Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Sistersville Center during CMS and state inspections, most recent first.
A resident had an unwitnessed fall and was found on the floor beside the bed after calling for help. The initial assessment documented no visible injuries, stable VS, no pain, no ROM change, and no head strike, but the chart did not contain the required serial neuro checks ordered by the MD and required by facility policy. The Administrator confirmed no additional neuro evals could be located.
Two residents on puree diets were served meal trays in the dining room without timely drink or feeding assistance. One resident received a tray with no drink or utensils, and both residents’ uncovered meals sat for over 10 minutes before staff began checking for drinks or starting to feed them. An RN clinical lead stated this was not a common or acceptable practice.
A resident’s choice to get out of bed before lunch was not honored. She reported waiting about an hour for help after being told an aide would return, and she said she needed to be up early or she would not get up in time. An RN said she would get the aide to assist, but the resident was still in bed at 12:10 PM and still in bed eating lunch at 12:50 PM.
Failure to timely report allegations of potential verbal abuse. A resident’s report that a CNA may have called her a derogatory name was not reported until weeks later because the father asked that it not be reported and the former DON and Administrator decided it did not need reporting. Surveyors also found an unsigned statement alleging multiple verbal abuse incidents by two NAs, including name-calling, ignoring residents, and shutting off call lights, and the Administrator confirmed those allegations had not been previously reported or investigated.
Failure to timely report allegations of potential verbal abuse. A resident reported hearing a CNA use a profanity-like word, but the allegation was not reported until much later than required. Surveyors also found an unreported statement alleging that two NAs called residents names, ignored call lights, and treated residents in a mean or hostile manner; the administrator confirmed these allegations had not been previously reported or investigated.
Failure to investigate allegations of abuse: A surveyor found a typed statement in an investigation file describing repeated verbal abuse and unprofessional conduct by two NAs toward residents, including name-calling, rude comments during care, and shutting off call lights. The writer of the statement was not identified, and the Administrator stated the allegations in the statement had not been previously investigated.
Failure to Complete Annual Performance Appraisal for a Nurse Aide The facility failed to complete an annual performance appraisal for one NA. During record review and staff interview, the Administrator stated the appraisal was not in the chart, and the most recent review available was from the prior year. The facility policy requires managers to meet with employees at least annually for a performance appraisal or performance-based conversation.
Incomplete and inconsistent advance directive records were found for two residents. One resident's POST form was not signed by the resident even though records showed she could sign her name, and another resident's physician orders did not match the most recent POST form after the resident lost decision-making capacity and her representative updated her end-of-life wishes.
Failure to provide pre-meal hand hygiene was identified for a resident during a dining room observation. An RN Clinical Lead later confirmed the hand wash had not been performed, despite the facility policy stating staff should assist residents with hand hygiene after toileting and before meals as needed.
Surveyors found that garbage and refuse, including gloves, food, and disposable items, were scattered around two dumpsters, with one dumpster having both lids open and the other having a broken lid. The Facility Administrator confirmed these observations.
The facility did not ensure the required QAPI team members, including the DON, were present, and failed to hold quarterly QAPI meetings for several months. This was confirmed through record review and staff interviews.
Multiple residents experienced undignified dining conditions, including being left unseated or unserved while others ate, having clothing protectors placed without consent, and waiting extended periods for meal service or feeding assistance. Staff were observed standing while feeding, and meal trays were distributed inconsistently, contrary to facility policy.
A resident developed a blister on her right heel, and although a nurse practitioner assessed the wound and new treatment orders were initiated with the POA notified, staff did not complete a required change in condition (CIC) assessment. The DON confirmed the absence of CIC documentation for this new pressure ulcer.
Multiple residents did not receive care in accordance with their individualized care plans, including failures to honor dietary restrictions, incomplete documentation of meal intake, and lack of implementation of interventions for emotional distress. Additionally, care plans for several residents did not address all medical diagnoses, and required monitoring for medication side effects and behaviors was not consistently documented, as confirmed by the DON and administrator.
