Peterson Rehab: Bleeding Patient Left Without Assessment - WV
No nurse assessed her. No physician was called. No vital signs were taken. When the bleeding continued and the family asked that a doctor come see her, one hadn't arrived yet when the family gave up waiting and called an ambulance themselves.
The episode happened on the evening of July 12, 2025. Federal inspectors documented it during a complaint investigation completed October 8, 2025.
RN #19 was working a different wing that night when someone called her over to the resident's unit around 5:38 p.m. She found care staff already holding ice on the bridge of the resident's nose. She noted that someone had ordered ice for the resident. Then she went back to passing medications on her assigned wing.
Some time passed. She was notified the nose was still bleeding. The family wanted the physician to come consult with the resident again. Before that happened, RN #19 was told the family had lost confidence in the care being provided and had contacted EMS.
The resident was transferred to a hospital for evaluation.
The facility's medical records contained nothing to explain what had happened or what was done about it. The medication administration record showed no documentation of vital-sign reassessment, no physician notification, no new treatment orders following the bleeding episode. An order summary covering July through October 2025 showed no new provider orders entered on or after July 12. The discharge summary contained no contemporaneous nursing assessment of the acute episode.
Nobody had written anything down.
When the inspector asked the facility's administrator about it, the administrator said the resident was only there for four days and that they didn't do a change of condition. The administrator explained that staff do verbal shift change and that there was no log for physician communication. Asked about the severity of the bleeding, the administrator said, "I don't think it was a bad nosebleed."
The inspector explained that according to the complainant, the family reported active bleeding lasting approximately one hour, and that the resident was on anticoagulant medication, which increases the risk for prolonged or uncontrolled bleeding.
The administrator sighed. She said she had placed a call to the nurse on duty during the time of the event.
The staffing sheet for July 12 showed the facility was operating at 2.5 hours of nursing care per resident per day, a figure consistent with reduced licensed-nurse coverage. RN #91 told the inspector the facility had been short-handed that evening due to staff call-ins, and that pulling nurses from other wings to cover was common practice when call-offs occurred.
RN #19 was one of those pulled nurses. She was responsible for her own wing's medication pass and got called to handle an actively bleeding, anticoagulated resident on a different floor. She applied ice and left.
Inspectors tried four times over two days to reach the former resident by phone, on the afternoon of October 6 and three times on October 7. No one answered. There was no way to leave a message.
The inspection finding was cited at the level of minimal harm or potential for actual harm, the lower end of the federal violation scale. The citation covers the facility's failure to ensure a licensed nurse completed a timely assessment and intervention for a resident at high risk of uncontrolled bleeding, and its failure to notify a physician or obtain treatment orders during the episode.
What the record doesn't contain is any account of how long the bleeding actually lasted, whether the resident's blood pressure dropped, whether the anticoagulant dose was reviewed, or what the hospital found when she arrived. The facility didn't document any of it. The administrator didn't think it was a bad nosebleed.
The family had already called 911.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peterson Rehabilitation and Healthcare from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
PETERSON REHABILITATION AND HEALTHCARE in WHEELING, WV was cited for violations during a health inspection on October 8, 2025.
The episode happened on the evening of July 12, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.