Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. George Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents. Staff did not label or date food items in nourishment refrigerators, and opened items were left for an indeterminate time. In the kitchen, staff did not follow hygiene practices, such as changing gloves and washing hands after touching high-contact surfaces. These actions violated facility policies and had the potential to impact 96 residents.
The facility failed to create care plans for two residents requiring supplemental oxygen due to respiratory failure. Despite medical records indicating oxygen therapy orders, neither resident had a care plan addressing their oxygen needs. Observations confirmed the use of nasal cannulas, and staff interviews highlighted the expectation for care plans to include diagnosis, rationale, and instructions for oxygen management.
A resident with severe cognitive impairment and a history of falls experienced two incidents where the care plan was not updated with necessary interventions. Despite the Fall Committee IDT identifying the need for appropriate footwear and a non-slip pad for the wheelchair, these were not added to the care plan, as confirmed by the DON and Administrator.
A resident with severe cognitive impairment and a history of stroke and hypertension was observed smoking while wearing a nicotine patch, contrary to a physician's order to hold the patch if smoking. Despite the resident's care plan indicating a potential for injury related to smoking, the patch was not held, as confirmed by the DON and facility Administrator.
A facility failed to maintain a medication error rate below 5%, resulting in a 5.88% error rate. An LPN did not prime insulin pens or wait the required time after injection for a resident with diabetes, contrary to manufacturer's instructions. The DON acknowledged the protocol was not followed.
A facility failed to protect residents from abuse, with incidents involving verbal abuse by an LPN and physical abuse between two residents. The LPN was reported to have raised her voice at a resident with severe cognitive impairment, while one resident physically attacked another on two occasions, causing injuries. The facility's investigations were inconclusive, and the abuse prevention policies were not effectively implemented.
A resident with severe cognitive impairment was verbally abused by an LPN, as witnessed by two CNAs. Despite facility policy requiring immediate reporting, the incident was not reported to the Administrator until hours later. The resident, who had a history of dementia and anxiety disorder, was involved in an altercation with the LPN, who raised her voice when the resident refused medication and attempted to hit her.
The facility failed to implement its abuse policy in two incidents. In one case, an LPN accused of verbal abuse was not removed from resident care, and in another, the facility did not interview the alleged perpetrator or other potential witnesses after a resident reported being poked in the breast by another resident. These actions were contrary to the facility's policy, highlighting deficiencies in handling abuse allegations.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, affecting the nourishment refrigerators and the kitchen. Observations revealed that food items brought in by visitors were not labeled or dated, and opened food items were left in the nourishment refrigerators for an indeterminate amount of time. Interviews with staff, including the Dietary Manager, Certified Nursing Assistants (CNAs), and the Director of Nursing (DON), indicated confusion and lack of clarity regarding responsibility for labeling, dating, and discarding food items. The facility's policies required that leftover food be labeled, dated, and discarded after three days, but these procedures were not consistently followed. In the kitchen, staff failed to adhere to proper hygiene practices during food preparation. Dietary Aide (DA) #16 was observed touching high-contact surfaces, such as a microphone button and refrigerator handle, without changing gloves or washing hands before handling food items. Additionally, DA #16 did not wash tomatoes before cutting them. DA #17 also failed to change gloves or wash hands after touching a drawer handle before handling bread rolls. Interviews with the Dietary Manager and the aides confirmed that these actions were against the facility's food safety policies, which required handwashing and glove changes after touching high-contact surfaces. The deficiencies in food storage and preparation practices had the potential to affect all 96 residents receiving food from the dietary department. The facility's policies on food safety and hygiene were not effectively implemented, leading to unsanitary conditions in food handling and storage. The lack of clear communication and responsibility among staff members contributed to these deficiencies, as evidenced by the conflicting statements regarding who was responsible for labeling and maintaining the nourishment refrigerators.
Failure to Develop Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the supplemental oxygen usage for two residents, both of whom had a medical history of acute and chronic respiratory failure. Resident #37 was admitted with diagnoses of acute respiratory failure with hypoxia and chronic respiratory failure with hypercapnia. Despite receiving oxygen therapy as indicated in their medical records, there was no evidence of a care plan that addressed their supplemental oxygen usage. Observations confirmed the resident was using a nasal cannula, and staff interviews revealed that the resident consistently wore the oxygen device while in bed. Similarly, Resident #76, who was readmitted with a diagnosis of acute and chronic respiratory failure with hypoxia, also lacked a care plan for their supplemental oxygen usage. The resident's medical records showed an order for oxygen therapy, yet the care plan did not reflect this need. Observations and staff interviews confirmed the resident's use of a nasal cannula. Interviews with nursing staff, including the Assistant Director of Nursing and the Director of Nursing, indicated an expectation for a care plan to be in place for residents with supplemental oxygen orders, detailing the diagnosis, rationale, and specific instructions for oxygen therapy management.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after two separate fall incidents, which is a deficiency in adhering to their policy of updating care plans with resident changes. The resident, who was admitted with a history of cerebral infarction and hypertension, had a severe cognitive impairment and required assistance with toileting. The care plan initially identified the resident as being at risk for falls due to weakness and decreased mobility. However, after a fall incident where the resident slipped during a transfer due to slippery socks, the care plan was not updated to include the intervention of using appropriate footwear. A subsequent fall occurred when the resident attempted to return from the smoking area, resulting in the wheelchair rolling out from underneath them. Although the Fall Committee IDT noted the need for a non-slip pad on the wheelchair seat to prevent further slipping, this intervention was also not added to the care plan. Interviews with the DON and the Administrator confirmed that these interventions should have been included in the care plan but were not, indicating a lapse in following the facility's care planning policy.