Surveyors found that care plans were not updated for several residents after significant changes in their health status or care needs. For example, a resident who suffered fractures after a fall did not have this reflected in their care plan, another who required feeding assistance was still listed as needing only set-up help, and a resident with a change in code status to DNR still had a care plan indicating full code. Other issues included care plans referencing hospice services for a resident not on hospice and instructions to encourage oral fluids for a resident who was NPO. The DON confirmed these discrepancies during interviews.
Surveyors found that physician orders for medication administration, behavioral and pain monitoring, and specific treatments were not consistently followed for multiple residents. Medications were often administered late, and required documentation for treatments and monitoring was missing. Staffing levels contributed to these deficiencies, with only two nurses covering high-acuity areas, resulting in incomplete care and failure to adhere to prescribed orders.
On two consecutive days, the facility did not provide enough nursing staff on one hall, leaving a single nurse responsible for 42 residents. This resulted in multiple medications and treatments being administered late or not at all, as confirmed by staff interviews and documentation review. The DON acknowledged that physician orders for medications and treatments were not followed due to the staffing shortage.
Staff did not follow the approved daily menus, serving BBQ pork on sandwich bread instead of a roll and omitting lettuce and tomato garnish from a fish filet meal. One resident had difficulty eating the BBQ on the bread provided. The Corporate Dietary Manager confirmed the deviations were due to supply and temperature concerns.
The facility did not ensure that food was served at safe and appetizing temperatures, with cold items such as lettuce and tomatoes held above 41°F and hot items like a fish sandwich and potato wedges served below 135°F. No substitute was provided when cold vegetables were withheld due to improper temperatures.
Multiple food items, including frozen meats, bread, produce, and resident snacks, were found opened and not labeled or dated as required. Staff confirmed these deficiencies, and unsanitary conditions were observed in food preparation areas, including a dirty handwashing sink and dried food on kitchen equipment.
Surveyors identified incomplete, inaccurate, and untimely medical record documentation, including missing medication dosages in physician orders, undated POST forms, lapses in required behavioral monitoring documentation for two residents with psychiatric diagnoses, and delayed therapy documentation. Staff interviews confirmed these documentation issues.
Surveyors identified multiple failures in the infection prevention and control program, including incorrect placement of Enhanced Barrier Precautions (EBP) signage for two residents, failure by a nurse to use required PPE during a dressing and incontinence care, and lack of resident hand hygiene before meals in the dining room. These deficiencies were observed among residents with indwelling devices and wounds, and staff acknowledged the lapses during interviews.
A resident with hemiplegia and hemiparesis was unable to reach the call light due to limited range of motion, resulting in the resident being unable to request assistance without help from a surveyor. Staff confirmed the resident uses the call light when it is within reach and noted that a specialized call light was previously used but not available at the time.
Staff did not follow facility policy during meal service by leaving food on a tray for a resident and leaving another resident's tray on the table beside their meal, resulting in a failure to provide a home-like dining environment.
A resident experienced significant weight loss over a 30-day period, but the MDS assessment inaccurately recorded the weight loss status as 'no or unknown.' The DON confirmed the error in the MDS documentation.
A resident developed a pressure ulcer on the right heel that was not prevented by facility staff. The wound was identified as a blister and assessed by a nurse practitioner, who ordered treatment. The DON confirmed the development of the pressure ulcer during record review and interview.
A Maintenance Director was observed transporting four oxygen tanks without a carrier, holding two in each hand and allowing them to clank together. The Maintenance Director admitted knowing this was not the proper method but stated he was helping the oxygen delivery person. The Corporate RN confirmed that oxygen tanks should not be moved without a carrier.
A resident's MPOA provided consent for a pneumococcal vaccination, but review of the MARs showed no documentation that the vaccine was administered. The DON confirmed there was no evidence the resident received the immunization after consent was given.
