Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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What surveyors actually found near you
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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 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 | — | 1 | 0 |
| Arbors At Woodsfield | 14.3 mi | — | 0 | 0 |
| Stellar Care Center | 15.8 mi | — | 43 | 1 |
| Belmont Healthcare Center | 19.8 mi | — | 4 | 0 |
| Pine View Center | 25.2 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.