Failure to Follow Physician's Order for Nicotine Patch Administration
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of a nicotine patch for a resident with severe cognitive impairment. The resident, who had a history of cerebral infarction and hypertension, was admitted to the facility and had a care plan indicating a potential for injury related to smoking. The physician's order specified that the nicotine patch should be held if the resident was smoking. However, on a specific date, a Licensed Practical Nurse (LPN) applied the nicotine patch to the resident's arm, and later that day, the resident was observed smoking while still wearing the patch. Interviews with the resident and staff revealed that the resident smoked one to two times a day and did not wish to stop smoking. The Director of Nursing (DON) acknowledged that the resident had been wearing the nicotine patch since a specified date and continued to smoke, indicating that the patch was not held as per the physician's order. The DON and the facility Administrator both expressed that their expectation was for medications to be administered according to physician orders, highlighting a failure in the facility's medication administration process.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 5.88% due to 2 errors out of 34 opportunities. This deficiency affected one resident who was observed during medication administration. The resident, admitted on 03/04/2021, had a medical history of type two diabetes mellitus with diabetic neuropathy and was prescribed insulin glargine and NovoLog. The errors occurred during the administration of these medications. During an observation, an LPN did not prime the insulin pens before injection and removed the needles immediately after administration, contrary to the manufacturer's instructions. The manufacturer's guidelines specified performing a safety test by priming the pen to ensure accurate dosing and waiting a specified time after injection to ensure the full dose was delivered. The LPN acknowledged the errors, and the DON confirmed that the nurse should have followed the protocol for effective medication administration.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by incidents involving two residents and a staff member. On one occasion, a Licensed Practical Nurse (LPN) was reported to have verbally abused a resident with severe cognitive impairment. The incident was witnessed by two Certified Nursing Assistants (CNAs), who reported hearing the LPN raise her voice at the resident. The LPN admitted to raising her voice but claimed it was to ensure the resident could hear her. The facility's investigation into the incident was inconclusive, and the LPN felt she did nothing wrong. In another incident, a resident with severe cognitive impairment physically abused another resident on two separate occasions. The first altercation resulted in knuckle marks on the victim's forehead, while the second incident led to scratches on the victim's face. Both incidents were witnessed by staff members, who intervened to separate the residents. The facility's follow-up investigations were inconclusive, with reports indicating a lack of clarity on what led to the incidents and the extent of the injuries sustained by the victim. The facility's policies on abuse prevention and prohibition were not effectively implemented, as evidenced by the repeated incidents of abuse. The facility's investigations into the incidents were unable to substantiate the abuse claims, despite evidence of physical harm to the victim. The facility's failure to protect residents from abuse and to conduct thorough investigations into reported incidents highlights a deficiency in ensuring the safety and well-being of its residents.
Failure to Immediately Report Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported immediately to the Administrator for a resident with severe cognitive impairment. On the evening of August 21, 2023, two CNAs heard an LPN verbally abuse a resident. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator, the incident was not reported until 10:15 PM, several hours after it occurred. The resident involved had a history of dementia with behavioral disturbance and anxiety disorder, and was known to have adequate hearing. The investigation revealed that one CNA heard the LPN yell at the resident and witnessed the resident swing at the nurse, while another CNA heard yelling but could not recall the specific words. The LPN involved stated that the resident refused medication and attempted to hit her, prompting her to raise her voice. Both CNAs identified the incident as verbal abuse, with one reporting it to the Administrator via text message after her shift. The Administrator expected staff to ensure resident safety and report abuse immediately, which did not occur in this instance.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement its abuse policy in two separate incidents involving residents. In the first incident, a Licensed Practical Nurse (LPN) was reported to have verbally abused a resident with severe cognitive impairment. Despite the report, the accused LPN continued to care for residents without being removed from duty, as required by the facility's policy. The facility's investigation revealed that the LPN admitted to raising her voice at the resident, but she was not suspended pending the investigation, contrary to the policy. In the second incident, the facility did not follow its abuse investigation protocol after an allegation of sexual abuse between two residents. The alleged victim, who had a history of trauma, reported being poked in the breast by another resident. The facility's investigation did not include interviews with the alleged perpetrator or other residents who might have witnessed the incident, as mandated by the facility's policy. The Administrator acknowledged the failure to interview surrounding residents and did not document an interview with the alleged perpetrator, although he claimed to have spoken with them. Both incidents highlight the facility's failure to adhere to its own abuse prevention and investigation policies. The Administrator and staff did not ensure that all residents were protected from harm during and after the investigations, as required. The lack of thorough investigation and immediate protective measures for residents indicates a significant deficiency in the facility's handling of abuse allegations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near St. George
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra St George | 0.1 mi | — | 4 | 0 |
| Coral Desert Rehabilitation And Care | 0.9 mi | — | 0 | 0 |
| Red Cliffs Health And Rehab | 1.2 mi | — | 0 | 0 |
| Advanced Health Care Of St. George | 1.3 mi | — | 0 | 0 |
| Seasons Healthcare And Rehabilitation | 1.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.