Peterson Rehabilitation And Healthcare

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on interview, and record review, the facility failed to document the resident's grievance, and failed to make prompt efforts to resolve those grievances. Resident Identifiers: Resident #76. Facility Census: 137.

Findings Include a) Resident #76During an interview on 10/07/25, at approximately 1:15 PM, the resident indicated that she had requested a room change due to difficulties sleeping at night. When asked about the reasons for her sleeplessness, Resident #76 mentioned that her roommate often makes a lot of noise

during the night.When asked if she had informed the facility about her issues, the resident replied that she had notified both the nurse and the Director of Nursing (DON) about her complaint and had requested a room change in late August. While she could not recall the name of the nurse she had spoken to, she was confident that she had communicated with the DON. She mentioned that she was still waiting for a transfer to another room and that the DON had informed her that the facility was working on moving her as soon as

a bed became available.A request for the Complaint and Grievance logs, on 10/07/25 at 10:35 AM revealed that the facility maintains documents titled Concern/Grievance logs . A review of the logs for the period 08/01/25 through 09/30/25 revealed no concerns or grievances noted for Resident #76.During an interview with the DON on 10/08/25 at approximately 9:55 AM, she stated that she was unaware of Resident #76's request. The DON confirmed that the facility was experiencing some difficulties with documentation and stated that they were actively working to train staff to ensure accurate documentation.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

-During an interview on 10/08/25 with LPN #36, she stated she went to check on Resident #46 on 08/06/25 due to Resident #46's family member's phone call reporting Resident complaining of pain in his penis.

On 10/08/25 at 11:40 AM, an interview was conducted with the DON. She acknowledged the complaints made on dates 08/06/25, 08/08/25 and 07/26/25 had not been logged on the concern/grievance logs, nor reported to the appropriate agencies.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

AM, POA stated that she visits resident about once every two months. She also stated that resident likes men and makes her own decisions. A review of Resident #76's Care Plan on 10/07/25 at 9:25 AM revealed

the following:FOCUSSexual behavior-seeking physical affection from male residents; related need for attentionDate Initiated: 01/25/2023Created by: (Unit Manager)Revision on: 01/25/2023Revision by: (Unit Manager)GOALWill only engage in sexual activity with consenting partnersDate Initiated: 01/25/2023Created by: (Unit Manager)Target Date: 01/25/2026INTERVENTIONSAvoid conversations/television/radio that could encourage or initiate inappropriate behaviorDate Initiated: 01/25/2023Created by: (Unit Manager) Provide privacy/remove to a private areaDate Initiated: 01/25/2023Created by: (Unit Manager)Supervise in social gathering/recreation programsDate Initiated: 04/05/2024Created by: [NAME] (Social Service Coordinator) During an interview with Resident #76 on 10/06/25 at approximately 1:24 PM, resident was observed sitting in the common area. Resident was pleasant but slurred her words while speaking. When asked about Resident #161, resident stated oh yeah! I When she was asked if Resident #161 had touched her anywhere, she smiled and said I liked him! Resident #76 did not say anythinh more. f) Resident #119 Record review on 10/06/25 at approximately 2:10 PM revealed the following note dated 11/27/24by RN #94 which stated:This patient (Resident #161) along with (Resident #53) sat outside the doorway of 704. Both patients yelling insults and curses into the room at 704-1 (Resident #119) This nurse overheard Waaaa, stick your finger up my A$$. Asked the patients to stop, unacceptable and no one wanted to hear such language. This patient threatened this nurse, Do you want to fight? Both patients refused to leave the spot outside the room, neither would move to a common area. Reported to charge nurse and social services. Will continue to monitor.Further record review revealed another note dated 12/11/24 at 4:49 PM by RN #94 which stated:Resident #161 exchanging inappropriate insults with roommate (Resident #119). During an interview wit Resident #119 on 10/06/25 at approximately 2:55 PM, when asked about the argument with Resident #161, he stated he is no longer here, and that he was an ass. A review of the Concern/grievance Log revealed that the incident was logged, but the facility did not recognize this as an instance of verbal abuse between residents and failed to report it to OHFLAC. In addition the facility failed to investigate and failed to take appropriate action to ensure that

