completed prior to assuming direct care of residents. Nurse Aide #21, hired on 10/08/25, had no dementia management training during the period reviewed and also had no competencies completed prior to assuming direct care of residents. The Regional Compliance Advisor reviewed the findings during interview and had no comments.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving verbal abuse were reported immediately, or within two hours after the allegation was made, as required. Record review of a Facility Reported Incident (FRI) showed that the initial reporting of a verbal abuse allegation lacked confirmation of when the incident was reported, either by fax or email. Witness statements indicated the incident occurred on 11/18/25, but no specific time was documented, and some statements were not collected until six days after the alleged event. During staff interviews, it was confirmed that there was no documentation verifying the date and time the FRI was sent, and no additional information was provided upon request.
Failure to Provide Timely Treatment and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate instances. In the first case, a resident with Alzheimer's disease and dementia, who lacked medical decision-making capacity, experienced a fall that was witnessed and reported by both a CNA and the resident's alert and oriented roommate. Despite this, there was no documentation of the fall in the resident's medical record, and no neuro-checks, treatment, or follow-up were performed at the time of the incident. The nurse on duty at the time did not document or address the fall, and subsequently resigned without providing a statement regarding the incident. In the second case, another resident did not receive multiple physician-ordered medications and treatments in a timely manner over the course of November and December. Missed orders included administration of medications via PEG tube for conditions such as seizures, GERD, and hyponatremia, as well as essential care tasks like tracheostomy care, skin care, repositioning, and enteral feeding management. These omissions were confirmed through a Medication Administration Audit Report and acknowledged by the facility administrator as unacceptable. Both deficiencies were identified during the survey process as random opportunities for discovery and had the potential to affect more than a minimal number of residents. The failures involved lack of documentation, failure to follow physician orders, and lack of timely care and treatment for residents with complex medical needs.
Failure to Ensure Safe Oxygen Transport and Timely Fall Documentation
Penalty
Summary
The facility failed to ensure a safe environment for residents by not following established procedures for transporting oxygen cylinders and by failing to document and respond to a resident fall that resulted in injury. Specifically, a nursing assistant was observed carrying a full oxygen tank by hand down the hallway, rather than using a required carrier or stand, in violation of facility policy designed to prevent accidental tipping and potential hazards. This incident was confirmed by both the nursing assistant and the Regulatory Compliance Officer. Additionally, a resident with Alzheimer's disease, dementia, and osteoporosis experienced a fall that was witnessed by his roommate and reported by a certified nursing assistant. However, there was no documentation of the fall in the resident's medical record, nor were any neurological checks, treatments, or follow-up actions recorded at the time of the incident. The nurse on duty during the fall did not document or address the event and subsequently resigned. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection.
Failure to Provide Ordered Assistive Eating Devices
Penalty
Summary
The facility failed to provide an assistive device as ordered by the physician for a resident during the dinner meal. The resident's dietary order specified a regular diet with regular texture, standard thin liquids, and that all food should be served in bowls. The resident's tray card also clearly indicated 'FOOD IN BOWLS' in both large and bold print. However, during observation, the resident did not receive their entree or side in bowls, only the dessert was served in a bowl. This was confirmed by Nursing Assistant #9, who acknowledged that the food was not served in bowls as required by the tray ticket and dietary order. The facility's policy stated that assistive devices and utensils should be provided as identified in the individualized plan of care to maintain or improve the resident's ability to eat or drink independently.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor resident preferences for showers for two residents. Resident #6 stated he wanted a shower and said, "All they do is give me a bed bath." His care plan documented that it was important to him to shower, and the facility shower schedule listed showers for Wednesdays and Saturdays on day shift. However, the ADL record for the prior three months showed long gaps with no bath or shower documentation, multiple bed bath/sponge bath entries, and only one documented shower during that period. At the time of interview, his hair appeared oily and uncombed, and he had several days of beard growth. Resident #56’s care plan documented that she required assistance with bathing and that it was important for her to choose between a tub bath, shower, bed bath, or sponge bath, with a stated preference for showers. She told the surveyor, "I am tired of always getting a bed or sponge bath. I want to shower!" Her hair was observed uncombed, and facial hair was present on the mustache line and chin. Her MDS also indicated that choosing between bathing options was very important to her. Although the facility shower schedule listed showers on Mondays and Thursdays, the bathing record for the prior two months showed repeated bed bath/sponge bath entries, many dates with no bath or shower documented, and only one documented shower. An employee stated the facility was going to expand the shower room doorway so the resident could enter safely and with dignity, and the Regional Compliance Advisor said he did not really know why residents' choices were not being honored.
Missing transfer and bed-hold documentation for hospital transfers
Penalty
Summary
The facility failed to provide appropriate documentation when Resident #9 was transferred out of the facility to the hospital. Record review showed the resident was transferred on 08/20/25, 09/15/25, and 09/22/25, but there was no bed hold documentation available for the 08/20/25 and 09/22/25 transfers and no transfer documentation available for the 09/15/25 transfer. The facility policy OPS404 Discharge and Transfer states that for unplanned, acute transfers, the patient and representative must be notified verbally and then in writing using the Notice of Hospital Transfer or state-specific transfer form, and that for any hospital transfer, the appropriate transfer form, medication list, advance directives, POLST/MOLST/POST, and a copy of the E-Interact form must be sent or placed in the medical record. The missing documentation was confirmed by the Regional Compliance Advisor #107.
