Inspection Reports for
San Rafael Health and Rehabilitation
455 West Mill Road, Ferron, UT, 84523
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Utah average
Utah average: 7.9 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of abuse, neglect, and exploitation involving multiple residents at San Rafael Health and Rehabilitation.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, and exploitation of residents. The facility failed to protect residents from harm and did not comply with regulatory requirements for abuse prevention and reporting.
Findings
The investigation found multiple instances of abuse, neglect, and failure to follow proper care protocols, including physical abuse of residents, inadequate staff training on abuse prevention, failure to report incidents timely, and deficiencies in care planning and documentation. The facility was found not in compliance with several regulatory requirements related to resident safety and abuse prevention.
Deficiencies (10)
F 600: The facility failed to prevent abuse, neglect, and exploitation of residents, including physical abuse by staff and failure to report and investigate incidents properly.
F 609: The facility failed to provide adequate training on abuse prevention, reporting, and investigation to staff, resulting in unawareness and improper handling of abuse allegations.
F 610: The facility failed to maintain accurate and complete medical records, including care plans and assessments, leading to inadequate care for residents.
F 656: The facility failed to develop and implement comprehensive care plans addressing residents' needs, including oxygen therapy, fall risk, and medication management.
F 689: The facility failed to ensure resident safety related to falls, medication management, and infection control, resulting in injuries and risks to residents.
F 756: The facility failed to maintain food safety and sanitation standards in the kitchen, including cleanliness and proper food storage.
F 812: The facility failed to maintain a safe and sanitary environment in the kitchen, including cleaning schedules and proper food handling.
F 842: The facility failed to maintain accurate and confidential resident medical records, including timely documentation and proper storage.
F 880: The facility failed to implement effective infection control and prevention policies, including staff training and monitoring of communicable diseases.
F 943: The facility failed to prevent abuse and neglect, failed to properly investigate and report incidents, and failed to provide adequate staff training on abuse prevention.
Report Facts
Residents involved: 41
Staff interviewed: 14
Training date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Anderson | Director of Nursing (DON) | Interviewed regarding abuse allegations and facility policies. |
| Adam Director | Assistant Director of Nursing (ADON) | Interviewed regarding abuse allegations and facility policies. |
| Cole Julian | Administrator | Signed Plan of Correction dated 11/30/2024. |
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