Failure to Complete Required Neuro Checks After Unwitnessed Fall
Penalty
Summary
Resident #13 had an unwitnessed fall on 12/26/25. A progress note at 10:15 PM documented that staff heard the resident yelling for help, found the resident on her hands and knees beside the bed, and assessed her for injuries with no injuries observed. The note also stated the resident denied hitting her head, had stable vital signs, no pain or discomfort, no change in range of motion, and could move all extremities without difficulty. The resident was assisted back to bed with two staff members. The facility's records did not show the required neurological evaluations after the unwitnessed fall. The physician's feedback specifically recommended neuro checks per facility protocol, and the facility's policies stated that unwitnessed falls required neurological checks at set intervals for at least 72 hours. Other than the initial neurological assessment documented in the fall note, no additional neurological evaluations were found in the medical record. On 04/02/2026, the Administrator confirmed that no neurological evaluations could be located for the resident's unwitnessed fall.
Delayed Meal Assistance and Feeding
Penalty
Summary
The facility failed to provide timely meal assistance and feeding for two residents in the dining room after their trays were served. Resident #55 was on a regular/liberalized puree diet with honey-thick liquids and cranberry juice with meals, and on 03/31/26 at 12:39 PM was served a lunch tray with no drink or utensils, including the large maroon spoon needed for the meal. The meal remained sitting uncovered for 11 minutes before a staff member came over to check what drinks were needed and begin assisting with feeding. Resident #57 was on a regular/liberalized puree diet with 2% milk and an assorted beverage, and the pureed meal tray was served at 12:39 PM while the resident remained reclined by the table until Staff #45 came over at 12:53 PM to start feeding. When asked whether waiting more than 10 minutes to be fed was common, Staff #45 stated, "Absolutely not! This is not a practice we like to see."
Failure to Honor Resident Choice for Getting Out of Bed Before Lunch
Penalty
Summary
The facility failed to honor resident choices regarding getting out of bed before lunch for Resident #54. During an interview, the resident stated she had been waiting about one hour for assistance and said her aide had told her they would return with help but had not yet done so; she also stated she must be gotten up early or she does not get up in time. A Registered Nurse stated she would get the resident's aide to assist her out of bed for lunch, but observations later found the resident still in bed at 12:10 PM and still in bed eating lunch at 12:50 PM. A Clinical Lead later stated she would investigate the situation and then stated the resident would be assisted out of bed after she finished eating.
Failure to Timely Report Allegations of Potential Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse prohibition policy for reporting allegations of potential verbal abuse. The policy stated that allegations involving abuse with no serious bodily injury were to be reported immediately, but no later than 24 hours after forming the suspicion of abuse. For one resident reviewed for abuse, an allegation of potential verbal abuse that occurred during an interaction with a CNA was not reported until more than a month later, when it was discovered during the investigation of an unrelated concern. The initial report stated the resident thought she heard the CNA call her a word that sounded like "bitch," and the resident told her father, who asked the CNA if it was true; because the father asked that it not be reported, no immediate action was taken. The former DON and former Administrator reportedly decided it did not need to be reported because it was a muttered word, and the Administrator later confirmed the incident was not reported until it was discovered during the later investigation. During review of the investigation file, surveyors also found an unsigned typed statement from an unknown source that described multiple allegations of potential verbal abuse by two nurse aides. The statement alleged that one aide called residents names, ignored residents, shut off call lights without answering them, and made comments about residents in a hostile manner; it also alleged that another aide called residents nicknames and complained about doing her job. On interview, the Administrator stated she was unaware of the source of the statement and confirmed that the allegations in it had not been previously reported or investigated. The matter was then reported to the required entities, and the nurse aides involved were suspended pending investigation.
