Guardian Elder Care At Wheeling

F-F689 the following concern regarding water temperatures:

- Water temperature of 124 degrees Fahrenheit will cause a 3rd degree burn in 3 minutes.

- Water temperature of 120 degrees Fahrenheit will cause a 3rd degree burn in 5 minutes.

- Burns can occur even at water temperatures below those identified, depending on an individual's condition and the length of exposure.

-Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black.

b) On 02/09/25 at 1:13 PM, the water temperature of the sink in room [ROOM NUMBER] was tested by surveyors feeling very hot. Surveyors requested the water temperatures be tested via thermometer. Maintenance Supervisor #73 tested the water temperature was tested by inserting the stem of the thermometer into the stream of running water, so that the sensor was fully immersed. A water temperature of 126 degrees Fahrenheit was reached.

c) Water Temperatures in Shower Rooms

Date and Time

- Shower room wing 1 had a water temperature of 126 degrees Fahrenheit.

- Shower room wing 2 had a water temperature of 121.6 degrees Fahrenheit.

- Shower room wing 7 had a water temperature of 122.5 degrees Fahrenheit.

d) During an interview with Maintenance Supervisor #73, on 02/09/25 at 1:21 PM, He stated the water temperatures were tested on ce every week. He said the temperatures averaged around 113 degrees Fahrenheit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 515002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 e) Number of Residents that go to the shower rooms by wings:

Level of Harm - Minimal harm or Wing 1 - 20 of 20 potential for actual harm Wing 2 - 16 of 18 Residents Affected - Some Wing 7 - 20 of 21

f) During an interview, on 02/09/25 at 3:10 PM, the Nursing Home Administrator confirmed that the maintenance director would ensure all water temperatures would be 110 degrees Fahrenheit or below.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 515002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45173 Residents Affected - Few Based on observation, record review and staff interview, the facility failed to date insulin upon opening for Resident #3 and dispose of expired insulin for Resident #18. These were random opportunities for discovery. Resident Identifiers: #3 and #18. Facility Census: 132.

Findings Include:

a) Medication Cart 800 wing

On [DATE REDACTED] at 1:00 PM, a tour of the medication cart on the 800 wing was completed. The tour found Resident #3's insulin glargine not dated upon opening and Resident #18's Novolog insulin expired on [DATE REDACTED]

after 28 days from opening. Registered Nurse (RN) #119 confirmed the insulin glargine was not dated upon opening and the Novolog insulin was expired.

b) Facility policy

On [DATE REDACTED] at 2:30 PM, a review of the facility policy was completed. The facility policy, entitled Medication Labeling and Storage, under the section entitled Medication Labeling section 5 states, Multi-dose vials that have been opened or accessed are dated and discarded within 28 days .

On [DATE REDACTED] at 3:30 PM, the Director of Nursing (DON) was notified and confirmed the insulin should be dated upon opening and discarded after 28 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 515002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 43340 potential for actual harm Based on observation, staff interview, and food tray temperatures the facility failed to serve food to residents Residents Affected - Some that was at an appetizing temperature. This failed practice was true for one (1) of two (2) wings tested for food tray temperatures throughout the Long-Term Care Survey Process. Facility census: 132.

Findings included:

a) Wing 1 Lunch Time Meal Observation

During an observation on 02/12/25 at 12:53 PM, it was noted that a food truck was brought out of the kitchen with all resident lunch trays for residents on the 100 Wing. Staff members immediately began to deliver the trays to the residents' rooms.

At 1:03 PM, when four (4) trays were left on the food truck, the Surveyor requested that CNA #135 select one tray that would be served last. CNA #135 selected Resident #45's tray and stated that she was actually getting ready to go out to eat with her family member and would not need her lunch tray. Registered Nurse (RN) #62 was asked to call the kitchen and ask them to come to the wing in order to temp the last tray on the food cart.

On 02/12/25 at 1:07 PM, Dietary Aide #300 tested the temperature of Resident #45's lunch tray with the following results:

-Hamburger: 116.5 degrees Fahrenheit (F)

-Carrots: 112.2 degrees F

-Ham: 104.0 degrees F

Dietary Aide #300 agreed the food temperatures obtained were not considered to be the appropriate desired temperature for the point of delivery to the residents. Dietary Aide #300 stated temperatures should be 120 degrees F or above for all hot food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 515002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 42120

Residents Affected - Some Based on observation, staff interview, and equipment manual review the facility failed to keep the ice machine in safe operating condition. This had the potential to affect all Residents who get their nutrition from

the kitchen, and residents who attend food related activities. Facility Census: 132.

