St Peters Rehab and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 12, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure two of 28 sampled residents (Resident (R)16 and R20) were free from abuse and neglect. On 4/7/24, Certified Nurse Aide (CNA) 7 refused to assist R16 out of bed, resulting in the resident laying in bed until the next shift arrived. On 4/8/24, R16 used her call light on the night shift to request help for repositioning. R16 continued to use her call light for assistance because no one came. R16 reported two agency staff members came into her room and said she was calling too much. […]

• Immediate jeopardy, isolatedF609Apr 12, 2024

  Based on interview, record review, and facility policy review, the facility failed to ensure allegations of neglect were reported to supervisors and/or the facility's Abuse Coordinator for two of 28 sampled residents (Resident (R)16 and R20). R16 reported allegations of neglect involving Certified Nurse Aide (CNA) 7 to Licensed Practical Nurse (LPN) 1. LPN1 did not report the allegations to the on-call nursing supervisor, Director of Nursing (DON), or Administrator, who was the facility's Abuse Coordinator. R20 reported allegations of neglect to (Nurse Aide) NA1. NA1 did not report the allegations to her supervisor or the facility's Abuse Coordinator. The facility census was 82. The administrator was notified on 04/09/24 at 7:47 PM of the Immediate Jeopardy, which began on 04/07/24. […]

• Actual harm, isolatedF689Jun 11, 2026

  Based on interview and record review, the facility failed to ensure staff utilized a gait belt and locked the wheelchair brakes prior to transferring one resident (Resident #4), in a review of 23 sampled residents. Staff did not put a gait belt on the resident when assisting the resident to from the toilet to the wheelchair. Staff did not lock the wheelchair brakes, the wheelchair moved as the resident went to sit in the wheelchair, and the resident fell to the floor. The resident fractured his/her proximal left humerus (the upper end of the upper arm bone, commonly known as a broken shoulder). The facility census was 83. On 06/11/26, the Administrator was notified of the past non-compliance which occurred on 02/23/26. […]

• Actual harm, isolatedF600Sep 4, 2025

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) in a review of 11 sampled residents, remained free from physical abuse when on Certified Nurse Aide (CNA) B aggressively moved the resident in bed, causing the resident to yell out for help, and report CNA B was too rough and hurt him/her. The resident was tearful, upset and said he/she did not want CNA B to come back after the incident. The resident sustained bruising to the right arm as identified on the facility skin assessment dated [DATE]. During an interview on 9/4/25, the resident said he/she was scared of CNA B. The facility census was 78.On 9/10/25 at 2:54 P.M. the administrator was notified of the past noncompliance which occurred on 8/25/25. […]

• Actual harm, isolatedF689Nov 27, 2024

  Based on observation, interview, and record review the facility failed to provide oversight and prevent injury for one resident (Resident #2), in a review of 18 sampled residents, when staff left the resident unattended in the shower room, resulting in the resident falling and sustaining a fracture. The facility census was 87. On 11/27/24 at 4:15 P.M., the administrator was notified of the past noncompliance which occurred on 10/12/24. On 10/12/24, the administrator became aware of the violation of resident safety when Resident #2 was left alone in the shower room by staff. Resident #2's care plan directed he/she required one staff assist for bathing, hygiene and dressing. Resident #2 attempted to dress him/herself and had a fall that resulted in a right hip fracture. […]