St Peters Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at St Peters Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF600May 29, 2026

  Based on record reviews and interviews conducted during a survey, the facility failed to ensure residents were free from neglect and abuse for three (3) (Resident #s 2, 15, and 18) of 22 residents reviewed. Specifically, a.) Resident #'s 2 and 18 care plans were not followed resulting in injury; and b.) Resident #15 was prevented from leaving their room by a staff member.Findings include:The Policy and Procedure titled Abuse Prevention and Investigation Policy, dated 3/25/2025, documented abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical pain, harm, or mental anguish, deprivation of goods or service and neglect was defined as the failure to provide timely, consistent, safe, adequate and appropriate services, treatment… […]

• No harm, potential for more than minimal, patternF561Jan 13, 2023

  Based on record review and interviews during an abbreviated survey (Case #NY00307971), the facility did not ensure that it promoted and facilitated the resident's right to self-determination through support of the resident's choice for 2 (Resident #s 1 and 2) of 3 residents reviewed. Specially, Resident #1 chose not to have a shower on 1/3/2023, their scheduled shower day. Resident #1 told the Certified Nurse Aide (CNA) #1 they did not want their shower, but CNA #1 continued to give them one and the resident became agitated. Resident #2 chose not to get undressed and ready for bed on 1/5/2023 at 5:00 PM, when CNA #1 told them they needed to. Resident #2 told CNA #1 no several times and CNA #1 then pulled the resident's shirt off over their head, and the resident became upset. […]

• No harm, potential for more than minimal, isolatedF686May 29, 2026

  Based on record review and interviews conducted during a survey, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, Resident #1 did not receive ordered treatments of Santyl ointment (a prescription topical ointment used to clean and remove dead tissue form severe burns and chronic skin ulcers), and dry dressing to left foot on the dates on 12/04/2026 - 12/09/2026.Findings include:Resident #1 was admitted to the facility with diagnoses of paroxysmal atrial fibrillation (an intermittent condition where the upper chambers of the heart beat chaotically and out of sync,) history of other venous… […]

• No harm, potential for more than minimal, isolatedF600Nov 22, 2022

  Based on record review and interviews during an abbreviated survey (Case #NY00298281), the facility did not ensure the resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #1, who was cognitively intact and recovering from a stroke, was free from abuse on the night of 6/28/2022 when Resident #1's roommate (Resident #2), who was also cognitively intact, placed their hand under Resident #1's brief, and tried to place Resident #1's hand on Resident #2's genital area stating they were having trouble ejaculating and wanted Resident #1's help. Resident #1 reported that Resident #2 made two attempts to do that. […]

• No harm, potential for more than minimal, isolatedF609Nov 22, 2022

  Based on record review and interviews during an abbreviated survey (Case # NY00298281), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the State Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure that an allegation of sexual abuse reported by Resident #1 on 6/29/2022, was reported within 2 hours after the allegation was made. The allegation was made at 7:30 AM and was reported to the Administrator at approximately 9:00 AM but was not reported to the New York State Department of Health (NYSDOH) until 3:14 PM on 6/29/2022, approximately 8 hours after the allegation was made. […]