PARKERSBURG CENTER
For profit - Corporation
66 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
60/100
#54 of 122 in WV
Photo by Parkersburg Care Center
Photo by Parkersburg Care Center
Photo by Parkersburg Care Center
1 / 5 photos
Last Inspection: January 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Parkersburg Center has a Trust Grade of C+, indicating it is slightly above average, but not exceptional. It ranks #54 out of 122 facilities in West Virginia, placing it in the top half, and is the top-rated option among five local facilities in Wood County. However, the facility's trend is worsening, with issues increasing from 4 in 2023 to 24 in 2024. Staffing is a concern, rated at 2 out of 5 stars, but the turnover rate of 37% is better than the state average, and there is more RN coverage than 85% of West Virginia facilities. While there have been no fines, which is a positive sign, recent inspections revealed concerning incidents such as a lack of an infection preventionist, residents not being served meals simultaneously, and unclean living environments, highlighting both strengths and weaknesses in care quality.
- Trust Score
- C+
- In West Virginia
- #54/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 44%
No red flags
4 → 24 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 4 issues
2024: 24 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below West Virginia average of 48%
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near West Virginia average (2.7)
Meets federal standards, typical of most facilities
Staff Turnover: 37%
Near West Virginia avg (46%)
Typical for the industry
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 44 deficiencies on record
Jan 2024
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of two (2) residents revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of choices received written notice of a room move and an explanation of why the room change was needed. Resident identifier: #14. Facility census: 63.
Findings included:
a) Resident #14
On 01/16/24 at 8:11 AM, the resident said she recently returned from the hospital and did not return to her original room. She said, I understand I had no bed hold and that was OK, but I got moved to one room when I got back and then 2 days later, I had to go to another room.
When asked why she was moved, the resident said she was told she needed to move, and she would have more room if she moved. She said she really didn't want to move, and she frequently gets moved all over the place.
Record review found the resident returned to the facility from a hospital admission on [DATE]. She was placed in room [ROOM NUMBER]-A. On 01/04/23 the resident was moved to room [ROOM NUMBER]-B.
At 3:25 PM on 01/16/24, Social Worker (SW) #32 said room moves are documented in the assessment tab. When the SW looked at the medical record, she said she couldn't find anything for the room moved on 01/04/24. The administrator (ADM) was present during the interview and said, The business office manager does the room moves.
On 01/16/24 at 3:46 PM, the Director of Nursing (DON), said the resident was moved because of a conflict with her roommate. The ADM, present during the interview, confirmed the facility had no documentation regarding the room move.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure Resident #14's grievance related to missing nightgowns was resolved promptly. This was true for one (1) of 18 sampled resident...
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Based on record review and staff interview, the facility failed to ensure Resident #14's grievance related to missing nightgowns was resolved promptly. This was true for one (1) of 18 sampled residents. Resident identifier: #14. Facility Census: 63.
Findings included:
a) Resident #14
A review of the facility's grievances for the previous year found a grievance form dated 12/13/23. Resident #14 made the grievance because she was missing one (1) pink and one (1) dark purple nightgown. She also indicated there were no lift pads at times.
The recommended corrective actions taken by the facility was to replace the gowns and (name of hospice company) providing lift pads.
During an interview with the Nursing Home Administrator (NHA) on 01/17/24 at approximately 8:30 AM the surveyor requested documentation showing they had ordered the gowns.
On the afternoon of 01/17/24 the NHA provided documentation showing the gowns had been ordered. Review of the computer printout provided by the NHA found the gowns were ordered on 01/17/24 at 9:24 AM which was after surveyor intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to send information which included medications, diagnosis, advan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to send information which included medications, diagnosis, advance directives, representative contact information, and any other necessary information to ensure a safe and effective transition of care. This was found to be true for two (2) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. Resident identifiers: #14 and #51. Facility census: 64.
Findings include
a) Resident #51
On 01/17/24 at 9:45 AM, record review found the resident was admitted to the facility on [DATE].
The resident was discharged to the hospital on [DATE].
Further review of the medical record found a note on 01/09/24, which read a report was called to the emergency room. There was no information indicating if any documentation was sent with the resident at the time of discharge.
b) Resident #14
On 12/17/23 the resident was sent to the emergency room due a low oxygen saturation rate of 84%.
The facility contacted the hospital on [DATE] and found the resident had been admitted for congestive heart failure and hypercapnia.
On 01/17/24 at 8:07 AM, the Director of Nursing (DON) said the nurse on duty is supposed to send all orders and the POST (Physician Order for Scope of Treatment) form with any resident when they go to the hospital. The DON confirmed after looking at the medical record, there was no documentation as to what if any information was sent with Resident #51 or Resident #14 when the residents were sent to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, the facility failed to ensure bed hold notices were completed with accurate informa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, the facility failed to ensure bed hold notices were completed with accurate information when two (2) of two (2) residents reviewed for the care area of hospitalization were transferred to the hospital. Resident identifiers: #51 and #14. Facility census: 63.
Findings included:
a) Resident #51
Record review found Resident #51 was sent to the hospital on [DATE].
At 10:00 AM on 01/17/23, the business Office Manager (BOM) #79 provided a completed copy of the bed hold policy sent to the Resident at the time of discharge indicating the resident had no bed hold days available. The BOM confirmed the Resident's payer source was through the Veterans Administration (VA) and the VA would have paid for three (3) bed hold days; however, the form documented the resident had no bed hold days available.
b) Resident #14
Record review found the resident was sent to the emergency room on [DATE] due a low oxygen saturation rate of 84%.
The facility contacted the hospital on [DATE] and found the resident had been admitted for congestive heart failure and hypercapnia.
On 01/17/24 at 8:07 AM, the Director of Nursing (DON) said the Business Manager is supposed to provide a copy of the bed hold agreement to all residents discharged / transferred from the facility.
On 01/17/24 at 8:28 AM, the Business Office Manager (BOM) stated, I have looked through all my records and I can't find any copy of a bed hold notice provided to Resident #14. The BOM said, I don't fill them out, someone else does and just puts a copy in my door.
On 01/17/24 at 9:09 AM, the Administrator provided a copy of a bed hold notice given to Resident #14 on 12/17/23. The bed hold notice indicated the resident had 12 paid days of Medicaid bed hold. After a medical record review of the number of hospitalizations for this resident in 2023, the Administrator concluded and confirmed the form was not accurate because the resident had 0 bed hold days available when transferred to the hospital on [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a Minimum Data Set (MDS) was completed accurately and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a Minimum Data Set (MDS) was completed accurately and reflected one (1) of 18 resident's status. Resident identifier: #3. Facility census: 63.
Findings included:
a) Resident #3
On 01/16/24 at 8:29 AM, the resident said, I am blind, I see only light. I have fallen several times due to my eyesight.
Review of the resident's medical record found the following falls:
04/08/23, the resident fell in his room after his roommate told him to get up and go to the bathroom by himself- he did not take his walker fell to the floor.
04/21/23, the resident fell in his room while staff were assisting him.
05/20/23, the resident fell while his brother was assisting him back from the bathroom.
05/23/23, the resident was found on the floor while ambulating from the bedside commode back to his recliner.
05/26/23, the resident was found sitting on the floor.
07/13/23, the resident fell while trying to find his shoes.
An admission MDS with an assessment reference date (ARD) of 04/05/23 found the resident had no falls prior to admission.
The next MDS completed was a significant change MDS with an ARD of 05/15/23. The MDS was coded as the resident had no falls since admission / entry or reentry or prior assessment. However, the medical record reflected the resident fell on [DATE] and 04/21/23.
The next MDS was a Medicare 5 day with an ARD of 06/01/23. This MDS coded the resident as having no falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent. The resident fell on [DATE], 05/23/23, and 05/26/23.
On 01/17/24 at 2:31 PM, the Registered Nurse clinical reimbursement coordination (RNCRC) looked at the resident's falls and said, I can't see all those falls on my end. I guess I need to correct those MDS's.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) with a diagnosis of Paranoid Schizophrenia. This failed practice ...
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Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) with a diagnosis of Paranoid Schizophrenia. This failed practice was found for one (1) of one (1) resident reviewed during the long-term care survey process. Resident identifier: #28. Facility census: 63.
Finding included:
a) Resident #28
On 01/17/24 at 2:15 PM, record review showed Resident #28 had a diagnosis of Schizophrenia upon admission; however, this was not on the PASARR from the hospital.
On 01/17/24 at 2:42 PM, an interview with Social Worker (SW) #32 confirmed the facility did not have PASARR which documented Resident #28 has a diagnosis of Schizophrenia. SW #32 said a new PASARR would be completed today.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, the facility failed to develop a baseline care plan within 48 hours of admission wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, the facility failed to develop a baseline care plan within 48 hours of admission which included current physician's orders for treatment with antibiotics. This was true for one (1) of one (1) new admission. Resident identifier: #23. Facility census: 63.
Findings included:
a) Resident #23
Record review found Resident #23 was admitted to the facility on [DATE]. At the time of admission, the resident was receiving the antibiotic, Cefdinir, for treatment of a urinary tract infection. In addition, the resident was receiving a topical antibiotic, Mupirocin to the bilateral lower extremities for a diagnosis of cellulitis.
At 8:15 AM on 01/23/24, the unit manager Licensed Practical Nurse and the Director of Nursing confirmed the antibiotic usage should have been listed on the 48-hour care plan.
On 01/23/24 at 8:22 AM, the above information was discussed with the administrator. No further information was provided by the close of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review, observation and staff interview the facility failed to revise Resident #60's care plan when her urinary catheter was removed. This was true for one (1) of 18 sampled residents....
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Based on record review, observation and staff interview the facility failed to revise Resident #60's care plan when her urinary catheter was removed. This was true for one (1) of 18 sampled residents. Resident Identifier: Resident #60. Facility Census: 63.
Findings Included:
a) Resident #60
An observation of Resident #60 on the morning of 01/16/24 found she had no indwelling urinary catheter.
A review of Resident #60's care plan on 01/17/24 found the following active care plan:
Focus Statement: (First Name of Resident #60) requires indwelling Foley catheter due to: other: retention. This focus statement was added to care plan on 12/19/23.
The goal associated with this focus statement read: Resident will have no signs and symptoms of Urinary tract infection X 30 days. This goal had a target date of 03/12/24.
