Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbors At Woodsfield during CMS and state inspections, most recent first.
The facility failed to store and prepare foods in a sanitary manner, affecting all 55 residents. Observations revealed expired food items, food splashes, debris, and grime in various areas of the kitchen. The Dietary Manager and Dietary Aide confirmed these findings, which were in non-compliance with the facility's policies on food handling.
The facility failed to ensure a dignified dining experience when meals were not served simultaneously to all residents seated at the same table. This affected four residents, with meal service times ranging from 11:09 A.M. to 11:26 A.M. An RN confirmed that each table should be served at the same time, and a resident expressed frustration over the inconsistent service. The facility's policy mandates promoting and maintaining resident dignity, which was not followed.
The facility failed to ensure that baseline care plans were developed and provided to residents and their representatives within 48 hours of admission. This deficiency affected five residents, each with various medical conditions and cognitive statuses. Despite the facility's policy mandating the development of baseline care plans within 48 hours, no such plans were found for the affected residents.
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported that the food, specifically potatoes and pizza, was either burnt, hard, or unseasoned. Observations and staff interviews corroborated these complaints, indicating a failure in the facility's food preparation and quality control processes.
The facility failed to conduct care conferences with residents in conjunction with MDS assessments, affecting two residents. One resident with chronic conditions and mildly impaired cognition did not have a completed care conference, while another resident with intact cognition was not invited to participate in scheduled care conferences. The Social Services Director confirmed missing documentation for these care conferences.
The facility failed to implement a restorative ambulation program for a resident with multiple mobility-related diagnoses, leading to a decline in the resident's functional mobility and strength. The oversight occurred after the resident was discharged from physical therapy, and no new referral was made to the restorative nursing program.
The facility failed to provide oral care for a resident dependent on staff for personal care. Despite the resident's care plan indicating a need for assistance with all ADLs, observations and interviews revealed poor oral hygiene, with plaque and grime on the resident's teeth. Staff confirmed that oral care was not being performed as required.
The facility failed to ensure interventions to prevent pressure ulcers were in place per orders for a resident with multiple diagnoses, including heart failure and dementia. Despite orders for an alternating air mattress and zero gravity boots, observations revealed the boots were not on the resident's feet but on the dresser. This lapse was confirmed by a registered nurse, indicating a failure to follow the care plan and physician's orders.
The facility failed to implement fall prevention interventions for a resident with severe cognitive impairment and physical limitations. Despite care plans and physician's orders, the resident's bed was repeatedly observed not in its lowest position, increasing the risk of falls.
The facility failed to prepare pureed foods to meet the needs of two residents requiring a pureed diet. Cook #420 struggled to achieve the appropriate texture for a vegetable salad and broccoli, despite guidance from the Dietary Manager and Regional Dietary Manager. The mixture remained gritty and contained chunks, and there were lapses in hygiene practices during food preparation.
A resident with multiple diagnoses, including morbid obesity and anxiety disorder, was served scrambled eggs despite her documented preference for fried eggs. When she raised the issue, staff initially did not accommodate her preference due to the meal ticket indicating scrambled eggs. The Dietary District Manager later confirmed the resident's preference and agreed to prepare fried eggs.
A resident with multiple diagnoses was administered an antibiotic for a urinary tract infection without meeting the necessary criteria. Despite preliminary urine results and the physician's instruction to await culture results, the resident was prescribed Macrobid based on symptoms. The antibiotic was discontinued after culture results showed mixed commensal flora, but the resident had already received four doses. The DON confirmed the physician often started antibiotics based on symptoms or family requests before final results.