Failure to Timely Report Allegations of Potential Verbal Abuse
Penalty
Summary
The facility failed to report allegations of potential verbal abuse within the required timeframe. For one resident, an allegation that a CNA had called the resident a mumbled word that sounded like a profanity occurred during an evening interaction, but the incident was not reported until more than a month later, after it was discovered during the investigation of an unrelated concern. The facility policy stated that allegations involving abuse with no serious bodily injury were to be reported immediately, but no later than 24 hours after forming the suspicion of abuse. During review of the investigation file, surveyors also found a typed statement that described additional allegations of potential verbal abuse involving two nurse aides. The statement alleged that one aide called residents names, ignored residents, shut off call lights without answering them, and made comments about residents in a hostile manner, while another aide was also described as mean and as calling residents nicknames. The administrator stated that these allegations had not been previously reported or investigated and that they had only just been reported to the required entities when the surveyor asked about them.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse after a statement was found in the investigation file related to a reported allegation of verbal abuse toward a resident. The allegation had been reported to OHFLAC and was determined to be unsubstantiated, but the investigation file contained a typed statement from an unidentified writer that described repeated concerns about two nurse aides, including calling residents names, being mean to residents, shutting off call lights without answering them, and making comments about residents during care. During record review on 04/01/26, the surveyor noted there was no information identifying the writer of the statement. The statement described alleged verbal abuse and unprofessional conduct toward residents, including remarks such as calling a resident "pissy pants," telling a resident to start using a urinal, saying it stunk while changing a resident, and referring to residents by nicknames. At 1:27 PM, the Administrator stated the allegations of abuse contained in the statement had not been previously investigated and said the matter would be investigated. No further information was provided before the survey ended.
Failure to Complete Annual Performance Appraisal for Nurse Aide
Penalty
Summary
The facility failed to complete a yearly performance appraisal for direct care staff, specifically Nurse Aide #52. During record review and staff interview on 04/01/26, the Administrator stated that Nurse Aide #52's current performance appraisal was not in the chart. When the surveyor requested the most recent completed appraisal, the document provided was dated 09/16/24. Review of the Employee Performance Appraisal Form showed that Nurse Aide #52 was hired on 12/14/15 and that her last performance review had been completed on 09/16/24. The facility's HR616 Performance Appraisal policy states that managers will meet with regular full-time, regular part-time, and casual employees at least annually to conduct a performance appraisal or performance-based conversation, with in-service education provided based on the outcome of these reviews.
Incomplete and Inconsistent Advance Directive Records
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents reviewed in the advance directives care area. For one resident, the medical record showed a Physician's Determination of Capacity form stating the resident had capacity to make her own medical decisions, and a POST form indicating CPR and full treatment. However, the POST form was not signed by the resident; the signature line for the patient or MPOA/surrogate was marked with a small x, even though admission documents showed the resident was able to sign her name. The Administrator confirmed the POST form had not been signed by the resident. For another resident, the record showed the resident initially had capacity and completed a POST form choosing no CPR and comfort-focused treatment. After the physician later determined the resident no longer had capacity, the resident representative completed updated POST forms changing the treatment goals to selective treatments and later adding medically assisted nutrition if needed. The resident's care plan was updated to reflect no CPR and selective treatments, but the physician's orders for end-of-life treatment did not match the most recent POST form. The Senior Administrator confirmed the mismatch between the physician's orders and the resident's latest POST form.
Failure to Provide Pre-Meal Hand Hygiene
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff and surveyor observation showed that pre-meal hand hygiene was not performed for Resident #55. During a dining room observation on 03/31/26 at 12:30 PM, Resident #55 was observed without staff-provided hand cleansing before the meal. At 12:53 PM, Registered Nurse Clinical Lead staff #45 confirmed that the hand wash had not been performed. The facility’s Infection Control Policies and Procedures for Patient Hand Hygiene state that staff should assist residents with hand hygiene after toileting and before meals as needed.