The interventions included:
--Monitor for signs and symptoms of infection and report to physician.
-- Monitor output for odor, color, consistency, and amount.
-- Provide Privacy and comfort.
-- Monitor urine for sediment, cloudy, odor, blood and amount.
-- Report to physician promptly if the urine contains any sediment, or blood is cloudy or odorous, or if the resident has a fever.
-- Monitor labs as ordered.
-- Catheter care twice a day and PRN (as needed)
-- Keep Catheter off the floor.
-- Assess continued need of catheter.
-- Provide privacy bag.
-- Encourage resident to consume fluids on meal trays, between meals and nourishments provided.
-- Provide skin care after each incontinent episode and apply a moisture barrier.
An interview with the Director of Nursing (DON) on 01/17/24 at 1:14 PM, confirmed Resident #60 no longer has an indwelling catheter. The DON was asked when the catheter was ordered and when it was removed. The DON was not able to provide specific dates because there was no order in the medical record for the catheter or for the removal of the catheter. The DON stated, She went out to an appointment around 12/18/23 and when she came back she had the catheter. The DON further stated, She then was sent to the emergency room (ER) at the end of December 2023 and when she came back the catheter had been removed. The DON agreed the focus statement on Resident #60's care plan should have been resolved when she returned from the ER without the catheter in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of activities of daily living received services ...
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Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of activities of daily living received services for personal hygiene. Resident identifier: #14. Facility census: 63.
Findings included:
a) Resident #14
On 01/16/24 at 8:11 AM, the resident said you have to be scheduled to get a shower and you can only have two (2) a week. I would like to get a shower more often than I do, my hair gets matted up in between the few showers I get here.
Review of the resident bathing / shower schedule from 11/16/23 through 01/16/24 found the Resident received a shower on 11/19/23 and 01/16/24. The Resident was discharged from the facility on 12/17/23 and returned on 01/03/24.
On 01/16/24 at 3:18 PM, the Resident's Nurse Aide (NA) #71, said the Resident receives bed baths because she doesn't like getting a shower. NA #71 said we did have a shower chair that we used to take her to the shower but she started doing bed baths. Sometimes she just says it's too cold in the shower room.
On 01/17/24 at 9:10 AM, the administrator said the shower bed on Resident #14's hall only goes up to 350 pounds and the Resident weighs more than that. We do have a bariatric shower bed but it doesn't fit through the doorway. When asked to look at the bed, the administrator said we do have another bariatric shower chair but it's on the other end of the hallway, which we could use because it would accommodate her weight. We did offer her another facility with wider doors but she didn't want to transfer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to follow a physician's order in regards to blood sugar monitoring ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to follow a physician's order in regards to blood sugar monitoring for Resident #10. This failed practice was found true for 1 of 5 residents reviewed for unnecessary medications during the Long Term Care Survey Process. Resident Identifier: #10. Facility Census 63.
Findings Include
a) Resident #10
A record review on 01/18/24 at 9:30 AM found Resident #10 was ordered NovoLog FlexPen Subcutaneous Solution Pen-injector to be injected per sliding scale. Call the doctor for a blood sugar over 341.
Review of Resident #10's Medication Administration Record (MAR) found on 01/17/24 Resident #10's blood sugar was 422. Resident #10's medical record had no mention of the doctor being contacted.
During an interview on 01/18/24 at 10:44 AM, with the Director of Nursing (DON), she stated, This was a different doctor and he has a different scale. The other doctor doesn't like to be called unless a resident's blood sugar is over 450. That's no excuse though, they should have read the order. No, they did not call the doctor. I will do staff education.
b) Resident #52
A review of Resident #52's medical record on 01/17/24 found he had three (3) falls from 05/27/23 to 06/09/23.
Resident #52 fell on [DATE]. The incident report indicated the resident was noted to be laying to the right side of body, and the fall was unwitnessed.
Resident #52 sustained another fall on 06/05/23 the resident was noted to laying on his right side on the floor, and the fall was unwitnessed.
Resident #52 again sustained a fall on 06/09/23 the resident was fond laying on the floor in the dining room. Resident #52 was noted to have skin tears on his right brow, right forearm, and right upper arm.
A further review of the record was completed. This review found the facility failed to start neurological checks after his unwitnessed fall on 05/27/23. Neurological checks were began after the falls on 06/05/23 and 06/09/23 but were not completed as required.
The neurological checks after the fall on 6/05/23 was missing the neurological checks for 6/05/23 at 7:15 AM, 7:45 AM, 8:15 am 9:15 AM, 10:15 AM, 11:15 AM, 12:15 PM.
The neurological checks following the fall on 06/09/23 were missing the neurological checks on 06/11/23 at 8:45 PM, and 06/12/23 at 4:45 AM and 12:45 PM.
An interview on 01/17/24 at 12:19 PM with the Director of Nursing (DON) confirmed there was no neurological checks for Resident #52 after the fall on 05/27/23. She also agreed the neurological assessments for 06/05/23 and 06/09/23 was not completed as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview the facility failed to ensure the residents environment over which it had control of was free from accident hazards. A prescription cream was fo...
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Based on observation, record review and staff interview the facility failed to ensure the residents environment over which it had control of was free from accident hazards. A prescription cream was found at Resident #40's bedside. Interventions for fall prevention were not in place for Resident #52. This failed practice was true for two (2) of five (5) residents reviewed for accidents during the Long Term Care Survey Process. Resident identifiers #40, #52. Facility Census 63.
Findings include:
a) Resident #40
Observation on 01/16/24 at 8:25 AM, found a tube of prescription Triamcinolone Acetonide Cream at the Resident's bedside.
During an interview on 01/16/24 at 9:30 AM with Resident #40, she states, I put the cream on in the morning and in the evening . There is a resident that is confused that wonders in my room, poor thing. But he doesn't bother me.
A second observation on 01/16/24 at 03:42 PM, found the Triamcinolone Acetonide Cream continues to be at the Reediest's bedside.
A third observation on 01/17/24 at 8:15 AM, found the Triamcinolone Acetonide cream continues to be at the Resident's bedside.
During an interview on 01/17/24 at 10:01 AM, Licensed Practical Nurse (LPN) #40, states, She can do it herself. There may be an order in there for her to do it herself, or maybe it is in her care plan.
During a record review on 01/17/24 at 10:03 AM, of Resident #40's orders there is an order for the Triamcinolone Acetonide cream to be applied 2 times a day. Once in the morning and once at night, but there is no order for the Resident to apply the cream herself.
Review of Resident #40's Medication Administration Record (MAR,) found nursing staff initial the MAR indicating they are applying the cream two (2) times a day.
On 01/17/24 at 10:25 AM, Licensed Practical Nurse (LPN) #40, states, We put it on sometimes and sometimes she does it.
Review of the Medication Package Insert reads under precautions (This medication is to be used as directed by the physician. It is for dermatological use only. Avoid contact with eyes.)
b) Resident #52
A review of Resident #52's care plan found Resident #52 had falls on 05/27/23, 06/05/23, 06/09/23, and 12/01/23.
Further review of Resident #52's care plan on the morning of 01/22/24 found the following care plan:
Focus Statement: (First Name) is at risk for falls: CVA, impaired mobility and history of falls.
Goal: Resident will have no falls with major injury through next review.
Interventions Included:
-- Bed in low position.
-- Fall mat to the right side of bed.
-- Perimeter mattress to bed to define bed boundaries.
An observation conducted with the Director of Nursing (DON) on 01/22/24 at 1:00 PM, found the resident did not have a fall mat to the right side of the bed. She confirmed the mat was not in place as the care plan directed as a fall intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
b) Resident #50
A review of Resident #50's care plan on 01/17/24 found the following focus statement:
(First name of Resident #50) requires S/P (supra pubic) Foley catheter due to obstructive uropathy...
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b) Resident #50
A review of Resident #50's care plan on 01/17/24 found the following focus statement:
(First name of Resident #50) requires S/P (supra pubic) Foley catheter due to obstructive uropathy. This focus was initiated on 03/18/21.
The goal associated with this focus statement read as follows:
He will have no signs and symptoms of urinary tract infection through next review. This goal was initiated on 03/18/23 and had a target date of 03/21/24.
The interventions related to this focus statement and goal included:
--Keep catheter off the floor. This intervention was added to the care plan on 03/18/21.
On 01/16/24 at 10:51 AM, an observation of Resident #50 found his urinary catheter line and bag touching the floor in the residents room. While the resident was resting in bed.
On 01/17/24 at 9:09 AM, another observation of Resident #50 found the urinary catheter line and bag resting on the floor while the resident was in bed.
On 01/17/24 at 11:00 AM, a final observation with Licensed Practical Nurse (LPN) #1 was made of Resident #50. Again his urinary catheter line and bag were touching the floor while the resident was in bed. LPN #1 confirmed the catheter bag and line were touching the floor.
01/17/24 12:07 PM spoke with the Administrator regarding their policy on Catheter care , and provided the surveyor with a copy that states Secure catheter tubing to keep the drainage below the level of the patient's bladder and off the floor.
On 01/17/24 at 2:18 PM, the DON confirmed there was no physician's order containing the diagnosis for the urinary catheter and no order to have a urinary catheter. There was only an order to perform catheter care in the medical record. The DON said she would get an order for catheter care and would talk to the staff about following their care plan.
Based on observation, record review and staff interview the facility failed to ensure a resident with an indwelling catheter had a proper medical justification for its use. Also the facility failed to ensure a resident with an indwelling catheter receives the appropriate care and services to prevent urinary tract infections. This was true for two (2) of two (2) residents reviewed for the care area of urinary catheter use. Resident Identifiers: Resident #60 and Resident #50. Facility census: 63.
Findings Include:
a) Resident #60
An observation of Resident #60 on the morning of 01/16/24 found she had no indwelling urinary catheter.
A review of Resident #60's care plan on 01/17/24 found the following active care plan:
Focus Statement: (First Name of Resident #60) requires indwelling Foley catheter due to: other: retention. This focus statement was added to care plan on 12/19/23.
The goal associated with this focus statement read: Resident will have no signs and symptoms of Urinary tract infection X 30 days. This goal had a target date of 03/12/24.
The interventions included:
--Monitor for signs and symptoms of infection and report to physician.
-- Monitor output for odor, color, consistency, and amount.
-- Provide Privacy and comfort.
-- Monitor urine for sediment, cloudy, odor, blood and amount.