Facility Failed to Store and Prepare Foods in a Sanitary Manner
Penalty
Summary
The facility failed to store and prepare foods in a sanitary manner, which had the potential to affect all 55 residents residing in the facility. Observations on 04/08/24 revealed expired food items in the dry storage room and walk-in refrigerator, including an eight-quart container of rice crispies, two dozen hard-boiled eggs, half a white onion, a whole onion, a half-gallon of parmesan cheese, and a bag of shredded cheddar cheese. The Dietary Manager confirmed these findings. Additional observations on the same day showed food splashes on prep area walls, food debris and crumbs on shelving and floors, and sticky grime on stainless-steel shelving. These findings were also confirmed by the Dietary Manager at the time of observation. Further observations on 04/10/24 revealed additional unsanitary conditions, including dusty and grimy shelving containing spices, sticky grime on the table with the steamer, thick layers of grime and debris on the oven and stove, and dark brown sticky grime on containers of flour and sugar. The shelf with the microwave had rust, and a container of baking soda was noted with an expired use-by date. The Dietary Manager confirmed these findings. Additionally, a white carafe on the clean dishes shelf had dried brown crust, and two clear containers had food debris. The Dietary Aide confirmed these findings and attempted to clean the carafe by rinsing it in water before placing it back on the clean dishes shelf. The facility's policies on food receiving, storage, preparation, and service were reviewed and found to be in non-compliance with safe food handling practices as outlined in the FDA Food Code.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents when meals were not served simultaneously to all residents seated at the same table. This deficiency was observed on 04/08/24, affecting four residents seated together. Resident #8 received her meal at 11:09 A.M., followed by Resident #47 at 11:19 A.M., Resident #2 at 11:22 A.M., and Resident #161 at 11:26 A.M. An interview with RN #135 confirmed that each table should be served at the same time. Additionally, Resident #47 expressed frustration and upset over the inconsistent meal service, stating it was common for residents at the same table to be served at different times. The facility's policy on promoting and maintaining resident dignity, dated 10/26/23, mandates that all staff members protect and promote resident rights and dignity, which was not adhered to in this instance.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and provided to residents and their representatives within 48 hours of admission. This deficiency affected five residents, each with various medical conditions and cognitive statuses. For instance, Resident #58, who had multiple diagnoses including chronic kidney disease and a pressure ulcer, did not receive a summary of the baseline care plan despite being cognitively intact. Similarly, Resident #263, with conditions such as congestive heart failure and diabetes, also did not receive a baseline care plan summary. Both residents had documented nursing admission assessments that identified needs and interventions, but there was no evidence of a baseline care plan discussion or summary provided to them or their representatives. Resident #20, admitted with diagnoses including rhabdomyolysis and acute kidney failure, had moderately impaired cognition. There was no evidence that a baseline care plan was completed or provided within 48 hours of admission. The Social Services Director (SSD) confirmed that care conferences should be completed upon admission and that baseline care plans should be given to residents if they want a copy. However, no baseline care plan was found in the records for Resident #20. Similarly, Resident #24, with diagnoses such as chronic obstructive pulmonary disease and atrial fibrillation, did not receive a baseline care plan within the required timeframe. The SSD reiterated the process for care conferences but acknowledged the lack of documentation for the baseline care plan. Resident #46, diagnosed with Alzheimer's disease and type II diabetes, also did not receive a baseline care plan within 48 hours of admission. The SSD confirmed that care conferences should be completed upon admission and that baseline care plans should be available in the assessment tab in PointClickCare. Despite this, no baseline care plan was found for Resident #46. The facility's policy on baseline care plans, dated 12/28/23, mandates that such plans should be developed within 48 hours of admission and include essential healthcare information. However, the facility failed to adhere to this policy for the five residents mentioned.
Failure to Ensure Palatable and Safe Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported that the food, specifically potatoes and pizza, was either burnt, hard, or unseasoned. Resident #58, who has heart failure and stage three chronic kidney disease, received lunch with potatoes that were dark brown and hard, and green beans that were unseasoned. Similar complaints were made by Resident #36, who has orthostatic hypotension and a history of malignant neoplasm of the kidney, and Resident #37, who has malignant neoplasm of the right breast and type two diabetes mellitus. Both residents reported that the potatoes served were hard and inedible. Resident #263, who has type two diabetes mellitus and a stage three pressure ulcer, also found the potatoes too hard to eat. Additionally, Resident #49, who has multiple diagnoses including rhabdomyolysis and chronic obstructive pulmonary disease, reported that the food tasted terrible and was not warm. A test tray confirmed that the pizza served was burnt and hard to chew. Observations and interviews with staff corroborated the residents' complaints. Cook #405 acknowledged that the potatoes looked dark but denied they felt hard. State tested Nursing Assistant (STNA) #122 observed that nobody was eating the potatoes and noted they appeared burnt. STNA #122 also reported that the pizza served was hard and burnt, and had to substitute it with a grilled cheese sandwich for a resident. These findings indicate a failure in the facility's food preparation and quality control processes, affecting the residents' dining experience and potentially their nutritional intake.
