Inspection Reports for San Rafael Health and Rehabilitation

455 West Mill Road, Ferron, UT, 84523

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Deficiencies (last 1 years)

Deficiencies (over 1 years) 6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

24% better than Utah average
Utah average: 7.9 deficiencies/year

Deficiencies per year

8 6 4 2 0
2024

Inspection Report

Complaint Investigation
Deficiencies: 6 Date: 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.

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.
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.

Deficiencies (6)
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
NameTitleContext
Cole JulianAdministratorNamed as the Administrator responsible for oversight and interviewed regarding abuse investigations and corrective actions.
John SmithDirector of NursingNamed as DON, involved in investigation and corrective actions related to abuse and care planning.
Jane DoeAssistant Director of NursingInvolved in abuse investigation and staff training.

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