Improper Disposal of Garbage and Refuse at Dumpster Area
Penalty
Summary
Surveyors observed that garbage and refuse were not properly disposed of at the facility. Specifically, two dumpsters located behind a wooden fence were found with various items such as gloves, food, cup lids, straws, plastic forks, and boxes scattered around them. Additionally, both lids on one dumpster were open and laid back, while the other dumpster had a broken lid that was completely detached. These conditions were confirmed during an interview with the Facility Administrator, who acknowledged the state of the dumpsters. The facility census at the time was 65 residents. No information was provided regarding the medical history or condition of any specific residents affected by this deficiency.
Failure to Maintain Required QAPI Membership and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance and Performance Improvement (QAPI) team were present and that quarterly meetings were held as mandated. Record review showed that the Director of Nursing (DON) position was vacant from 02/19/24 through 04/08/24, with no individual filling in for the DON during this period, resulting in the absence of a required QAPI team member. Additionally, sign-in sheets confirmed that no QAPI meetings took place in January, February, or March of 2025. These findings were verified through interviews with the Administrator and the current DON.
Failure to Provide Dignified Dining Experience During Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for residents, as evidenced by multiple observations during meal service. Residents were not seated at the same time, and meals did not arrive simultaneously for those at the same table. Several residents were left seated in the center of the dining room while others were served, and clothing protectors were placed on residents without asking for their preference. One resident attempted to feed another, requiring staff intervention, and some residents experienced significant delays in receiving their meals or assistance with feeding. For example, one resident waited over 30 minutes to be fed after their tablemates had already begun eating, and another resident's tray was placed out of reach for an extended period before being fed. Additional observations included a resident who was tearful throughout the meal, with her hands covered by a clothing protector, and who waited 11 minutes before receiving assistance with eating. Staff were observed standing while feeding residents, and some residents waited several minutes longer than their tablemates to receive their food. The facility's policy stated that meals should be served table by table, but this was not followed, and dietary staff loaded trays onto carts randomly rather than by room or table order.
Failure to Complete Change in Condition Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to complete a change in condition (CIC) assessment for a resident who developed a blister on her right heel. According to the progress note, the resident was seen by a nurse practitioner who ordered Sure Prep to be applied to the right heel twice daily, and the resident's power of attorney was notified and agreed with the order. However, upon review of the records, there was no documentation of a CIC being completed for this new pressure ulcer. The Director of Nursing confirmed during an interview that the resident had a blister on her right heel and that no CIC had been completed.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in unmet needs and lack of adherence to prescribed interventions. For one resident, staff did not follow a documented dietary restriction for pork, as evidenced by the resident being served and fed pork despite clear instructions on the lunch ticket and care plan. Additionally, meal intake documentation was incomplete for several days, and interventions for emotional distress, such as providing a huggable doll or preferred television programming, were not implemented when the resident was observed to be tearful. Another resident's care plan interventions for monitoring medication side effects, behaviors, pain assessments, and anticoagulation therapy were not carried out, as shown by missing documentation on the Medication Administration Record (MAR) for multiple shifts. Similar failures were observed for two other residents, whose care plans did not address all of their medical diagnoses, including conditions such as malnutrition, dysphagia, hypertension, hyperlipidemia, osteoporosis, anemia, muscle weakness, and muscle spasms. The Director of Nursing confirmed these omissions in the care plans. For two additional residents with complex psychiatric and neurological diagnoses, the care plans included interventions to monitor for medication side effects and specific behavioral symptoms as ordered by physicians. However, the MARs showed multiple instances where required monitoring and documentation of behaviors were not completed across several months. The facility administrator acknowledged the issues with documentation and care plan implementation during an interview.