the abuse would not continue.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

through the next review.Date Initiated: 11/29/2024Created by: (MDS Coordinator)Revision on: 06/09/2025Revision by: (MDS Coordinator)Target Date: 08/04/2025Cancelled Date: 06/09/2025INTERVENTIONS/TASKS:Administer medications per physician order. Monitor for effectiveness and side-effects.Date Initiated: 11/29/2024Created by: (MDS Coordinator)Revision on: 06/09/2025Revision by: (MDS Coordinator) Cancelled Date: 06/09/2025Approach resident in a calm manner to avoid frustration and behavior escalation; If resident becomes agitated and shows signs of escalation, re-approach later.Date Initiated: 11/29/2024Created by: (MDS Coordinator)Revision on: 06/09/2025Revision by: (MDS Coordinator) Cancelled Date: 06/09/2025 A note on 05/15/25 at 5:30 PM by RN #73 stated:Resident was observed entering room [ROOM NUMBER]. Bed 1 (Resident #5) was asleep and bed 2 (Resident #84) told him to leave. On 05/15/25 at 1:37 PM SW #38 noted:QCC 5/15/25: In attendance were social services, nursing, and activities. (Resident #161) was in attendance as well. Code status discussed and may change.

Funeral home reviewed. Diet discussed with [Resident]. Weight was discussed, as [Resident] has had a gain. Weight gain explained by nursing. Care plan reviewed and discussed. [Resident] stated he has no concerns or questions. During an interview with SW 38 on 10/07/25 at approximately 10:32 AM, he stated that he was currently responsible for submitting reports to OHFLAC and APS when necessary. He also stated that Resident #161 had been followed by SW 304, who was no longer at the facility, as she had retired about one month ago. SW #38 also confirmed that he was aware of complaints Resident #161 going into female resident's rooms and being inappropriate with them. He stated that SW #304, who had been the Director of Social Services at the time, had dealt with the complaints, and he assumed that she would have submitted a report to OHFLAC and APS if she had deemed it necessary. Upon being asked what he would have done regarding the complaints about Resident #161, SW #38 stated that he would have consulted with the Administrator and deferred to her judgment on filing a report. During an interview with the Administrator and Director of Nursing (DON) on 10/07/25 at approximately 1:30 PM, they confirmed that the resident's Care Plan had not been updated to reflect implementations to prevent further abuse of other residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documented during or after the bleeding episode. The MAR contained no documentation of vital-sign reassessment, physician notification, or new treatment orders following the event.The Order Summary (07/01/2025-10/31/2025) reflected no new provider orders entered on or after 07/12/2025, and the Discharge Summary contained no contemporaneous nursing assessment or documentation of the acute episode.At 16:01 hours, the facility Administrator stated to the surveyor that the resident was only here for four days - we didn't do a change of condition. The Administrator further explained that staff do verbal shift change and that there was no log for physician communication. When asked about the duration and severity of the bleeding, the Administrator stated, I don't think it was a bad nosebleed.The surveyor explained that according to the complainant, the resident's family reported active bleeding lasting approximately one hour and that the resident was receiving anticoagulant medication, which increases the risk for prolonged or uncontrolled bleeding. The Administrator did not provide documentation of any nursing assessment, physician notification, or change-of-condition report related to the incident. The administrator sighed and stated that she placed a call in to the nurse on duty on the evening of 07/12/2025 during the time of the event. During an interview conducted on 10/07/2025, RN #19 stated that she was assigned to a different wing than the resident on the evening of 07/12/2025. She stated that at approximately 17:38 hours,

she was called to the resident's unit and informed that the resident was experiencing a nosebleed. RN #19 stated, someone ordered ice for the resident, and that care staff were holding ice on the bridge of the resident's nose. She stated that she then returned to passing medications on her assigned wing. Some time later, she was notified that the resident's nose was still bleeding and that the family wanted the physician to consult with the resident again. Shortly afterward, prior to the physician seeing the resident, RN #19 was informed that the family was not satisfied with the care being provided and had contacted EMS to transfer the resident to the hospital for evaluation.This surveyor asked RN #91 if the facility had been short-staffed on the evening of 07/12/2025. RN #91 stated that the facility was short-handed due to staff call-ins, and that it was common practice to pull nurses from other wings for coverage when call-offs occurred. The facility's staffing sheet for that date reflected an HPPD of 2.5, consistent with reduced licensed-nurse coverage.Attempts to reach the former resident via phone were unsuccessfully attempted