-- Report to physician promptly if the urine contains any sediment, or blood is cloudy or odorous, or if the resident has a fever.
-- Monitor labs as ordered.
-- Catheter care twice a day and PRN (as needed)
-- Keep Catheter off the floor.
-- Assess continued need of catheter.
-- Provide privacy bag.
-- Encourage resident to consume fluids on meal trays, between meals and nourishments provided.
-- Provide skin care after each incontinent episode and apply a moisture barrier.
Further review of the record found no physician order for the catheter or medical justification from the physician as to why the catheter was necessary. The record also contained no documentation as to when or what care the facility provided to the residents catheter while she had it.
The only nursing note related to Resident #60's catheter was entered into the medical record on 12/18/23 at 4:46 PM which read as follows: Resident returned with Foley catheter in place, draining yellow darker urine to bedside collection. Resident states that the Foley is hurting and is bothersome, resident states that it was difficult for urology to get placed.
During an interview with the Director of Nursing (DON) on 01/18/24 at 8:36 AM, she stated I talked with the nurse who wrote this note she indicated she called the doctor who did not return her call and she didn't follow up after that. During this interview the DON was asked to provide anything that would show the staff implemented the interventions on the care plan related to Resident #60's catheter. She indicated she was unable to provide any documentation to show the interventions and care was done. The DON also indicated there was no documentation from a physician stating the reason Resident #60 required the catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to make sure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident s...
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Based on record review and staff interview, the facility failed to make sure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect a limited number of residents residing in the facility. Staff identifiers: #66 and #14. Facility census: 63.
Findings Include:
On 01/22/24 at 3:27 PM, review of Nurse Aide #66 and Licensed Practical Nurse #14's personal files did not include any documentation that these staff could demonstrate the skill sets to perform their duties as directed.
On 01/23/24 at 8:26 AM, the administrator confirmed she was unable to provide evidence of competency evaluations for NA #66 and LPN #14.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to complete a performance review of every nurse aide at least once every 12 months. This had the potential to affect a limited number of...
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Based on record review and staff interview, the facility failed to complete a performance review of every nurse aide at least once every 12 months. This had the potential to affect a limited number of residents at the facility. Staff identifier: #66. Facility census: 63.
Findings Include:
a) Nurse Aide (NA) #66
On 01/22/24 at 3:27 PM, review of NA #66's personnel record found no evidence of a yearly performance review.
At 8:26 AM on 01/23/24, the Administrator said she was unable to provide a copy of a yearly performance review for NA #66.
No further information was provided by the close of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconcilia...
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Based on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and
that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The facility failed to ensure Resident #60's controlled substances which were signed out on the controlled substance log were documented as administered on the medication administration record (MAR). This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: Resident #60. Facility Census: 63.
Findings include:
a) Resident #60
A review of Resident #60's medical record on 01/22/24 at 1:44 PM, found the resident was ordered oxycodone 10 milligrams (MG) by mouth every six (6) hours as needed for pain.
Further review of Resident #60's MAR and the control substances log for Resident #60's oxycodone for the months of 12/2023 and 01/2024 found the following occasions when Resident #60's oxycodone was signed out on the controlled substance log but not documented on the MAR.
-- 12/24/23 at 1:00 PM
-- 12/25/23 at 5:10 PM
-- 12/27/23 at 8:00 PM
-- 01/02/24 at 10:00 AM
-- 01/05/24 at 5:44 PM
-- 01/09/24 no time was documented on the controlled substance log as required nor was this dose documented on the MAR.
Also the controlled substance log contained a Late Entry which was entered by a nurse for a dose of Oxycodone that was taken out of the card and administered to the resident on 01/01/24 at 2:54 PM. This dose was not documented on the controlled substance log until after a dose was removed at 01/02/24 at 3:00 AM. These doses were removed by different nurses. The failure to document the removed dose at the time of removal for the 01/01/24 dose would have made the controlled substance count inaccurate when the night shift nurse for 01/01/204 came on duty. This discrepancy was not identified.
An Interview with the Director of Nursing (DON) at 3:55 PM on 01/22/24 confirmed these findings. She indicated they should have been documented on the MAR as well as the controlled substance log. When asked about the late entry on the controlled substance log she indicated that should have been identified at the end of shift count and obviously it was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to provide a Pneumococcal immunization as required. This failed practice was found true for one (1) of five (5) residents reviewed for im...
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Based on record review and staff interview the facility failed to provide a Pneumococcal immunization as required. This failed practice was found true for one (1) of five (5) residents reviewed for immunizations during the Long-Term Care Survey Process. Resident identifier: # 40. Facility Census 63.
Findings include:
a) Resident #40
During a record review, on 01/22/24 at 1:24 PM, of Resident # 40's vaccines it was found that she had the Prevnar (PCV) 13 vaccine on 11/05/21 and was not given a second vaccination as required.
The Center for Disease Control (CDC) recommends:
The second dose of PPSV23 be given at least 8 weeks after PCV13 and 5 years after PPSV23 (Pneumococcal Polysaccharide Vaccine.)
During an interview, on 01/22/24 at 1:46 PM, the Director of Nursing (DON) stated, I know what happened. Resident #40 was out at the hospital and the order did not get put back in, so I am assuming that is what happened. She has not had the PPSV 23.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide residents with a dignified dining experience. Residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide residents with a dignified dining experience. Residents dining together were not served at the same time. This was a random opportunity for discovery. Resident identifiers: #8, #25, #31, #29, #27, #1, #58, #10, #28, and #38. Facility census: 63.
Findings included:
a) Dining room observations
On 01/16/24 at 12:01 PM, Residents #8, #25, #31, and #29, were observed sitting together at table. #1. Residents #27, #1, #58, and #10 were observed sitting together at table #2 . Resident #28 was sitting at table #3 by themselves.
Resident #38 was seated at table #4 by themselves.
The trays were served in this order:
Resident #29, was served at table #1
Resident #58 was served at table #2
Resident #38 was served at table #4
Resident #8 was served at table #1
Resident #31 served at table #1
Resident #1 served at table #2.
Resident #1 required assistance to eat; therefore, the tray was left sitting in front of her while other residents were eating their meal at the same table.
Then Resident #25 was served at table #1, Resident #27 was served table #2, Resident #10 was served at table #2 and Resident #28 served last at table #3.
On 01/16/24 at approximately 12:22 PM, the Director of Nursing (DON) was made aware of the observations in the dining room regarding the sequence of the tray pass.
b) room [ROOM NUMBER]
Observations of the lunch meal began on 01/16/24 at 11:50 AM. At 11:56 AM facility staff delivered the lunch meal to Resident #9 and Resident #13. Resident #14 and Resident #46 were not served their meal at this time.
At 11:58 AM, Nurse Aide (NA) #66 was overheard asking Resident #14 if she wanted to go to the dining room. Resident #14 declined, and NA #66 stated, Well you will just have to wait on your tray.
Resident #14 and Resident #46's tray was not delivered until 12:15 PM on 01/16/24, at which time both meals were delivered to Resident #14 and Resident #46.
An interview with Nurse Aide #4 at 12:13 PM on 01/16/24, found Resident #14 and #46 did not get their tray because their tray goes to the dining room, and they have to wait for it to come to the dining room first and then they bring it out to the floor to them.
c) room [ROOM NUMBER]
Observation at 11:54 AM on 01/16/24, found Resident #39 was eating his lunch in his room.
The roommate, Resident #54, had not received a tray. Resident #54 told the surveyor, I don't know where my food is and I'm ready to eat.
At 12:04 PM on 01/16/14, Nurse Aide (NA) #66 was asked, where is Resident #54's tray? NA #66 said, his tray is probably going to come out in the dining room. NA #66 told Resident #54, you will get your tray when it comes out in the dining room.
At 12:13 PM on 01/16/24, NA #4 delivered the Resident's tray and stated, His tray gets cycled to the dining room. He did eat in the dining room, but he doesn't anymore.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, record review, staff interview and resident interview, the facility failed to provide a clean, comfortable homelike environment by not cleaning the heater/air conditioning unit f...
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Based on observation, record review, staff interview and resident interview, the facility failed to provide a clean, comfortable homelike environment by not cleaning the heater/air conditioning unit filter in Resident #48's room and by not ensuring the dining room chairs are in good repair. This was a random opportunity for discovery, and had the potential to affect more than a limited number of residents. Resident identifier: #48. Facility Census: 63.
Findings include:
a) Resident #48
An observation of Resident #48's room on 01/16/24 at 2:00 PM, it was discovered the heater had dust flying out of it and the filters were covered with dirt and dust.
During an interview on 01/16/24 at 2:30 PM, Resident #48 stated, I haven't been in this room long, who knows when they cleaned it last. They haven't cleaned it since I have been in here.
During an interview on 01/16/24 at 03:36 PM, the Maintenance Assistant (MA) #60 stated, Oh my goodness, yes that is dirty. I am gonna go look to see when is the last time it was cleaned. It won't be dirty after today.
During a record review on 01/17/24 at 10:00 AM, of the facilities work history report for the Heating Ventilation and Air Cooling (HVAC) units it was discovered the units air filters are to be cleaned every thirty days. The last cleaning of the air filters was on 10/31/23.
b) Dining room chairs
During the Resident Council Meeting on 01/17/24 at 2:00 PM, the Resident Council members made a complaint the chairs in the dining room were not safe to sit in and they are afraid they will fall.
During the Resident Council Meeting on 01/17/24 at 2:00 PM in which the facility administrator was invited to attend, she stated, They complained last month in Resident Council Meeting, I am checking into buying used chairs from a nearby nursing home that had shut down. I got approval that if I can't get those then I can get new ones, but I have to try and get them first.
During an observation on 01/17/24 at 3:58 PM, of the facilities dining room chairs, there were 21 chairs at the dining room tables. Of the 21 chairs, 11 of them were not sturdy or had loose arms. Four (4) of the chairs had wooden dowels to hold the chair together that could easily be pulled out of the wood. The chairs had many scrapes on them and one chair had no cushion.
During an interview on 01/18/24 at 11:00 AM, with the Recreation Assistant #78, she stated, We definitely need chairs. Those are not safe and they look awful.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
c) Resident #50
A review of Resident #50's care plan on 01/17/24 found the following focus statement:
(First name of Resident #50) requires S/P (supra pubic) Foley catheter due to obstructive uropathy...