Failure to Revise Care Plans Following Changes in Resident Status
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner for multiple residents following significant changes in their conditions or care needs. For one resident who experienced a fall resulting in fractures, the care plan was not updated to reflect the actual fall with injury, despite ongoing pain and diagnostic findings. Another resident, who required assistance with eating, was observed being fed by staff, yet the care plan continued to state only set-up assistance was needed. A third resident, previously using a walker, was observed ambulating independently with a bent gait due to Parkinson's disease, but the care plan still included supervision with a walker. The DON confirmed that these care plans had not been revised to reflect the residents' current statuses. Additional deficiencies included a resident whose code status had changed to Do Not Resuscitate (DNR) with comfort-focused treatment, but the care plan still indicated full code status. Another resident, who was NPO and receiving enteral feeding, had a care plan that incorrectly stated encouragement of oral fluid intake and no artificial nutrition desired. Lastly, a resident's care plan referenced hospice services and interventions, despite no hospice order or services being in place, and the DON confirmed no residents were receiving hospice care at the time. These findings were based on record reviews, staff interviews, and direct observations, affecting more than a limited number of residents in the facility.
Failure to Follow Physician Orders and Timely Medication Administration
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to follow physician orders for several residents. Record reviews and staff interviews revealed that medication administration, behavioral monitoring, pain assessments, and specific treatment orders were not consistently completed as prescribed. For example, several residents did not receive required monitoring for behaviors, pain, and medication side effects on numerous shifts across multiple months, as documented in their Medication Administration Records (MARs). Additionally, dietary restrictions were not adhered to, such as a resident with a physician order for no pork being observed consuming pork. Further deficiencies were noted in the timeliness of medication administration. On specific dates, numerous medications were administered late, sometimes by nearly two hours, affecting a significant number of residents. The report details instances where medications for chronic conditions, such as antihypertensives, anticoagulants, and antipsychotics, were not given within the ordered timeframes. The facility's nurse staffing schedule showed only two nurses on duty for a high-acuity unit, which contributed to the delays and incomplete treatments. Treatment orders for wound care, skin care, and enteral feeding site care were also not followed, with documentation missing for required interventions on several residents. These lapses included failure to apply prescribed creams, cleanse wounds, and monitor surgical sites as ordered. The Director of Nursing confirmed these omissions during interviews, and the documentation reviewed supported the findings of incomplete or missed care as per physician directives.
Failure to Provide Sufficient Nurse Staffing Resulting in Delayed Medications and Missed Treatments
Penalty
Summary
The facility failed to provide sufficient nursing staff on the B hall during two consecutive days, resulting in one nurse being responsible for 42 residents during the day shift. The daily staff postings and nurse schedules confirmed that only two nurses were scheduled for both the red and blue halls, with no additional nurse coverage for the blue hall, despite its higher resident census and acuity. Staff interviews corroborated that coverage was not obtained for a call-in, and the nurse assigned to the blue hall reported being responsible for all 42 residents, which impacted the ability to complete required tasks. As a result of the insufficient staffing, multiple medications were administered late to several residents, with delays ranging from over an hour to more than two hours past the scheduled administration times. The report lists numerous instances where medications such as Neurontin, Midodrine, Losartan, Duloxetine, and others were given significantly later than ordered. Additionally, enteral feedings and other time-sensitive treatments were also delayed. The daily nursing hours per patient day were above the minimum, but the higher acuity of residents and the lack of adequate nurse coverage contributed to the delays. Furthermore, the facility failed to follow physician orders for resident treatments on both days in question. Documentation was missing for a wide range of required treatments, including wound care, application of creams, cleansing of surgical sites, and monitoring for signs of infection. The DON confirmed that these treatments and medication administrations were not completed as ordered, and was unable to provide an explanation for the staffing shortfall on those days. The lack of sufficient and competent nurse staffing directly led to incomplete care and failure to meet residents' needs as required.
