Peterson Rehabilitation And Healthcare

Based on record review of Section C of the most recent MDS record Residents #1, #19, # 40, and #64 had capacity and were cognitively intact. c)

During an interview with theAdministrator, on 2/11/24 at 12:25 PM, she verified the facility failed to post notice of the availability of the results of the most recent survey in prominent areas in the facility and make accessible to all residents.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

establish a grievance policy and make prompt efforts to resolve grievances.

resident interview, observation and staff interview the facility failed to ensure the grievance forms

was a random opportunity for discovery and was true for Resident #40.

Facility Census: 132.

Findings Include: a) Resident #40 Upon entrance to the facility on [DATE] an observation found the grievance forms were up too high for residents who could not stand up. If a resident is confined to the wheelchair they are unable to obtain a grievance form without asking staff or others to hand them the form.

On 02/11/25 at 11:45 am Resident #40 indicated they were not able to reach the grievance forms nor the box provided to place the grievance forms without standing up from the wheelchair.

On 02/11/25 at 11:50 AM, during and interview with Social Worker #147 it was confirmed the resident was unable to reach the forms or the box.

She stated, residents could come to my office and ask for a form but resident's would not be able to file it anonymously if they could not stand up.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

Findings included: a) Resident #13 A record review completed on 02/12/25 at 9:14 PM revealed Resident #13's most recent PASSAR dated 04/05/24 included the following: -Section III. MI/MR Assessment, Question 30.

Current Diagnosis (check all that apply), was marked a.

None.

Question 47.

The individual has a primary diagnosis of: was marked dementia b) Review of resident's diagnoses list revealed residents primary diagnosis was unspecified psychosis not due to substance or known physiological condition on 02/20/24.

She was also given a diagnosis of hallucinations, unspecified on 02/20/24. c)

During an interview with Social Worker #147 on 02/12/25 at 2:24 PM, they acknowledged Resident # 13 did not have a PASSAR that reflected her current diagnosis of psychosis or hallucinations.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

Survey Process.

Resident identifiers: #125 and #67.

Facility census: 132.

Findings included: a) Resident #125 A medical record review, completed on 02/11/25 at 9:07 AM, revealed Resident #125 had been admitted to the facility on [DATE] with the following diagnoses: -Bipolar -Major Depression Disorder A PAS, completed on 01/28/25, marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply).

Additionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI was also marked NONE.

During an interview on 02/12/25 at 2:24 PM, the Director of Social Services reported that resident's Bipolar and Major Depression Disorder diagnoses had not been captured on the 01/28/25 PAS and a new one had not been completed. b) A review of Resident #67's medical record on 02/12/25 at 9:20 PM revealed the resident PASSAR dated 12/06/22 included the following: Section III. MI/MR Assessment, Question 30.

Current Diagnosis (check all that apply), was marked m.

Major Depression.

A review of Resident #67's diagnosis list on 02/12/25 at 9:22 PM revealed Resident #67 diagnosis on admission his date of 12/02/21 included bipolar disorder.

During an interview on 02/12/25 at 2:26 pm with Social Worker (SW) #147, she acknowledged that resident had a diagnosis of bipolar upon admission and there had been no new PASSAR completed to reflect this upon after admission to this facility.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

Findings included: a) Resident #27 On 02/12/25 a review of Resident #27's) medical records revealed a diagnosis of schizoaffective disorder on admission.

A review of the current care plan showed there was no care plan addressing schizoaffective disorder.

During an interview on 02/13/25 at 1:55 PM the Director of Nursing (DON) confirmed there was no schizoaffective disorder care plan for Resident #27.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

reviewed, and revised by a team of health professionals.

appropriate diagnosis for Resident #128's urinary catheter, antipsychotic medication and behavior

for three (3) of 32 sampled residents reviewed during the survey process.

Resident Identifier: #128, #90 and #86.

Facility Census: 132.

Findings Include: a) Resident #128 On 02/11/25 at 3:21 PM, a record review was completed for Resident #128.

The review found the care plan listed the resident's need for a urinary catheter was personal preference.

However, further review of the record found urinary retention as the correct diagnosis for the urinary catheter.

On 02/12/25 at 2:22 PM, the Director of Nursing (DON) confirmed the diagnosis for the urinary catheter on the care plan was incorrect.

The DON stated, I don't know why that was on the care plan .the reason was urinary retention. b) Resident #90 On 02/12/25 at 8:30 PM, a record review was completed for Resident #90.

The review of the care plan found focus areas of antipsychotic medication and behaviors listed.

However, on further review the resident was not prescribed an antipsychotic medication nor was he having any type of behaviors.

An interview was held with the DON on 02/13/25 at 10:31 AM.

The DON stated, he is not taking antipsychotic medication or having behaviors anymore .the care plan should have been updated. c) Resident #86 - Peg tube On 02/12/25 at 11:30 AM, a review of Resident #86's records revealed theresident's care plan addresses peg tube care.

Page 7 of the care plan, under the focus category At risk for alteration in skin integrity related to impaired mobility.

Interventions for that focus/goal included treatment to peg tube site per orders. Resident #86's current order and diagnosis list did not reveal the resident currently had a peg tube.

Per review of discontinued orders it was revealed resident's orders for peg tube was discontinued on 05/18/23.

On 02/12/25 at approximately 2:47 PM during an interview with DON and Administrator they both acknowledged the resident did not currently have a peg tube.

When asked if peg tube care was listed in her care plan, the Administrator reviewed care plan and acknowledged the care plan stated treatment to peg tube site per orders.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

--09/21/24 Pain score

--09/21/24 Antidepressant side effect tracking --09/21/24 Antipsychotics side effect tracking --09/21/24 Socially inappropriate or disruptive behavior --09/21/24 Wandering/elopement behavior --09/21/24 2.0 Supplement On 02/13/24 at approximately 2:30 PM, the DON confirmed the missing documentation on 09/21/24.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

Wing 2 - 16 of 18

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.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

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] 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] 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] 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] 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.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

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.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

serve food in accordance with professional standards.

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.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

During an interview on [DATE] 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] 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] 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] 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.

515002 02/13/2025

Peterson Rehabilitation and Healthcare 20 Homestead Avenue Wheeling, WV 26003

Based on observation, and staff interview, the facility failed to maintain an appropriate infection

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.

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.

515002

Form Approved OMB

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