Sistersville Center

In the surveyor’s words

From the most serious findings on record at Sistersville Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 14, 2024

  Based on policy review, staff interview, and record review, the facility failed to protect the residents right to be free from abuse that resulted in mental anguish for Resident #57, #56, #61, and #62. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. The facilities lack of action to investigate the sexual abuse allegations placed Residents #57, #56, #61, and #62 at continued risk of sexual abuse for over six (6) months prior to Surveyor intervention. Resident identifiers: #64, #57, #56, #61, #62, #42, #43, #44, #45, #48, #49, #50, #51, #52, #58, #66. Facility census: 64. […]

• Immediate jeopardy, patternF607Feb 14, 2024

  Based on staff interview and record review, the facility failed to implement their written Abuse Prohibition policy as it related to identifying investigating and reporting allegations of sexual abuse. The facility also failed to follow procedures to investigate any such allegations and prevent future sexual abuse from happening. The facilities lack of action to identify, investigate, and report the sexual abuse allegations placed sixteen (16) female residents residing on the dementia unit at continued risk of sexual abuse for over six (6) months prior to surveyor intervention. Review of facility records found that there were 16 other female residents on the locked memory care unit where Resident #64 resided and were potential victims of his behavior. […]

• Immediate jeopardy, patternF609Feb 14, 2024

  Based on policy review, record review and staff interview, the facility failed to ensure that alleged violations involving resident sexual abuse were reported, not later than 2 hours of the events / allegations being brought to the facility's attention, to appropriate state agencies as required. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. All sixteen (16) female residents on the dementia unit had the potential to be affected. The facilities lack of action to investigate and report the sexual abuse allegations placed the residents on the dementia unit at risk for serious injury or death. The abuse continued over six (6) months prior to surveyor intervention. […]

• Immediate jeopardy, patternF610Feb 14, 2024

  Based on record review and staff interview, the facility failed to have evidence of thorough investigations and prevention of further abuse while investigations were in progress. The facility was aware of sexual abuse by a male resident toward female residents. They did not conduct investigations when the abuse occurred. They did work to protect female residents from further sexual abuse after multiple occurrences of sexual abuse were observed. For the one (1) unusual occurrence that was reported there was no five (5) day follow up that contained an appropriate corrective actions. Resident #64 was touching female residents in the breast and vaginal area. The staff felt it was not a big deal if the female residents were not in distress. […]

• Actual harm, patternF835Feb 14, 2024

  Based on staff interview and record review, the facility administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration including the facility administrator and director of nursing (DON) was aware of resident to resident sexual abuse going on in the facility and failed to take appropriate action(s) to protect vulnerable residents. This was a random opportunity for discovery throughout the complaint survey process. The lack of action on the part of the administration created a problem for all seventeen (17) female residents living on the dementia unit. […]