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c) Resident #50
A review of Resident #50's care plan on 01/17/24 found the following focus statement:
(First name of Resident #50) requires S/P (supra pubic) Foley catheter due to obstructive uropathy. This focus was initiated on 03/18/21.
The goal associated with this focus statement read as follows:
He will have no signs and symptoms of urinary tract infection through next review. This goal was initiated on 03/18/23 and had a target date of 03/21/24.
The interventions related to this focus statement and goal included:
--Keep catheter off the floor. This intervention was added to the care plan on 03/18/21.
On 01/16/24 at 10:51 AM, an observation of Resident #50 found his urinary catheter line and bag touching the floor in the residents room. While the resident was resting in bed.
On 01/17/24 at 9:09 AM, another observation of Resident #50 found the urinary catheter line and bag resting on the floor while the resident was in bed.
On 01/17/24 at 11:00 AM, a final observation with Licensed Practical Nurse (LPN) #1 was made of Resident #50. Again his urinary catheter line and bag were touching the floor while the resident was in bed. LPN #1 confirmed the catheter bag and line were touching the floor.
On 01/17/24 at 2:18 PM, the DON stated the staff were not following the care plan and she would talk to them.
b) Resident #24
A record review on 01/17/24 at 1:01 PM, of Resident #24's Dementia Care plan, revealed a care plan focus statement related to Resident #48's diagnosis of Advanced Alzheimers, and Dementia with cognitive loss.
The interventions for this focus statement include:
-- Have signs in and outside of the room to enable resident to recognize things.
During an interview on 01/17/24 at 1:11 PM, with Minimum Data Set (MDS) Nurse #21, she stated, I do the Dementia care plans along with the social worker. No, the sign is not on the door. No, the care plan is not being followed.
During an interview on 01/18/24 at 8:46 AM with Licensed Practical Nurse (LPN) #1, she stated, There used to be a sign on his door, I haven't seen it for a while. He sometimes will take stuff and move it, but not sure what happened to it.
Based on record review, staff interview and observation the facility failed to implement and/or develop care plans for three (3) of 18 sampled residents. For Resident #52 the facility failed to develop a care plan for the resident's use of an anticoagulant medication. Also, Resident #52's fall care plan was not implemented. For Resident #24 the facility failed to implement their dementia care plan. Finally, for Resident #50 the facility failed to implement his catheter care plan. Resident identifiers: #52, #50, and #24. Facility Census: 63.
Findings included:
a) Resident #52
1. Anticoagulant
A review of Resident #52's care plan on 01/22/24, found a physician order for Eliquis (an anticoagulant medication) five (5) milligrams twice a day. This order was written on 07/06/23 and was a current order at the time of this review.
A review of Resident #52's care plan found it was void of any focus statements, goals, or interventions related to Resident #52's use of this anticoagulant medication.
On 01/23/24 at 9:05 AM, an interview with the Director of Nursing (DON) confirmed Resident #52's care plan did not contain a focus, goal, or interventions related to Resident #52's use of anticoagulation medications.
2. Falls
A review of Resident #52's care plan on the morning of 01/22/24 found the following care plan:
Focus Statement: (First Name of Resident #52) is at risk for falls: CVA (Cerebral Vascular Accident) , impaired mobility and history of falls.
Goal: Resident will have no falls with major injury through next review.
Interventions included:
-- Bed in low position.
-- Fall mat to the right side of bed.
-- Perimeter mattress to bed to define bed boundaries.
An observation conducted with the Director of Nursing (DON) on 01/22/24 at 1:00 PM, found the resident did not have a fall mat to the right side of the bed. She confirmed the mat was not in place as the care plan directed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and resident interview the facility failed to develop an activity program t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and resident interview the facility failed to develop an activity program to meet the needs and interest of the residents. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #4, #24, and #14. Facility census 63.
Findings include:
a) Activity Program
During the Resident Council Meeting on 01/17/24 at 2:00 PM the Resident Council members complained there was not much to do at the facility anymore and there was not anything to do in the evening except go to bed.
During a record review on 01/18/24 at 10:00 AM of the facilities activity calendars for 10/2023, 11/2023, 12/2023, and 01/2024 a noticeable difference was noted in the amount of activities offered and the type of activities offered. In 10/2023 there were at least 5 activities offered daily and 2 days a week activities were offered at 7:00 PM in the evening. In January 2024 on most days there were only 2 activities scheduled and no activities scheduled past 3:30 PM in the afternoon.
During an interview on 01/18/24 at 10:22 AM, with Recreation Assistant (RA) #78, she stated, They cut my hours in November so I work 20 hours as an activity assistant and then do housekeeping for 20 hours for this contract company. Our administrator is gonna try to get the hours back up. I hope she can . I love doing activities.
During an interview on 01/18/24 at 10:27 AM, with the administrator, she stated, The activity director had three (3) weeks of vacation he had to use or lose it, He will be back tomorrow. The company said we had to cut a full time shift, they did not care how we did it. The administrator before me had cut the employee in scheduling and cut 20 hours from an activity assistant. This happened the first of November. The lady in the office helps out some days doing 1:1 visits
During a record review, on 01/18/24 at 10:29 AM, of the facility's activity calendar for 01/18/24 there are no activities scheduled until 1:30 PM which is social hour and bingo at 3:30 PM.
During an observation, on 01/22/24 at 10:30 AM, of the facility's scheduled activity Strength for life, the scheduled activity did not occur.
During an observation, on 01/22/24 at 2:00 PM, of the facility's scheduled activity Social Hour, the scheduled activity did not occur.
During an interview, on 01/22/24 at 2:15 PM, with the administrator, she stated, No, they did not occur. We had a mix up on the schedule. Someone will be doing bingo at 3:30 PM. The Activity Director is not back to work yet. He cannot come back until he talks with me. He will do that one day this week.
b) Resident #4
During an interview on 01/16/24 at 10:29 AM with Resident #4, she stated, They really don't do much that I like to do here, and there are no activities in the evenings.
A record review on 01/17/24 at 1:00 PM, of Resident #4's activity participation log for 10/2023, 12/2023 and 01/2024 revealed most of the activities the resident participates in, are self directed and not actual group activities. No participation record could be provided for 11/2023.
A record review on 01/17/24 at 1:15 PM, of Resident #4's Section F of the most recent Minimum Data Set (MDS) revealed it is very important to her to do things with groups of people.
During a record review on 01/17/24 at 1:20 PM, of Resident #4's activity care plan found a focus statement which read: While in the facility, (First Name of Resident #4) has the opportunity to engage in daily routines that are meaningful relative to their preference.
The interventions for this focus statement included:
-- (First Name of Resident #4) likes to participate in groups of people such as church, socializing, coffee and music.
c) Resident #24
During an observation on 01/16/24 at 1:30 PM, Resident #24 was wandering around the hallway on hall 100.
During an interview on 01/16/24 at 1:30 PM, Resident #24, stated, There is nothing to do.
A record review on 01/17/24 at 2:00 PM, of Resident #24's section F of the most recent MDS, revealed it's important for him to do things with groups of people and it's important for him to listen to music and watch TV.
During an observation on 01/17/24 at 2:10 PM, of Resident #24's room, there was no TV or radio in his section of the four (4) bay room.
A record review on 01/17/24 at 2:30 PM, of Resident #24's care plan contained the following focus statement,
While in the facility, (First name of Resident #24) has the opportunity to engage in daily routines that are meaningful to their preferences.
The interventions for this focus statement included:
-- Encourage and facilitate (First name of Resident #24)'s activity preferences:
looking out the window at wildlife, watching westerns, listening to country music on the radio, going outside, reading Parkersburg News & Sentinel, or hunting , fishing, cars, or outdoor magazines.
A record review on 01/17/24 at 2:40 PM, of Resident #24's activity participation log for 10/2023, 12/2023, and 01/2024 reveals most of the activities the resident participates in, is self directed and not actual group activities. No participation record could be provided for 11/2023.
d) Resident #14
On 01/16/24 at 8:10 AM, the Resident said I would like to have more activities. I enjoy bingo and making crafts. If they had crafts, I would attend those.
Review of the Resident's current care plan found a focus:
While in the facility the resident has the opportunity to engage in daily routines that are meaningful.
Interventions included:
The resident plays games on the tablet, colors, crafts, bingo, watching television, etc.
Review of the current activity calendar found no craft activities are scheduled for the month of January 2024.
Review of the 12/2024 activity calendar found three (3) craft activities were scheduled: making an ornament, a [NAME], and a gingerbread house. The participation log indicated the Resident attended all three (3) craft activities.
On 01/23/24 at 9:00 AM, the activity assistant (AA) #78 confirmed there were no craft activities on the current calendar. AA #78 said, I know she likes to make things, we could always add some crafts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect m...
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Based on observation and staff interview the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 63.
Findings include:
a) Initial tour of the kitchen
On 01/16/24 at 7:40 AM, observation of the stove found the drip pan, oven racks, and the oven floor had a heavy build of a charred black substance. The ovens backsplash also had a build up debris. The metal grates covering the burners also had a build up of black, dried debris.
Dietary Manager (DM) #10 stated he had boiled oatmeal earlier this morning which had covered the burner; however, all the burners were littered with charred debris.
b) Fruit
During an observation on 01/16/24 at 12:14 PM, of the lunch meal it was discovered that none of the individual bowls of fruit cocktail on the Resident's lunch trays were covered.
During an interview on 01/16/24 at 12:31 PM, Nursing Assistant (NA) #16 stated, The fruit is usually covered with cellophane or it's in a bowl with a lid, I do not know why it was passed like that.
During an interview on 01/16/24 at 1:30 PM with Dietary Manager, he stated, I usually don't cover the fruit because they only walk 2 feet to the residents door. Staff were observed taking trays out of a cart, parked in the middle of the hallway, to resident rooms which were more than 2 feet away from the serving cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e) Dining room hand washing
On 01/16/24 at 12:09 PM, the first tray was passed in the dining room. No hand washing was provided...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e) Dining room hand washing
On 01/16/24 at 12:09 PM, the first tray was passed in the dining room. No hand washing was provided to residents prior to the tray pass.
On 01/16/24 at 12:22 PM, the following observation was presented to the Director of Nursing (DON.) serving. No further information was provided by the close of the survey.