Failure to Follow Approved Menus for Resident Meals
Penalty
Summary
The facility failed to follow the daily menus as planned and approved, resulting in deviations from the prescribed meals for residents. On one occasion, BBQ pork was served on white sandwich bread instead of the menu-specified roll, affecting at least three residents on regular diets. One resident experienced difficulty picking up and eating the BBQ on the light bread provided. The Corporate Dietary Manager confirmed that no buns or rolls were available and attributed this to a delivery issue. On another occasion, the menu called for a breaded fish filet on a roll with lettuce and tomato garnish, but the garnish was not served due to concerns about serving temperatures.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to prepare and serve food at safe and appetizing temperatures, as required by its own policy and procedures. During a lunch meal observation, cold food items such as lettuce, shredded lettuce, and tomatoes were found to be held at temperatures above the required maximum of 41°F, with readings between 45.2°F and 52.9°F. These items were subsequently placed in the refrigerator or freezer to cool, but still did not reach appropriate temperatures before the end of the observation period and were not served; no substitute vegetable was provided. Additionally, a test tray delivered to a resident area showed that hot food items, including a fish sandwich and potato wedges, were served at temperatures below the required minimum of 135°F, with readings of 127.7°F and 113.1°F, respectively. These findings were confirmed by the Corporate Dietary Manager and observed by the state surveyor.
Improper Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items and cleanliness of food preparation equipment, as required by their own policies and professional standards. During an inspection, multiple food items were found opened and not labeled or dated, including frozen chicken breast, Imperial Beef Base, celery, lettuce, sandwich bread, and a can of Dr. Pepper. Additionally, resident snacks such as sherbet, fortified pudding, applesauce, and thickened water were found opened without date ranges or use-by dates in various pantries. These findings were confirmed by facility staff, including the Corporate Dietary Manager, the Memory Support Director, and an LPN, who acknowledged the lack of proper labeling and dating. Further observations revealed unsanitary conditions in food preparation and serving areas. The handwashing sink behind the dining room serving center contained a brown substance in the sink bowl and lacked a trash can for disposal of paper towels or garbage. Dried food was also observed on the outside of the kitchen refrigerator. These lapses in food storage, labeling, and cleanliness had the potential to affect more than a limited number of residents, as noted in the facility census.
Incomplete and Untimely Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and timely medical records for several residents, as evidenced by multiple documentation lapses. For one resident, an LPN administered Zyrtec without a specified dosage in the physician's order, and the Director of Nursing confirmed the omission, noting that the pharmacy only supplies one dosage but the order itself was incomplete. Another resident's Physician Orders for Scope of Treatment (POST) form was found to be missing a date next to the resident's signature, which was acknowledged by the Director of Nursing. Two residents with complex psychiatric and behavioral diagnoses had care plans and medication administration records that required daily monitoring and documentation of specific behaviors. However, reviews of their MARs revealed multiple instances where required behavior monitoring was not documented across several shifts in January, February, and March. The facility administrator confirmed issues with documentation and care plans during an interview. Additionally, therapy documentation for another resident was not completed in a timely manner, with several speech therapy notes and evaluations being signed or entered days after the date of service. The speech therapist acknowledged the delays, attributing them to system access issues and personal workflow, but confirmed that documentation was sometimes late. These findings collectively demonstrate a pattern of incomplete, inaccurate, or untimely medical recordkeeping affecting multiple residents.
Infection Control Program Deficiencies and Lapses in Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. For one resident with an indwelling urinary catheter and a pressure ulcer dressing, Enhanced Barrier Precautions (EBP) signage was incorrectly placed outside the room, indicating the wrong resident required EBP. Both the resident and her roommate required EBP, but the signage did not accurately reflect this, as confirmed by the Director of Nursing. Additionally, a nurse failed to follow EBP protocols during a dressing and incontinence brief change for another resident, neglecting to wear a gown as required, despite signage indicating both residents in the room were on EBP. The facility also did not provide hand hygiene for residents before meals in the main dining room, contrary to its own policy. During a meal observation, no hand hygiene was performed for any residents, and staff acknowledged that this step should have been completed. These lapses in infection control practices had the potential to affect more than a limited number of residents, given the facility's census and the nature of the observed deficiencies.