Failure to Conduct Care Conferences with Residents
Penalty
Summary
The facility failed to conduct care conferences with residents in conjunction with Minimum Data Set (MDS) assessments, affecting two residents. Resident #24, admitted with chronic obstructive pulmonary disease, atrial fibrillation, and cognitive communication deficit, had a mildly impaired cognition according to a quarterly MDS. Despite having a discharge planning meeting and several care conferences scheduled, there was no record of a care conference being completed on 01/24/24. Resident #24 confirmed not having had a care conference or being able to make decisions regarding treatment. The Social Services Director (SSD) confirmed that the initial care conference was not completed with the interdisciplinary team included. Resident #49, admitted with rhabdomyolysis, neoplasm of unspecified behavior of the bladder, chronic obstructive pulmonary disease, and atrial fibrillation, had intact cognition according to a quarterly MDS. Although a care conference was held on 07/28/23, there was no evidence of care conferences being completed for the scheduled dates of 10/10/23 and 02/26/24. Resident #49 confirmed not being invited to participate in care conferences. The SSD revealed that care conferences are scheduled upon admission, annually, quarterly, and with significant changes, but documentation for the February 2024 and October 2023 care conferences was missing.
Failure to Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to ensure that recommendations for a restorative ambulation program were implemented for Resident #37, who had a history of degenerative disease of the nervous system, peripheral vascular disease, type two diabetes mellitus with neuropathy, and other conditions affecting mobility. Despite a physical therapy evaluation indicating the need for a restorative ambulation program to maintain the resident's ability to walk 100 feet with contact guard assistance, the program was not implemented. This lapse occurred after the resident was discharged from physical therapy on 03/06/24, and no new referral was made to the restorative nursing program. Interviews with the resident and staff revealed that the resident had not received assistance with walking for weeks, leading to a decline in her functional mobility and strength. The restorative nurse stated that she had not received a referral for the resident's ambulation program since September 2023, and the program was discontinued when the resident was placed on the therapy caseload. The physical therapy assistant acknowledged the oversight in not completing a new referral to the restorative nursing program after the resident's discharge from physical therapy.
Failure to Provide Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident who is dependent on staff for personal care. Resident #46, who has diagnoses including Alzheimer's disease, type II diabetes, panic disorder, post-traumatic stress disorder, and fibromyalgia, was observed to have poor oral hygiene. The resident's care plan indicated a need for assistance with all activities of daily living, including oral care, due to an ADL self-care performance deficit. Despite this, observations and interviews revealed that the resident's teeth had a layer of plaque and grime, indicating that oral care was not being performed as required. Interviews with the resident's representative and a State Tested Nursing Assistant (STNA) confirmed that oral care was not being provided consistently. The STNA acknowledged that oral care should be completed daily for residents who are dependent on staff, and confirmed that Resident #46 had not received the necessary oral care. Additionally, a request for the facility's oral care policy was made but not received, further highlighting the deficiency in care provided to the resident.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure interventions to prevent pressure ulcers were in place per orders for Resident #39. The resident, who was admitted with multiple diagnoses including heart failure, type II diabetes, chronic obstructive pulmonary disease, atrial fibrillation, and dementia, had specific orders for an alternating air mattress and zero gravity boots while in bed. Despite these orders, observations on two separate occasions revealed that the zero gravity boots were not on the resident's feet but rather on the dresser. This was confirmed by a registered nurse who acknowledged that the boots should have been on while the resident was in bed. The resident's care plan indicated a high risk for impaired skin integrity due to factors such as being confined to bed, dementia, diabetes, incontinence, and existing skin breakdown. The care plan included interventions like skin prep to bilateral heels, turning and repositioning, and preventative treatments as ordered. However, the failure to ensure the zero gravity boots were in place as ordered represents a lapse in following the care plan and physician's orders, potentially compromising the resident's skin integrity and increasing the risk of pressure ulcers.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with a history of falls. Resident #27, who has severe cognitive impairment and multiple physical limitations, was observed on multiple occasions with her bed not in its lowest position, contrary to her care plan and physician's orders. The resident's medical record indicated a history of falls, including a recent fall where she was found on the floor next to her bed, which was supposed to be in its lowest position to prevent such incidents. Despite the care plan and physician's orders specifying that the resident's bed should be in its lowest position when not providing care, observations on two separate days revealed that the bed was not lowered as required. Licensed Practical Nurse (LPN) #107 confirmed that the bed should be in its lowest position and adjusted it during the surveyor's visit. However, the bed could not be fully lowered due to the bed's design, which allowed it to be moved when in its lowest position, causing the wheels to contact the floor.