Based on observation, record review and staff interview the facility failed to develop and implement an ongoing infection control program aimed at preventing the spread of diseases and infections. This failed practice had the potential to affect all residents residing in the facility. Resident identifiers: #7, #60, #4, #10, #22, #23. Facility Census 63.
a) Surveillance Log
During a record review, on 01/22/24 at 1:00 PM, of the facilities Infection Control Monthly Line Listing it was revealed that no infections had been tracked for December 2023 and January 2024.
During an interview on 01/22/24 at 01:16 PM, the Director of Nursing (DON) stated, Our Nurse Practice Educator (NPE), eft around the 1st of December and our new one started yesterday, our line listing has not been updated since she left at the first of December.
During a record review, on 01/22/24 at 3:39 PM, the following residents were listed as examples of residents who had infections, were receiving an antibiotic in December 2023 and/or January 2024, and should have been on the line listing:
-Resident #7 was started on Ciprofloxacin for Conjunctivitis
-Resident #60 was started on Keflex for a wound infection
-Resident #4 was started on Amoxicillin for an abscess tooth
-Resident #10 was started on Doxycycline Monohydrate for a heart valve/bacterial infection
-Resident #22 was started on Rocephin for a urinary tract infection (UTI) on 01/01/24. On 01/02/24 this antibiotic was discontinued, and Keflex was started which was not susceptible for treating the organism causing the UTI. On 01/04/24 a third antibiotic, Levaquin was started for treatment of the UTI.
-Resident #23 was admitted to the facility on [DATE] with an antibiotic, Cefdinir, for treatment of a UTI.
During a record review, on 01/23/24 at 8:30 AM, of the facilities Infection Control Policies and Procedures, Policy Title: Infection Control Outcome and Process Surveillance and Reporting it reads: Outcome surveillance which consists of collecting/documenting data on individual cases and comparing the collective data to standard, written definitions of infection. The monthly Infection control report will be used.
In addition, seven (7) residents residing in the facility had been diagnosed with Influenza A during January 2024. These residents were not on the line listing.
b) Resident #48
Observation on, 01/16/24 at 8:30 AM, found Resident #48 had an airborne precautions sign placed on his room door that was to include, gown, gloves, and goggles. Goggles were not available in the isolation cart outside of Resident #48's room.
Record review on 01/16/24 at 11:00 AM, found Resident #48's had a diagnosis of Influenza A.
During an interview, on 01/16/24 at 11:10 AM, with Nursing Assistant (NA) #17, the NA stated, They are supposed to be there, but they aren't so we just put on what is outside the door.
c) Hall 100
An observation, on 01/16/23 at 12:15 PM, of the lunch meal found no hand hygiene was provided to the residents residing on Hall 100 before they were given their lunch tray.
During an interview, on 01/16/23 at 12:18 PM with NA #16, she stated, Where I worked at before had wipes that came out with the trays to wipe their hands, I don't know why this place doesn't have them.
d) Hall 200
During observation of the dining activity on 200 hallways for the lunch meal on 01/16/24, staff did not provide hand hygiene to the residents prior to serving the meal.
At approximately 12:05 PM, on 01/16/24, nurse aides (NA's) #66 and #4 confirmed no hand hygiene was provided prior to the meal service.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on record review, and staff interview the facility failed to have an infection preventionist. This failed practice had the potential to affect all residents currently residing in the facility. F...
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Based on record review, and staff interview the facility failed to have an infection preventionist. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 63.
Findings include:
a) Infection Preventionist
During an interview, on 01/22/24 at 12:11 PM, the Director of Nursing (DON), stated, I do the Infection preventionist job. We also have a lady that works down the road, that has had the class that helps me with it.
On 01/22/24 at 1:30 PM the DON confirmed there are no staff currently employed at this facility who have completed the specialized training and hold an Infection Preventionist Certificate of training.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and staff interview, the facility failed to ensure the nurse staffing information posting accurately reflected the number of staff who actually worked. This was a random opportuni...
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Based on observation and staff interview, the facility failed to ensure the nurse staffing information posting accurately reflected the number of staff who actually worked. This was a random opportunity for discovery. Facility census: 63.
Findings include:
On 01/22/24 at 12:06 PM, observation of the posted nurse staffing information (the information posted daily in the facility for visitors and residents) provided by the facility staff shows no Licensed Practical Nurse and or Registered Nurse ( LPN/RN) staff from 11pm-7am on the following nights: 12/22/23, 12/23/23, 12/25/23, 12/29/23.
Further investigation of staff time cards showed at least one (1) RN/LPN from 11PM-7AM on 12/22/23, 12/23/23, 12/25/23, 12/29/23.
On 01/22/24 12:20 PM, the Administrator confirmed the posted nurse staffing was incorrect.
Jan 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
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Based on record review, staff interview, and review of facility evidence of reportable incidents, the facility failed to ensure all alleged violations of abuse and neglect were reported immediately....
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Based on record review, staff interview, and review of facility evidence of reportable incidents, the facility failed to ensure all alleged violations of abuse and neglect were reported immediately. In addition, the facility failed to ensure the results of the investigation were reported within five (5) working days of the occurrence to other required agencies. This deficient practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Two (2) residents were found to have falls with major injury; however, the allegations were not reported in accordance with State law for Resident #1 and the results of a thorough investigation were not reported within five (5) working days to the officials in accordance with State law for Resident #16. Resident identifiers: Resident #1 and #16. Facility census: 65.
Findings included:
a) Policy Review
A review of facility policy, OPS300 titled: Abuse Prohibition, revision date of 10/24/22, noted under section 7.3, the facility would report allegations to the appropriate state and local authorities involving neglect, including injuries of unknown source or serious bodily injury, no later than two (2) hours after the allegations made, if the event results in serious bodily injury. Under section 9.2, the policy showed the facility would report findings of a completed investigation within five (5) working days to the Department of Health using the state approved forms.
b) Resident #1
A record review for Resident #1, showed the resident sustained a fall, 01/15/23 at 1:30 PM. An initial evaluation, on 01/15/23 at 3:14 PM, by the facility physician, showed a scalp laceration and a closed head injury. Resident #1 was sent to the hospital for further evaluation. Resident #1 received nine (9) staples for a 7.5 x 5 laceration on the right side of the head.
A review of the facility's reportable incident for Resident #1, noted the fall with injury occurred on 01/15/23 at 1:30 PM. Further review of the facility's documentation of the incident, showed no evidence the fall, with major injury, had been reported to APS, and showed no evidence the incident was reported to the State Agency within the two (2) hour required reporting time frame for a fall occurrence with major injury. The documented date and time the facility reported to the State Agency was noted to be on the following day (01/16/23) at 16:29 (4:29 PM).
An interview, with the Administrator and Senior Administrator, on 01/18/23 at 11:45 AM, verified there was no evidence Resident #1's fall with major injury was reported within the two (2) hour time frame requirement for a fall with major injury to all State agencies. It was also verified, during the interview, the facility failed to report the fall with major injury to APS as required.
c) Resident #16
A record review for Resident #16, showed the resident had sustained a fall on 01/02/23 at 2:45 AM. The record review noted Resident #16 was found on the floor, laying on the right side and was complaining of pain in the right lower extremity. Resident #16 was sent to the hospital for further evaluation and was found to have a fracture of the right hip and was admitted for surgical intervention.
A review of the facility's reportable incidents, found no evidence the results of an investigation, completed by the facility, was reported to the State Agencies in accordance with State law. There was no evidence the State Survey Agency or APS was sent the results of an investigation within five (5) working days of the incident.
An interview, with the Administrator and Senior Administrator, on 01/18/23 at 11:45 AM, verified there was no evidence results of an investigation of the incident, in which Resident #16 sustained a fall with major injury, noted on 01/02/23, was submitted to any State Agency within five (5) working days of the incident as required.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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Based on staff interview, record review and review of facility evidence of reportable incidents, the facility failed to ensure, in the response to allegations of abuse, neglect, including incidents ...
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Based on staff interview, record review and review of facility evidence of reportable incidents, the facility failed to ensure, in the response to allegations of abuse, neglect, including incidents of unknown origin or incidents involving major injury, evidence that all alleged violations were thoroughly investigated for one (1) of three (3) residents reviewed for safety/falls. This deficient practice was based on a random opportunity of discovery and had the potential to affect a limited number of residents residing in the facility. Resident identifier: Resident #16. Facility census: 65.
Findings included:
a) Resident #16
A review of OPS300 Abuse Prohibition, revision date of 10/24/22, under section 7.7 and 7.8, showed the facility would initiate an investigation within 24 hours and the investigation would be thoroughly documented.
A record review for Resident #16 showed the resident had sustained a fall on 01/02/23 at 2:45 (AM). The record showed Resident #16 was noted to be on the floor laying on the right side and was complaining of pain in the right lower extremity. Resident #16 was sent to the hospital for further evaluation and was found to have a fracture of the right hip and was admitted for surgical intervention.
A review of the facility's reportable incidents, found no evidence of a thorough investigation completed by the facility.
An interview, with the Administrator and Senior Administrator, on 01/18/23 at 11:45 AM, verified the incident, in which Resident #16 sustained a fall with major injury, noted on 01/02/23, had not been thoroughly investigated and should have been.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure each resident had a clean, comfortable homelike environment that was free of cluttered hallways. Resident equipment was observ...
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Based on observation and staff interview, the facility failed to ensure each resident had a clean, comfortable homelike environment that was free of cluttered hallways. Resident equipment was observed lined up against the wall, outside of resident rooms, of both 100 and 200 hallways. This deficient practice was true through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Census: 65.
Findings included:
An observation, on 01/17/23 at 9:00 AM, revealed equipment, such as wheelchairs and Hoyer lifts, outside of resident's rooms, lining the hall. The equipment was observed to be outside resident rooms down both the 100 and 200 hallways.
An observation on 01/17/23 at 1:03 PM, revealed the resident equipment continued to be lined up outside of resident's rooms, occurring on both 100 and 200 hallways.
An observation, on 01/18/23 at 8:00 AM, revealed resident equipment was lined up down the hall, outside of resident's rooms The resident equipment was observed on both the 100 and 200 hallways of the facility.
An interview with the Administrator and Senior Administrator, on 01/18/23 at 11:50 AM, confirmed resident equipment, such as wheelchairs and Hoyer lifts, were stored in the hallway, outside of the residents rooms on both hallways and verified the storage practice did not contribute to a homelike environment for the residents.
