Inspection Reports for San Rafael Health and Rehabilitation
455 West Mill Road, UT, 84523
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8
6
4
2
0
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 6
Nov 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of abuse, neglect, and exploitation involving Resident #38 and other residents at San Rafael Health and Rehabilitation.
Findings
The investigation found multiple instances of abuse, neglect, and failure to follow proper procedures, including physical abuse of Resident #38 by staff, inadequate investigation and reporting of incidents, failure to protect residents from harm, and deficiencies in care planning and staff training. The facility was found not in compliance with several regulatory requirements related to abuse prevention, resident rights, and quality of care.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, and exploitation. The facility failed to protect residents from harm and did not adequately investigate or report incidents. Staff were found to have physically abused Resident #38, and the facility failed to take timely corrective actions. Training and policy enforcement were inadequate.
Deficiencies (6)
| Description |
|---|
| Failure to prevent and properly investigate abuse and neglect of Resident #38 and others. |
| Inadequate staff training and failure to follow abuse prevention policies. |
| Failure to implement effective care plans and assessments for residents. |
| Failure to maintain a safe environment and prevent falls and injuries. |
| Failure to properly document and report incidents and investigations. |
| Inadequate infection control and sanitation in the kitchen and facility. |
Report Facts
Deficiencies cited: 6
Residents involved: 41
Staff interviewed: 14
Training hours: 0.5
Date of incident: Nov 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cole Julian | Administrator | Named as the Administrator responsible for oversight and interviewed regarding abuse investigations and corrective actions. |
| John Smith | Director of Nursing | Named as DON, involved in investigation and corrective actions related to abuse and care planning. |
| Jane Doe | Assistant Director of Nursing | Involved in abuse investigation and staff training. |
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