on 10/6/2025 at 4:30 PM, 10/7/2025 at 10:00 AM, at 1:00 PM, and 3:30 PM. There was no means to leave

a message. These findings demonstrate that the facility failed to assess, notify, and obtain treatment orders for an anticoagulated resident experiencing active bleeding.Conclusion:The facility failed to ensure that a licensed nurse completed a timely assessment and intervention in response to an acute change in condition for a resident identified as high risk for bleeding due to anticoagulant therapy. The absence of a documented change-in-condition assessment, vital signs, and provider notification during a reported episode of prolonged bleeding demonstrates the facility's failure to provide the necessary care and services to maintain the resident's highest practicable physical well-being, in noncompliance with 42 CFR S483.25 (Quality of Care - F-F0684).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

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 0697

Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, and Interviews, the facility failed to ensure that PRN(as needed) pain management was provided timely for a resident who required such services, consistent with Physician Orders, and the comprehensive person-centered care plan. Resident Identifier: # 46 Facility Census:137 Findings included: a) Resident #46 and family Interviews: -During an interview on 10/07/25 at 2:10 PM, Resident #46 indicated at times he has had to wait a long period of time for staff to get his PRN Pain Medication to him. -During a phone interview with Resident #46's granddaughter, on 10/07/25 at 2:30 PM, she reported that during a visit with her grandfather on July 26, 2025 her grandfather told her he was hurting. She stated she asked staff for pain medication for him at approximately 2:30PM. After waiting over an hour, she reported to her mother and stayed on the phone with her for another couple of hours before the nurse gave her grandfather his pain medication. -During an interview with Resident #46's daughter on 10/07/25 at 250PM, She reported her father was often in pain but didn't feel the facility was giving him his pain medications when he needed them. She stated on 8/26/25 her daughter called her to report that Resident # 46 was in pain and requested pain meds for him. She stated it took at least another hour before the pain meds were given. b)

Record Reviews:-During a record review on 10/07/25 at 1:20Pm, Physician ordered Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 1 hours as needed for SOB/pain Dated 07/17/25. Monitor: Pain Score every shift Other Active: 7/18/2025 19:00 - On 10/07/25 at 1:45PM, a record review of the Treatment Administration Request (TAR) document found the Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML was recorded administered at 18:19 PM on 08/26/25. -A

record review, completed on 10/07/21at 3:00 PM, revealed Resident # 46 had the following diagnoses muscle spasms, FX 1st lumbar Vertebra, compression fracture of T11/T12, and Diabetes, muscles spasms, right hip pain. -A record review of resident #46's care plan, on 10/07/25 at 3:15PM indicated Resident # 46 has a terminal prognosis with hospice care r/t end-of-life dx Pain control the resident was at risk for pain related to end of life dx. Resident has potential for pain r/t FX 1st lumbar Vertebra, compression fracture of T11/T12, and Diabetes, muscles spasms, right hip pain. Encourage the resident to request pain medication

before the pain becomes too intense or prior to activities that the resident knows there is a potential for increased pain c) Staff Interview:During an interview with the DON on 10/08/25 at 9:20 AM, she acknowledged that resident # 46 PRN pain medication was not administered timely upon resident's request 0n 08/26/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

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 potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and observation the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident room [ROOM NUMBER]. Facility Census: 137.Findings Include a) room [ROOM NUMBER]During an interview with Resident #27 in room [ROOM NUMBER], on 10/07/25 at approximately 10:20 AM, the bathroom door was open and a ‘pool noodle' was observed taped with orange tape, to the entire length of the water pipe leading to the commode. The flush handle too was covered with foam and tape. When asked about it, Resident #27 stated, It was there when I came to this room! During an

interview with the Director of Nursing (DON), on 10/07/25 at approximately 11:00 AM, she stated that it had been installed when another resident occupied the room. DON confirmed that it was an infection control issue because it could not be properly sanitized. She stated, I'll get it removed immediately!

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet