San Rafael Health and Rehabilitation
455 West Mill Road · Ferron, UT · 84523 · 4353842301
51 certified beds Government - County
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
3 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.78 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.46 | 0.55–0.75 |
| Weekend hours / resident-day | 3.27 | ≈ weekday level |
| Nursing turnover / year | 58% | median 45% |
| Fines (3-yr window) | 2 · $29,347 |
Inspection citations (27 in the current record)
-
Immediate jeopardy · J November 15, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 13, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J November 15, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 13, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J November 15, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected December 13, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G November 15, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 13, 2024 · Quality of Life and Care
-
Potential for harm · E November 15, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 13, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D November 15, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected December 13, 2024 · Quality of Life and Care
-
Potential for harm · D November 15, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected December 13, 2024 · Pharmacy Service
-
Potential for harm · D November 15, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected December 13, 2024 · Pharmacy Service
-
Potential for harm · F November 15, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 13, 2024 · Nutrition and Dietary
-
Potential for harm · E November 15, 2024
Provide and implement an infection prevention and control program.
Corrected December 13, 2024 · Infection Control
-
Potential for harm · E November 15, 2024 · found via complaint
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected December 13, 2024 · Resident Rights
-
Potential for harm · E November 15, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 13, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D November 15, 2024 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 13, 2024 · Resident Assessment and Care Planning
-
Potential for harm · F November 15, 2024 · found via complaint
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected December 13, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · E March 15, 2023
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected March 24, 2023 · Resident Rights
-
Potential for harm · E March 15, 2023
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected March 29, 2023 · Nursing and Physician Services
-
Potential for harm · D March 15, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected March 24, 2023 · Pharmacy Service
-
Actual harm · G June 17, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 23, 2021 · Quality of Life and Care
-
Actual harm · G June 17, 2021
Provide safe, appropriate pain management for a resident who requires such services.
Corrected July 23, 2021 · Quality of Life and Care
-
Potential for harm · D June 17, 2021
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 23, 2021 · Resident Assessment and Care Planning
-
Potential for harm · D June 17, 2021
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected July 23, 2021 · Quality of Life and Care
-
Potential for harm · E June 17, 2021
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected July 23, 2021 · Nursing and Physician Services
-
Potential for harm · E June 17, 2021
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected July 23, 2021 · Pharmacy Service
-
Potential for harm · E June 17, 2021
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected July 23, 2021 · Pharmacy Service
-
Potential for harm · D June 17, 2021
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected July 23, 2021 · Administration
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 15, 2024 | Fine | $25,929 |
| February 6, 2024 | Fine | $3,418 |
Better-scoring options nearby
No better-scoring facility within 25 miles in the current data. See the whole state.
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 465085 · certified since September 1, 1981. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.