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview, family and resident interviews, and review of Resident Council Meeting minutes, the facility failed to ensure food served was palatable, and at a safe and appe...
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Based on observation, staff interview, family and resident interviews, and review of Resident Council Meeting minutes, the facility failed to ensure food served was palatable, and at a safe and appetizing temperature. This was found to be true during a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 65.
Findings included:
a) Resident Interviews and Family Interviews
Confidential resident interviews were conducted. Five (5) residents, whom the facility assessed as having intact cognition, revealed food temperature and palatability of the food had been and continued to be an issue in the facilty. The complaints consisted of cold food, food items not tasting good or food items being over cooked or uneatable.
One (1) of two (2) confidential family interviews revealed food served to residents was often cold.
b) Review of Resident Council Meeting minutes
A review of the Resident Council Meeting minutes from 07/22/22 through 12/30/22, revealed residents had complained about the food not being good or food served cold during the 07/22/22, 09/29/22, 11/29/22 and 12/30/22 resident council meetings. No minutes were provided for 08/22.
c) Observation of meal service
Observations of meal service delivery was conducted on 01/17/23 during the lunch meal. The last resident tray to be served, on the 100 hallway, was selected for temperature inspection. The temperatures were obtained by the Food Service Supervisor, at 12:38 PM, which found the pureed fish to be at 110 degrees Fahrenheit (F). At this time, the Food Service Supervisor stated the food temperature of the pureed fish did not meet the facility standard for palatability or required temperature, based on State requirements of food items to be servied at 120 degrees F at the point of service.
d) Staff interview
An interview, with the Food Service Supervisor, on 01/17/23 at 1:10 PM, revealed the facility was aware of food complaints and had been testing meal trays twice a week. The Food Service Supervisor, stated further, the results of the test trays have been hit or miss with the temperatures being within an acceptable range.
An interview with the Administrator, on 01/18/23 at 8:10 AM, verified food temperatures identified on the test tray on 01/17/23, were not in an acceptable range for palatability and further improvement with the food delivery was needed.
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Apr 2022
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation and record review, the facility failed to ensure care was provided in an environment that promoted dignity for each resident. Based on a random opportunity for discovery, Reside...
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Based on observation and record review, the facility failed to ensure care was provided in an environment that promoted dignity for each resident. Based on a random opportunity for discovery, Resident #34 was noted to have a sign above the bed with personal care needs addressed which would be visible to any person entering the resident's room. Resident identifier: Resident #34. Facility census: 62.
Findings included:
a) Resident #34
An observation, on 04/25/22 at 11:03 AM, revealed a sign posted above Resident #34's bed noting No blood pressure or needle sticks to be performed to the right arm.
An interview, on 04/26/22 at 9:48 AM, with the facility's Administrator, verified there was a sign, with resident care information, above the resident's bed. Additionally, the Administrator stated because of dignity issues, no signs should be posted above resident's beds to provide information.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure two (2) of 24 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POS...
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Based on record review and staff interview, the facility failed to ensure two (2) of 24 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA). Resident identifiers: Resident #6 and #40. Facility census: 62.
Findings Included:
a) Resident #6
Record review on 04/25/22 at 3:01 PM found a POST Form on Resident #6's chart was unsigned by the Resident or MPOA. (Patient/Patient MPOA representative/surrogate signature required). The POST form was dated 07/05/21.
During an interview on 04/26/22 at 10:06 AM with the Director of Nursing (DON) confirmed Resident #6's POST form was incomplete without a Resident or MPOA signature.
b) Resident #40
Record review on 04/25/22 at 3:05 PM found a POST Form on Resident #40's chart was unsigned by the Resident or MPOA. (Patient/Patient MPOA representative/surrogate signature Required). The POST form was dated 11/12/21.
During an interview on 04/26/22 at 10:06 AM with the DON confirmed Resident #40's POST form was incomplete without a Resident or MPOA signature.
No other information was provided prior to the end of survey on 04/27/22 at 11:00 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to update care plan and [NAME], this is true for (1) one of 20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to update care plan and [NAME], this is true for (1) one of 20 residents reviewed for care plans. Resident identifier #57. Facility Census 62
Findings included:
a) Resident #57
On 04/25/22 at 3:00 PM, review of Care Plan did not show resident receiving a bedside commode and showed one (1) person assist with toileting. [NAME] also did not show bedside commode being utilized and showed independent with toileting.
On 4/26/22 at 1:00 PM, interview with IP (infection preventionist) Registered Nurse #22 and verified Care Plan was not updated, Resident #57 utilized bedside commode when resident #57 tested positive for covid six (6) weeks ago and will not let staff take bedside commode out of room now. IP RN #22 stated, information in Care Plan and [NAME] had not been update to reflect current plan of care for resident #57 and will update Care Plan and [NAME] immediately.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation , record review and staff interview, the facility failed to ensure that a resident who required respiratory care, was provided that care in accordance with professional standard...
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Based on observation , record review and staff interview, the facility failed to ensure that a resident who required respiratory care, was provided that care in accordance with professional standards of practice and in accordance with the resident's plan of care. This deficient practice was identified in one (1) of five (5) residents reviewed during the Long Term Care Survey Process (LTSP) who were receiving oxygen therapy. Resident identifier: Resident #49. Census: 62
Findings included:
a) Resident #49
A review of the Policy titled: Oxygen Therapy via Nasal Cannula, with an effective date of 12/01/06, noted that oxygen therapy would be administered as ordered by a physician and would include the correct flow rate, mode of delivery and frequency.
A record review for Resident #49 showed a current order which started on 03/29/22, for the resident to receive oxygen therapy at four (4) Liters per minute.
An observation of the oxygen administration for Resident #49, on 04/25/22 at 01:52 PM, revealed the oxygen flow rate was set on six (6) Liters per minute.
An interview with the Director of Nursing (DON) on 04/25/22 at 01:52 PM verified the oxygen was set on six (6) Liters per minute and confirmed the order for the oxygen was to be administered at four (4) Liters per minute.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to identify a pharmacist's recommendations made during...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to identify a pharmacist's recommendations made during the Medication Regimen Review (MRR). The MRR was not reported to the physician or acted upon in a timely manner. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: 51. Facility census: 62.
Findings include:
a)Resident (R) #51
Review of the medical record on 04/26/22, revealed R #51 was admitted to the facility on [DATE]. The pharmacist progress note written 04/08/22 identifies comments/recommendations made during the monthly MRR and states see report. The medical record is silent for this report.
During an interview on 04/26/22 at 1:06 PM, the Director of Nursing (DON) acknowledged she did not download the last medication regimen reviews. The DON reported she was unaware the pharmacists had made any recommendations for R #51 and confirmed the physician was not notified.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility, failed to label and date foods in the refrigerator and to keep the utensil drawer clean and organized in a sanitary manner. This failed practic...
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Based on observation and staff interview the facility, failed to label and date foods in the refrigerator and to keep the utensil drawer clean and organized in a sanitary manner. This failed practice had the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census 62
Findings included;
a) Kitchen
On 4/25/22 at 10:35 AM initial tour the kitchen with Director Food/Nutrition Services #62. Observed in walk in refrigerator a pitcher of ice tea not label and dated. Observed an open to air stick of butter not covered and dated. Director Food/Nutrition Services #62 immediately discarded items observed.
Continuing with initial tour of the kitchen found utensils drawer to have an excessive amount of debris and utensils were mixed together in no sanitary manner. Director of Food/Nutrition Services #62 agreed that the utensil drawer needed cleaned and organized.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
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Based on observation , staff and resident interview, the facility failed to maintain an environment that was sanitary and with functioning equipment. This deficient practice was identified during a ...
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Based on observation , staff and resident interview, the facility failed to maintain an environment that was sanitary and with functioning equipment. This deficient practice was identified during a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident #17 did not have a functioning toilet and the portable toilet used was not maintained in a sanitary manner. Resident Identifier #17. Facility census: 62.
Findings included:
a) Resident #17
A review of the Policy and Procedure titled: Preventive Maintenance: Routine Maintenance, dated with a revision date of 06/01/07, addressed requests for routine maintained on the physical plant, fixtures and equipment would require a work order. The policy further showed once work was completed, the maintenance supervisor or designee would write the action taken on the work order and completed work orders would be filed and maintained for one year.
During a resident interview, on 04/25/22 at 10:57 AM, Resident #17 explained the toilet in the room had been broken for approximately a month and she has had to use a portable toilet located in the bathroom. Resident #17 stated the portable toilet was not emptied as it needed to be causing the room to smell.
An observation of the resident's bathroom, on 04/25/22 at 10:57 AM, revealed the toilet covered with plastic and a portable toilet in the bathroom. The portable toilet was more than 3/4 full with contents and there was a strong odor present. Additionally the lid to the portable toilet had been left open.
An observation on 04/25/22 at 11:34 AM, with Licensed Practical Nurse #13 (LPN #13), verified the toilet in the room was not usable and verified the portable toilet in Resident #17's bathroom was full and should not have been that dirty. LPN #13 confirmed a strong odor was present in the room.
An observation on 04/25/22 at 01:45 PM, with the Director of Nursing (DON), verified the portable toilet was in need of being emptied and should have been emptied when used. The DON also stated she was unaware the toilet was broken.
An interview , on 04/25/22 at 04:00 PM. with the Administrator, revealed no evidence of a time frame in which the toilet was unusable and confirmed she could not locate a work order or any evidence the toilet had been reported being broken or if it had been repaired
An interview, with the Maintenance Supervisor, on 4/26/22 at 08:42 AM, revealed the toilet had been fixed some time ago, but could not provide any dates, however, he was unaware the toilet was currently unable to be used.
Further, the Maintenance Supervisor could not produce any paper work or work order showing the date the toilet was broken and when repairs were made.
An interview, with Registered Nurse #22 (RN #22) and the Administrator, on 04/27/22 at 10:30 AM, revealed there was not a process in place to notify and monitor maintenance problems to ensure equipment remained in good working order or was repaired when broken.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations, resident interview and staff interview, the facility failed to keep odors maintained, emptying of bedsi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations, resident interview and staff interview, the facility failed to keep odors maintained, emptying of bedside commodes, repairing of broken pipes in the kitchen, repairing chipped paint in the kitchen, keeping floors clean in the kitchen and not keeping drain odors in bathroom contained. Facility census 62.