Care Plan Not Revised to Match Current Orders and Resident Needs
Penalty
Summary
The facility failed to ensure the comprehensive care plan was revised for a resident with multiple documented needs and devices. For Resident #9, the record showed enteral feeding orders for Osmolite 1.5 Cal at 60 ml/hr for 22 hours per day with downtime from 11:00 AM to 1:00 PM and 25 ml H2O flushes every 4 hours. However, the care plan still listed conditions and devices that were not current, including an actual pressure ulcer, a Foley catheter, and a PICC line, and it also listed tube feeding downtime as 10:00 AM to 2:00 PM instead of the ordered 11:00 AM to 1:00 PM. An LPN confirmed that Resident #9 did not currently have a pressure ulcer, urinary catheter, or PICC line, and confirmed the correct tube feeding downtime. For Resident #11, the dining room observation showed the resident had a straw in a cup in the wheelchair cup holder during lunch and a straw in a water pitcher at bedside in the room. The tray card indicated no straws, and NA #52 verified that the resident had been using straws in the dining room and room. The diet order stated regular/liberalized dysphagia puree texture with thin liquids, no bread, certain approved foods, and no straws, while the care plan contained conflicting directions by stating both no straws and to use straws and handled cups. A staff message from the SLP stated the resident was to use straws, and the conflicting care plan entries were verified by the Regulatory Compliance Officer.
Late Initiation of Tube Feeding and Water Flushes
Penalty
Summary
The facility failed to provide nutritional and hydration care and services to a resident dependent on tube feeding. Resident #9 had orders for Osmolite 1.5 CAL at 60 ml/hr for 22 hours per day with downtime from 1100-1300, along with 25 ml water flushes every 4 hours. On 12/07/25 at 2:45 PM, the resident was observed with no tube feeding or water infusing, despite the feeding being scheduled to start at 1:00 PM. Y-tubing was hanging on the tube feed pole, and when the surveyor asked LPN #102 to check the order and confirm when the feeding should begin, she stated it started at 1:00 PM and then said she would get it started immediately. The Administrator later confirmed that the feeding was late being started.
Undated Tube Feeding Syringe
Penalty
Summary
Resident #9 had tube feeding care management deficiencies identified during observation and staff interview. On 12/07/25 at 2:45 PM, the tube feeding syringe used during administration was observed without the current date on it. The facility procedure for enteral feeding administration states that the syringe and administration connector cover are to be stored in a labeled and dated container, and that the syringe can be used for up to 24 hours. At 2:48 PM, the Administrator confirmed that the syringe should have the current date on it and be used only daily.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post accurate daily nurse staffing information on 07/05/25, 07/06/25, and 12/07/25. On entrance to the facility for the recertification survey at approximately 11:25 AM on 12/07/25, the nursing schedule was posted in a prominent location and contained the required data elements, but the information displayed was for 12/05/25 rather than the current day. A review of the facility’s time detail reports showed that the posted staffing hours did not match the timekeeping records for 07/05/25 and 07/06/25, including differences in RN, LPN, and CNA/CN hours. The lack of current posted staffing data on 12/07/25 was reviewed with the Infection Control RN, who was the designated RN in charge at the time of entrance, and with the Regional Compliance Advisor, and neither had comments regarding the incorrect date or staffing information.
Inaccurate order and care plan for straw use with thin liquids
Penalty
Summary
The facility failed to ensure an accurate physician order for thin liquids via straw for Resident #11. During a dining room observation on 12/07/2025, the resident had a straw in a [NAME] Cup in the wheelchair cup holder during the lunch meal and also had a straw in a water pitcher at bedside in the room. At 1:35 PM, Nurse Aide #52 verified the resident’s tray card listed 2 handled cup w/no lid, food in mugs, [NAME] Cup, and NO STRAWS, and the resident and NA #52 stated the resident had been using straws in the dining room and in the room. The resident’s diet order stated regular/liberalized dysphagia puree texture, standard thin liquids consistency, no bread, may have regular cottage cheese, cheeseballs, and Reese’s mini cups, food in coffee cups, Kennedy cup for beverages, no straws. The care plan report stated to provide a regular dysphagia puree diet as ordered, with no bread, may have regular cottage cheese, food in coffee cups, 2 handled cup, and no straws. However, the care plan also stated divided scoop plate pureed solids, thin liquids, use straws and handled cups. A staff message from the SLP on 11/17/2025 stated the resident was to use straws, and an SLP evaluation dated 11/17/25 recommended thin liquids via straw.
Failure to Complete Required Smoking Assessment
Penalty
Summary
The facility failed to follow its smoking policy for a resident who chose to smoke. During interview, the resident complained that the facility had changed the designated smoking schedule and required staff accompaniment and use of a smoking apron when going outside to smoke. The resident’s care plan documented a preference for smoking outside as part of the resident’s customary daily routine. The resident’s medical record showed the last smoking assessment had been completed in August 2025, and when survey staff asked whether another assessment had been completed after that date, facility staff stated that it had not been done and then produced a smoking assessment that had just been completed on 12/10/25. The facility’s smoking policy required residents to be assessed on admission, quarterly, and with a change in condition for the ability to smoke safely, and the next quarterly assessment was due in November 2025 but was not completed until 12/10/25.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 198 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Parkersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows Center | 1.4 mi | ★★★★★ | 31 | 0 |
| Ohio Valley Health Care | 3 mi | ★★★★★ | 21 | 0 |
| Eagle Pointe Healthcare Center | 3.5 mi | ★★★★★ | 2 | 0 |
| Belpre Landing Nursing And Rehabilitation | 4.2 mi | ★★★★★ | 7 | 0 |
| Rockland Ridge Nursing & Rehabilitation Center | 4.2 mi | ★★★★★ | 3 | 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 July 2026) and official state health department websites.