Failure to Prepare Pureed Foods to Appropriate Texture
Penalty
Summary
The facility failed to prepare pureed foods to meet the needs of residents requiring a pureed diet, affecting two residents. During an observation, Cook #420 struggled to achieve the appropriate pureed texture for a vegetable salad with Italian dressing. Despite multiple attempts and guidance from the Dietary Manager (DM) #430, the mixture remained gritty and contained chunks. Cook #420 and DM #430 were unable to resolve the issue, and the mixture was eventually discarded. Cook #420 then attempted to puree broccoli, but again faced difficulties achieving the correct texture. It was only after the intervention of the Regional Dietary Manager (RDM) #160, who added milk and thickener, that the mixture reached the appropriate consistency. Throughout the process, there were also lapses in hygiene practices, such as Cook #420 using the back of her gloved hand to wipe her nose without changing gloves or washing hands, and placing her gloved hand on a prep table where used spoons had been discarded. These actions were confirmed through interviews with DM #430 and RDM #160. The deficiency was observed to affect two residents who were on a pureed diet. The facility census at the time was 55. The report highlights the facility's inability to consistently prepare pureed foods to the required texture, as well as lapses in hygiene practices during food preparation. The observations and interviews confirm that the staff involved were not adequately trained or equipped to handle the dietary needs of residents requiring pureed foods, leading to the deficiency noted in the report.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to ensure a resident received food according to assessed food preferences/dislikes. Resident #58, who has diagnoses including morbid obesity, anxiety disorder, and depressive disorder, reported that she did not like the facility's scrambled eggs and generally received fried eggs instead. However, on one occasion, she was served scrambled eggs despite her preference being documented otherwise. When she addressed this with staff, she was told that nothing could be done because her meal ticket indicated scrambled eggs. The Dietary District Manager later confirmed that Resident #58's food preference list indicated a dislike for scrambled eggs and agreed to prepare fried eggs for her.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure antibiotics were not used unless criteria were met for the treatment of urinary tract infections, affecting one resident. Resident #11, who had diagnoses including neurogenic disorder with Lewy bodies, Parkinson's disease, psychotic disorder with delusions, anxiety disorder, and chronic kidney disease, was administered an antibiotic without meeting the necessary criteria. The resident's medical record showed she was catheterized for a urinalysis, and preliminary results indicated the presence of leukocytes, blood, and bacteria in the urine. Despite the physician's instruction to await the urine culture results, the resident was prescribed Macrobid based on her complaints of burning on urination. The resident's progress notes revealed that the urine culture and sensitivity report, received later, showed only mixed commensal flora, which did not meet the criteria for treatment. The antibiotic was discontinued after the culture results were reviewed, but the resident had already received four doses of Macrobid. The Director of Nursing (DON) confirmed that the resident received an antibiotic for a urinary tract infection that did not meet the treatment criteria and acknowledged that the physician often started antibiotics based on symptoms or family requests before final culture results were available. The facility's policy on the Antibiotic Stewardship Program aimed to optimize infection treatment while reducing adverse events associated with antibiotic use. The infection preventionist coordinated the program, and the medical director served as the primary medical point of contact. Despite this policy, the physician did not always adhere to the antibiotic stewardship program, leading to the unnecessary administration of antibiotics to Resident #11.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Woodsfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stellar Care Center | 1.7 mi | ★★★★★ | 52 | 1 |
| Sistersville Center | 14.3 mi | ★★★★★ | 14 | 0 |
| New Martinsville Health & Rehab | 15.2 mi | ★★★★★ | 13 | 0 |
| The Enclave At Barnesville | 16.3 mi | ★★★★★ | 21 | 0 |
| Emerald Pointe Health And Rehab Ctr | 16.6 mi | ★★★★★ | 1 | 0 |
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