Findings Included:

a) Ice Machines

On 02/13/25 at 12:40 PM a tour with the Maintenance Director found the ice machines located in the Kitchen area had a drainpipe running on the floor to a drain. Nutrition rooms on units one (1) and three (3) had no required air gap on the ice machine drains. The drainpipes were touching the drains.

Continued tour found unit one (1), five (5) and six (6) had no required filter on the ice machines.

On 02/13/25 throughout the tour, the Maintenance Director confirmed the drainpipes should not be touching

the floor or drain and all the ice machines should have a filter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 515002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42120

Residents Affected - Some 43340

Based on record review and staff interview, the facility failed to provide an accurate and complete medical

record for seven (7) of 32 residents. Resident identifiers: #3, #17, #280, #128, #123, #71 and #75. Facility Census: 132.

Findings Include:

a) Resident #3

On [DATE REDACTED] at 9:18 AM, a record review was completed for Resident #3. The review found the [NAME] Virginia (WV) Physicians Orders for Scope of Treatment (POST) was incomplete. The resident's signature under section E was not dated.

On [DATE REDACTED] at 2:21 PM, the Director of Nursing was notified and confirmed the resident's signature was not dated.

b) Resident #17

On [DATE REDACTED] at 9:30 AM, a record review was completed for Resident #17. The review found the WV POST form under section B had both selective treatments and comfort-focused treatments selected. The directions under section B specify pick one (1).

On [DATE REDACTED] at 2:21 PM, the DON was notified and confirmed both choices were selected and only one (1) should have been selected.

c) Resident #280

On [DATE REDACTED] at 10:30 AM, a record review was completed for Resident #280. The review found a verbal/telephone consent was obtained form the Medical Power of Attorney (MPOA) on [DATE REDACTED]. The guidance states to receive the MPOA's signature in a reasonable amount of time.

On [DATE REDACTED] at 2:21 PM, the DON was notified and confirmed the MPOA's signature should have been obtained.

d) Resident #128

On [DATE REDACTED] at 1:00 PM, a record review was completed for Resident #128. The review found the transfer form was completed on [DATE REDACTED] at 8:00 AM but was dated for [DATE REDACTED] at 12:30 PM.

On [DATE REDACTED] at 2:21 PM, the DON was notified and confirmed the date on the transfer form was incorrect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 515002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 e) Resident #71

Level of Harm - Minimal harm or A record review, completed on [DATE REDACTED] at 10:50 AM, revealed a POST form with the following details: potential for actual harm -CPR Residents Affected - Some -Full Treatment

-No Artificial Means of Nutrition

The POST form was signed by Resident #71 but was not dated.

During an interview on [DATE REDACTED] at 02:19 PM, the DON confirmed the POST had not be dated by resident and could not be considered legally valid.

f) Resident #123

A record review, completed on [DATE REDACTED] at 11:00 AM, revealed a POST form with the following details:

-CPR

-Full Treatment

-Provide Feeding through New or Existing Surgically-Placed Tubes

The POST form was signed by Resident #123 but was not dated.

During an interview on [DATE REDACTED] at 2:18 PM, the DON confirmed the PAS had not be dated by resident and could not be considered legally valid.

g) Resident #75

A record review of dialysis care revealed Resident #75's Physician orders for no blood draws / injections / blood pressures from right vascath arm.

A medical record review found documentation of blood pressures being obtained in the right arm.

During an interview on [DATE REDACTED] at about 9:10 AM Resident #75 stated, he would not allow anyone to take blood pressures from his right arm. He stated, he protects his right arm.

45173

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 515002 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 515002 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 45173 potential for actual harm Based on observation, and staff interview, the facility failed to maintain an appropriate infection control Residents Affected - Few program for foley catheter care. This was a random opportunity for discovery. Resident Identifier: 85. Facility Census: 132.

Findings Include:

a) Resident #85

On 02/10/25 at 12:46 PM, an observation of Resident #85's urinary catheter drainage bag touched the floor.

On 02/10/25 at 12:48 PM, Nurse Aide (NA) #163 confirmed the drainage bag was touching the floor. NA #163 stated, let me raise the bed .it shouldn't be touching the floor.

On 02/10/25 at approximately 2:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the urinary catheter drainage bag should not be touching the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 515002