Peterson Rehabilitation and Healthcare
20 Homestead Avenue, Wheeling, WV 26003 · Ohio County · 150 certified beds · avg 140 residents/day · certified since Jan 1, 1967
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · May 28, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 31, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 28, 2024 · F-0605 · triggered by a complaint
The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Why it matters: Using sedating drugs as a 'chemical restraint' can rob residents of alertness and mobility and increases risks of falls and death, especially in people with dementia.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 31, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 28, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 31, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 28, 2024 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 31, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (62)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 1, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 8, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 8, 2025 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 8, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Oct 8, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Oct 8, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 8, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Oct 8, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 28, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 28, 2024 | ▲ J · Immediate jeopardy, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. · from a complaint |
| May 28, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 28, 2024 | ▲ G · Actual harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 28, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 28, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Oct 17, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 23, 2023 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Aug 23, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 23, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 7, 2023 | F · Potential for harm, facility-wide | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 7, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 7, 2023 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Jun 7, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Feb 22, 2022 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 22, 2022 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 22, 2022 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not make sure resident assessments were done by a qualified health professional. Assessments guide all of a resident's care, so the person doing them must be properly trained. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 22, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (18 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 12 | 0 | E |
| 2023 | 22 | 0 | F |
| 2024 | 6 | 4 | J ▲ |
| 2025 | 21 | 0 | E |
| 2026 | 1 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $147,234.
| Date | Type | Amount / length |
|---|---|---|
| Feb 13, 2025 | Fine | $14,518 |
| May 28, 2024 | Fine | $127,823 |
| Oct 2, 2023 | Fine | $1,748 |
| Sep 11, 2023 | Fine | $3,145 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | West Virginia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.99 | 3.55 | 3.95 | bottom 29% in West Virginia; bottom 14% in the U.S. |
| Registered Nurse hours | 0.50 | 0.70 | 0.69 | bottom 21% in West Virginia; bottom 37% in the U.S. |
| Weekend total nurse staffing | 2.82 | 3.07 | 3.50 | bottom 40% in West Virginia; bottom 22% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.35 | 0.40 | 0.48 | top 47% in West Virginia; bottom 43% in the U.S. |
| Total nursing staff turnover (%) | 43.4 | 44.1 | 45.8 | bottom 50% in West Virginia; top 46% in the U.S. |
| RN turnover (%) | 36.4 | 42.4 | 42.9 | top 38% in West Virginia; top 40% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.12, RN 0.52, weekend 2.94. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lrans Family Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 04/09/2024 |
| Stallion WV Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/09/2024 |
| Stallion WV TBD Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 04/09/2024 |
| Bharti, Sanjay | Individual | Contracted Managing Employee | NOT APPLICABLE | 04/09/2024 |
| Borkoski, Heather | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/09/2024 |
| Gottlieb, Refoel | Individual | Corporate Officer | NOT APPLICABLE | 04/09/2024 |
| Gotts Consulting WV LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/09/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Good Shepherd Nursing Home | 0.8 mi | Wheeling, WV | ★★★☆☆ | 2/5 | |
| Continuous Care Center Wheeling Hospital | 0.8 mi | Wheeling, WV | ★★★★★ | 5/5 | |
| Rolling Hills Rehab and Care Ctr | 4.6 mi | Bridgeport, OH | ★☆☆☆☆ | 1/5 | abuseSFF |
| Country Club Retirement Ctr IV | 6.1 mi | Bellaire, OH | ★☆☆☆☆ | 1/5 | |
| Continuing Healthcare of Shadyside | 8.4 mi | Shadyside, OH | ★☆☆☆☆ | 2/5 | |
| Sienna Hills Nursing & Rehabilitation | 9.6 mi | Adena, OH | ★★★☆☆ | 3/5 | |
| Moundsville Healthcare Center | 10.6 mi | Moundsville, WV | ★★★☆☆ | 3/5 | |
| Belmont Manor | 11.6 mi | St Clairsville, OH | ★★★★☆ | 3/5 | |
| Park Health Center | 11.6 mi | St Clairsville, OH | ★★☆☆☆ | 2/5 | |
| Continuing Healthcare at Forest Hill | 11.7 mi | St Clairsville, OH | ★☆☆☆☆ | 2/5 | |
| Wellsburg Healthcare Center | 14.5 mi | Wellsburg, WV | ★★★★★ | 5/5 | |
| Cumberland Pointe Care Center | 14.6 mi | St Clairsville, OH | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 515002.