Findings included:
a) Dirty floors
On 4/25/22 at 10:35 AM, during initial tour of the kitchen observed floors to be very dirty with brown substance stuck to the floor. Director Food/ Nutrition Services #62 stated, the staff mop after lunch every day. Asked if the kitchen floor is on a deep cleaning schedule and Director Food/Nutrition Services #62 stated when housekeeping can but, they are working behind.
On 4/26/21 at 8:45 AM, interview with Cooperate Chef stated, I did not leave the facility until 11 PM on 4/25/22 due to cleaning of dietary department floor. Cooperate Chef stated, I had to pour boiling water on floor to get dirt to lift. The floor was also scrubbed with a scrubbing machine and they went through two ( 2) scrub pads to get the floor clean.
b) Chipped Paint in dish room
On 4/25/22 at 10:35 AM, during initial tour of kitchen observed chipped paint hanging on back wall of 3 bowl sink. Director Food/Nutrition Services #62 stated, that chipped paint has been there since 2019 when roof leaked. [NAME] County Health Department came 2/6/22 and took pictures and cited Kitchen for the chipped paint.
On 4/25/22 at 11 AM, interview with Maintenance Director (MD) #23 stated that he had painted the wall and did not realize that the wall had chipped again. Asking for a copy of work order that was put into TELS to repair wall with chipped paint. MD #23 stated, I will have to go print it off my computer.
MD #23 did not produce a copy of TELS work order.
c) Broken Pipes in Kitchen
On 4/25/22 at 10:35 AM, during initial tour in the kitchen observed a plastic bucket and metal cooking pot underneath the prep sink in the kitchen catching water from leaking pipes. Director Food/Nutrition Services stated, the work order was put into TELS by myself and it has been over three (3) weeks since I put work order in TELS.
On 4/25/22 at 11:15 AM, interview with Maintenance Director (MD) #23 if water leak from broken pipes in kitchen is on the list to be repaired. MD #23 stated, I have fixed those pipes several times and the kitchen staff keep bumping the pipes when mopping. Asked MD #23 if the work orders for broken pipes can be produced. MD #23 stated yes and never did provide.
d) Odors from bedside commode
On 4/25/22 at 11:45 AM when touring 100 Hall observed bedside commode in room [ROOM NUMBER] and lid was up on bedside commode and was not empty with offensive odors coming out in hall. When asking Licensed Practical Nurse (LPN) #13 to witness bedside commode being full and smelling in room and LPN #13 agreed it needed emptied and had an odor.
f) room [ROOM NUMBER]
During an annual recertification with a simultaneous complaint investigation for offensive odors in the facility on 04/25/22 observed a musty / sewer odor coming from the bathroom in room [ROOM NUMBER].
A second observation on 04/26/22 at 2:50 PM found the musty /sewer odor continues.
An interview on 04/26/22 at 3:15 PM with the Administrator, confirmed the bathroom in room [ROOM NUMBER] had a musty / sewer odor.
During an Interview on 04/26/22 at 3:21 PM the Administrator stated that the Maintenance Director called Mr. Rooter pluming five (5) or Six (6) months ago and got a plug to keep the smell down.
A review of the receipt from Mr. Rooter Pluming revealed they checked for sewer gas with the date 08/23/21.
No further information was provided prior to the end of the survey process on 04/27/22 at 11:00 AM.
e) During a resident interview, on 04/25/22 at 10:57 AM, Resident #17 explained the toilet in the room was broken and she has had to use a portable toilet located in the bathroom. Resident #17 stated the portable toilet was not emptied as it needed to be causing the room to smell.
An observation of the resident's bathroom, on 04/25/22 at 10:57 AM, revealed the toilet covered with plastic and a portable toilet in the bathroom. The portable toilet was more than 3/4 full with contents and there was a strong odor present. Additionally the lid to the portable toilet had been left open.
An observation on 04/25/22 at 11:34 AM, with Licensed Practical Nurse #13 (LPN #13), verified the portable toilet in Resident #17's bathroom was full and should not have been that dirty. LPN #13 confirmed a strong odor was present in the room.
An observation on 04/25/22 at 01:45 PM, with the Director of Nursing (DON), verified the portable toilet was in need of being emptied and should have been emptied when used. The DON also stated she was unaware the toilet was broken and the resident had been using the portable toilet.
A review of the comprehensive assessment, with a target date of 04/19/22, under Section G. showed the resident to require supervison with one person assist to use the toilet room, and to transfer on and off the toilet.
Feb 2021
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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b) Invalid Physician's Order for Scope of Treatment (POST) form
On 02/22/21 at 5:00 PM, record review revealed a POST form on Resident #49's chart. The bottom of the form indicated it was produced b...
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b) Invalid Physician's Order for Scope of Treatment (POST) form
On 02/22/21 at 5:00 PM, record review revealed a POST form on Resident #49's chart. The bottom of the form indicated it was produced by [NAME] Virginia's Center for End-of-Life Care in 2017. In Section D, verbal consent from the Health Care Surrogate (HCS) was accepted on the POST form. The verbal consent was dated 08/12/20 and witnessed by RN #10 and LPN #30. Above the signature line the following typed guidance is displayed: Signature of Patient/Resident, Parent of Minor, or Guardian/MPOA Representative/Surrogate (Mandatory).
Review of instructions on how to complete the POST form from Using the POST Form: Guidance for Healthcare Professionals 2016 Edition outlined: The patient or representative/surrogate and physician/APRN (advanced practice registered nurse) must sign the form in this section. These signatures are mandatory. A form lacking these signatures is NOT valid.
On 02/23/21 at 12:52 PM, the Administrator acknowledged there was no written signature of Resident #49's representative and that verbal consent had been accepted.
Based on record review and staff interview, the facility failed to accurately complete and convey residents code status choices in resident records. The facility failed to properly complete a Physician's Order for Scope of Treatment (POST) Form and convey the accurate code status choice on the Condition Alert page. The failed practice was true for two (2) of 17 resident advance directives reviewed. Resident identifier: #44 and #49. Facility census : 59.
Findings included:
a) Resident #44
A record review, on 02/22/21 at 1:40 PM, revealed a Post Form and Amedisys Verification of Do Not Resuscitate Order that stated, Do Not Resuscitate (DNR). The Condition Alert page at the front of the resident record stated, Full Code.
An interview with Registered Nurse (RN) #10 , at 02/22/21 at 1:50 PM, revealed staff used the Condition Alert page when in an emergency situation as a quick guide on how to proceed when a resident codes. RN #10 confirmed when Resident # 44 changed status from a Full Code to a DNR the medical record department usually updated the resident record. RN #10 confirmed that the Condition Alert page should reflect DNR and not full code to match the most current code status choice of Resident #44 reflected on the Post Form.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to accurately assess a Minimum Data Set (MDS) for Insulin. The ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to accurately assess a Minimum Data Set (MDS) for Insulin. The facility assessed a resident for insulin when insulin was not administered. The failed practice was true for one (1) of 17 MDS reports reviewed. Resident identifier: #7. Facility census: 59.
Findings included:
a) Resident #7
A record review, on 02/22/21 at 1:37 PM, revealed a Quarterly Minimum Data Set (MDS) dated [DATE] with an answer Yes to insulin for seven (7) days.
Further record review, on 02/22/21 at 1:40 PM, revealed a physician order, Victoza Solution Pen-injector 18 MG/3 ML (Liraglutide) with start date : 8/18/2020 at 9:00 AM Inject 1.2 mg subcutaneous one time a day related to Type 2 diabetes mellitus with unspecified complications.
An interview with Minimum Data Set (MDS) Coordinator #21, on 02/23/21 at 1:40 PM, revealed Resident #7 was assessed for insulin based on the medication Victoza Solution Pen-injector. MDS Coordinator stated, I did not realize that Victoza was not insulin.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview and staff interview the facility failed to ensure proper handling of oxygen nasal cannula and tubing. This was a random opportunity for discovery. Resident i...
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Based on observation, resident interview and staff interview the facility failed to ensure proper handling of oxygen nasal cannula and tubing. This was a random opportunity for discovery. Resident identifiers #310. Facility Census: 59.
Findings included:
a) During interview with Resident #310 on 02/22/21 at 12:10 PM the oxygen nasal cannula and tubing was under the end of the bed, wrapped around the wheel chair. The resident was trying to step over the tubing that was approximately one foot off the ground. The oxygen cannula was on the floor under the bed.
Interview with Center Executive Director (CED) on 02/22/21 at 01:15 PM, she stated there are bags in each room that the oxygen nasal cannula and tubing should be placed in when not in use.
At 02/22/21 at 2:00 PM received paper copy of the facilities policy: Oxygen: Nasal Cannula policy revised 11/01/2019 states Replace disposable set-up every seven (7) days. Date and store in treatment bag when not in use
On 02/23/21 at 09:46 AM Resident #310 was sitting in his wheel chair, with his oxygen nasal cannula and tubing rolled up laying on his bed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure medications in the medication room refrigerator were n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure medications in the medication room refrigerator were not expired. The medications were found during medication room observation. Facility census: 59.
Findings included:
a) Observation of the medication room was completed with Licensed Practical Nurse(LPN) #6 on [DATE] at 10:54 AM. During review of stock medication in the refrigerator there was the following three (3) medications that were expired:
--Humulin Kwikpen expired 04/2020
--Humulin Kwikpen expired 9/2020
--Novolin 70/30 bottle expired 10/2020
LPN #6 opened door to the medication room and requested an other staff member to find the Director of Nursing (DON). The DON arrived to medication room and accepted the expired medication for disposal.
Interview with DON on [DATE] at 11:11 AM she stated the pharmacy has not been in the building due to COVID-19. DON stated she spent time last week disposing of expired meds in Omnicell and was unaware there was an Omnicell container in the refrigerator. (Omnicell is a Medication Delivery System.)
The Humulin Kwikpen's could have the potential to effect two (2) residents that has orders for the Humulin Kwikpen. No one at the facility is receiving Novolin 70/30.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
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Based on observation and staff interviews, the facility failed to ensure that the plastic barrier wall (zip wall) was free from the potential effects of avoidable breaches in infection control pract...
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Based on observation and staff interviews, the facility failed to ensure that the plastic barrier wall (zip wall) was free from the potential effects of avoidable breaches in infection control practices. This deficient practice was found during a random opportunity for discovery. Facility Censes 59.