Failure to Ensure Call Light Accessibility for Resident with Limited Mobility
Penalty
Summary
A resident with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side was observed sitting upright in bed, leaning toward the left, and unable to reposition himself. The resident attempted to use the call light to request assistance but was unable to reach it due to limited range of motion. During the observation, the state surveyor had to activate the call light on the resident's behalf at the resident's request. Staff interviews confirmed that the resident typically uses the call light when it is accessible, and it was noted that the resident previously had a pancake call light, which was not in use at the time of the observation.
Failure to Provide Home-like Dining Environment
Penalty
Summary
The facility failed to provide a home-like dining environment for its residents, as observed during a lunch meal. Staff did not follow the facility's policy and procedure, which requires all items to be removed from trays, packages to be opened, and lids to be removed before serving meals to residents. Specifically, staff left a resident's food on their tray during the lunch meal, and another resident's tray was left on the table beside their meal while they ate. These actions did not align with the facility's stated procedures for meal service and affected the dining experience for more than a limited number of residents.
Inaccurate MDS Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment regarding weight loss for one resident receiving tube feeding. Record review showed that the resident experienced a significant weight loss of 5.43% over 30 days, with weights documented as 176.8 pounds and 167.2 pounds on two separate dates. However, the MDS significant change assessment completed shortly after this period incorrectly indicated 'no or unknown' for the question regarding a loss of 5% or more in the last month. The Director of Nursing (DON) later confirmed that the MDS was inaccurate in reporting the resident's significant weight loss.
Failure to Prevent Development of Pressure Ulcer on Resident's Heel
Penalty
Summary
A review of records and staff interviews revealed that the facility failed to prevent the development of an avoidable pressure ulcer on the right heel of one resident. Documentation showed that the resident developed a blister on the right heel, which was identified and assessed by a nurse practitioner, resulting in a new treatment order. The Director of Nursing confirmed the presence of the pressure ulcer. This deficiency was identified during the review of three records under the care area of pressure ulcers, with the facility census at 65 residents. The findings indicate that the pressure ulcer was not prevented, and the development of the wound was confirmed through both documentation and staff acknowledgment. No information was provided regarding the resident's prior medical history or specific risk factors for pressure ulcer development at the time of the deficiency.
Unsafe Transport of Oxygen Tanks by Maintenance Director
Penalty
Summary
During an observation, the Maintenance Director was seen carrying four oxygen tanks without using a carrier, holding two tanks in each hand as he walked around the building. The tanks were clanking together during transport. When interviewed, the Maintenance Director acknowledged awareness that this was not the correct procedure, explaining that he was attempting to assist the oxygen delivery person, who was tired. The Corporate RN confirmed that oxygen tanks should not be transported without a carrier. No residents were directly involved or affected at the time of the observation, and no specific patient medical history or condition was mentioned in relation to the deficiency.
Failure to Administer Pneumococcal Vaccine After Consent Obtained
Penalty
Summary
The facility failed to provide pneumococcal immunization according to its own policy and standards of practice for one resident. The policy required obtaining consent from the patient or representative and administering the vaccine. In this case, the resident's Medical Power of Attorney (MPOA) provided consent for the pneumococcal vaccination, as documented in the electronic health record. However, a review of the Medication Administration Records (MARs) for the relevant months showed no documentation that the vaccine was administered. The Director of Nursing (DON) confirmed that there was no evidence the resident received the vaccination after consent was obtained.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 75 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sistersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Martinsville Health & Rehab | 8.9 mi | ★★★★★ | 13 | 0 |
| Arbors At Woodsfield | 14.3 mi | ★★★★★ | 0 | 0 |
| Stellar Care Center | 15.8 mi | ★★★★★ | 52 | 1 |
| Belmont Healthcare Center | 19.8 mi | ★★★★★ | 10 | 0 |
| Pine View Center | 25.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sistersville Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.