Findings included:
a) Observed on 02/23/21 at 09:15 AM reveled the plastic zipper wall on 100 hallway used as a barrier between observation area and the rest of the facility had multiple openings. The zipper was coming apart from the zipper, with multiple duck tape attempts to repair the zipper wall. The plastic zipper wall was affixed to the ceiling and each wall using wood 2X4 with staples. The zipper wall was loose on one side and blowing air from the observation area into the facility.
Interview with Nurse Aide (NA) #12 on 02/23/21 at 03:55 PM, stated that she did not think the zipper wall should be flowing open like it is, it looks like it was tore from the wall.
At 04:21 PM on 02/23/21 Interview with Center Executive Director (CED) at the zipper wall, she acknowledged the holes in the zipper wall and the flow of air coming into the facility from the observation area. CED explained there are no resident with COVID-19 in the observation area. CED stated the zipper wall will be immediately taken down.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
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Based on interview, observation and record review, the facility failed to provide reasonable accommodation of resident needs, which had the potential to endanger the health and safety of three (3) r...
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Based on interview, observation and record review, the facility failed to provide reasonable accommodation of resident needs, which had the potential to endanger the health and safety of three (3) residents. These were random opportunities for discovery. Resident Identifiers: #13, #22, and #49. Facility Census: 59
Findings included:
a) Bathroom Door Locked Three Times, Indicating a Pattern
On 02/22/21 at 01:06 PM, Resident #13 reported that his bathroom door was locked from the other side. Resident #13 stated it happened yesterday as well. He states he shares the bathroom with two (2) men on the other side of the bathroom. Resident #13 stated a resident nicknamed, Nickname of other Resident, is one of the men on the other side of his bathroom and that particular resident locks the bathroom door when he is using the bathroom and doesn't unlock it when he's finished.
Surveyor requested that CNA #3 assist in unlocking the bathroom door from the other side so Resident #13 could use the bathroom.
The Director of Nursing (DON) stated during an interview on 02/23/21 at 2:32 PM, she was unaware there was an issue with Resident #13's bathroom door being locked from the other side. The DON stated the resident on the other side of the bathroom leaving the door locked is new to that room and she will address it with the other resident and her staff to prevent any further incidents.
On 02/23/21 at 3:15 PM, Resident #13's bathroom door was again locked from the other side. Surveyor BL observed Resident #13 jiggling the bathroom door and exclaiming, It's locked again!!
Review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Review Date of 02/17/21, denoted: Walk in room - how resident walks between locations in his/her room was coded as 0 indicating no help or staff oversight at any time. Review of Resident #13's care plan, with a revision date of 02/04/21, revealed the following goal: [Resident #13's First Name] will maintain highest capable level of ADL (activities of daily living) ability throughout the next review. The care plan further states: [Resident #13's First Name] requires assistance for ADL (activities of daily living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: Recent illness, hospitalization, activity intolerance, confusion.
b) Call Lights Not Within Reach
On 02/22/21 at 12:58 PM, Resident #22's call light was on the floor out of resident's reach. Resident #22 was lying in bed. The call light was on the floor beside the bed. RN #10 accompanied Surveyor to Resident #22's room and acknowledged the call light was on the floor and not within Resident #22's reach.
On 02/22/21 at 1:16 PM, Resident #49's call light was on the floor out of resident's reach. Resident #49 was lying in bed. The call light was on the floor beside the bed. The Administrator accompanied Surveyor Resident #49's room and acknowledged the call light was on the floor and not within Resident #49's reach.
Review of the facility's Call Lights policy identified the purpose of the policy was to ensure safety and communication between staff and patients. The policy states: All [Name of Facility] patients will have a call light or alternative communication device within their reach at all times when unattended.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to notify the physician when one (1) of three (3) residents re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to notify the physician when one (1) of three (3) residents reviewed for the care area of hospitalization had an increase in temperature. Resident identifier: #54. Facility census: 59.
Findings included:
a) Resident #54
On 02/22/21 at 11:45 AM, during the initial screening of Residents, the Resident said she had been really sick and had been hospitalized . She stated, I didn't have COVID but I don't know why I went out. I had a really high temperature.
Review of the medical record found the following temperatures recorded in the residents electronic medical prior to the resident being sent to the hospital on [DATE]:
01/20/2021 22:15 104.0 °F (Fahrenheit) Oral
01/20/2021 17:22 102.5 °F Oral
01/20/2021 15:00 101.9 °F Axilla
01/20/2021 07:00 101.4 °F Oral
01/19/2021 23:00 100.4 °F Oral
01/19/2021 15:00 99.1 °F Oral
01/19/2021 07:00 98.2 °F Oral
01/18/2021 23:00 98.0 °F Oral
01/18/2021 15:00 100.3 °F Oral
01/18/2021 10:34 100.9 °F Oral
01/18/2021 07:00 100.9 °F Oral
01/17/2021 23:00 98.5 °F Oral
01/17/2021 14:18 100.0 °F Oral
On 02/23/21 at 10:37 AM, the Director of Nursing (DON) confirmed there was no documentation to support the physician was notified of the increased in temperatures on 01/17/21, 01/18/21 and 01/19/21. The physician was notified of a change in condition on 01/20/21. When asked what the facility did to address the increase in temperature, the DON said the resident was taking Norco 5-325 mg. which has Acetaminophen in it so that should have helped with the temperature.
Review of the medication administration record (MAR) found an order for:
Norco tablet 5-325 mg. (Hydrocodone-Acetaminophen). Give 1 tablet by mouth as needed for Pain. May have 1 tablet BID (2 times a day) PRN (as needed).
On 01/17/21, the Resident received Norco at 8:30 AM and 9:00 PM.
On 01/18/21, the Resident received Norco at 8:00 AM and 9:00 PM
On 01/19/21, the Resident received Norco at 8:00 AM (this was the last dose of Norco administered according to the MAR.)
On 01/20/21 at 7:00 AM a change in condition (einteract SBAR) summary for providers was completed. The physician was notified of a temperature of 101.4 degrees F.
01/20/2021 12:45 General Note: physician in facility. new orders received for Covid-19 POC x1; flu swab; viral panel. resident aware of new orders and verbalized understanding. TAR (treatment administration record) updated. specimens obtained per orders. courier notified of need to transport specimen to (name of hospital) lab for processing. awaiting results of COVID-19 and Flu swabs.
1/20/2021 1:00 PM, General Note: POC results negative. flu swab negative. awaiting results of viral panel at this time.
On 01/20/21 at 6:38 PM, the a new order was written for Acetaminophen 325 MG, give 2 tablets every 4 hours as needed for Temperature of 100 F or above.
At 11:20 PM on 01/20/21, the residents temperature was 104 degrees F. Notified (name of physician) of resident temp 104 orally. increased lethargy and altered mental status. alert to self and place with shallow respirations and upper posterior wheezes auscultated bilateral upper lobes. Tylenol given at 1730. order given to send to (name of hospital) ER. ambulance called. Notified ambulance service of negative covid results and resident weight. awaiting arrival of EMS squad.
02/23/21 11:15 AM, the DON said the nurse practioner saw the Resident on 01/18/21. Review of the nurse practioners note found the following, .being tx. with cellulitis with improvements .
The Nurse Practioner noted the resident's temperature was 98.5 degrees F. The DON noted the temperature would have pulled from the electronic medical record. (98.5 was the temperature recorded at 11:00 PM on 01/17/21.) The DON could not find any documentation in the nurse practioners notes to substantiate she was aware of an increase in temperatures on 1/17/21 - 100 degrees F at 2:18 PM.
According to the MAR, the resident received the antibiotic, Bactrim DS, 1 tablet BID for 10 days for cellulitis. The antibiotic was started on 01/02/21 and ended on 01/12/21.
At the close of the survey on 02/24/21, no evidence was provided to substantiate the physician/nurse practioner was aware of the increase in the Resident's temperature until 01/20/21.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) liability notice in a timely fashion for three (3) of three (3) ...
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Based on record review and staff interview, the facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) liability notice in a timely fashion for three (3) of three (3) residents reviewed for beneficiary protection notification. This failure placed residents at risk of not being informed of their appeal rights prior to the end of Medicare covered services. Resident identifiers: #261, #260, and #259. Facility census: 59
Findings included:
a) Beneficiary Notice Review
On 02/23/21 at 11:00 AM, a review was completed regarding the beneficiary protection notification liability notices given for the following three (3) residents who were discharged to home:
--Resident #261. The last covered day of Part A service for Resident #261 was 01/14/21. The NOMNC liability notice form reflects verbal notification to resident's representative on the same day, 01/14/20.
--Resident #260. The last covered day of Part A service for Resident #260 was 12/28/20. The NOMNC liability notice form reflects verbal notification on to resident's representative on 12/27/20. A one (1) day notification was provided.
--Resident #259. The last covered day of Part A service for Resident #259 was 09/02/20. The NOMNC liability notice form was signed and dated by resident on the same day, 09/02/20.
The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services.
On 02/23/21 at 12:25 PM, the Minimum Data Set (MDS) Coordinator #21 confirmed she was the employee responsible for issuing the NOMNC liability notices and agreed that a two (2) day notice was not given for the three (3) residents reviewed.
On 02/23/21 at 12:48 PM, the Administrator acknowledged error in providing timely notification.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
- • 37% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Parkersburg Center's CMS Rating?
CMS assigns PARKERSBURG CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Parkersburg Center Staffed?
CMS rates PARKERSBURG CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 37%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Parkersburg Center?
State health inspectors documented 44 deficiencies at PARKERSBURG CENTER during 2021 to 2024. These included: 43 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Parkersburg Center?
PARKERSBURG CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 66 certified beds and approximately 61 residents (about 92% occupancy), it is a smaller facility located in PARKERSBURG, West Virginia.
How Does Parkersburg Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, PARKERSBURG CENTER's overall rating (3 stars) is above the state average of 2.7, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Parkersburg Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Parkersburg Center Safe?
Based on CMS inspection data, PARKERSBURG CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Parkersburg Center Stick Around?
PARKERSBURG CENTER has a staff turnover rate of 37%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Parkersburg Center Ever Fined?
PARKERSBURG CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Parkersburg Center on Any Federal Watch List?
PARKERSBURG CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.