San Rafael Health and Rehabilitation
455 West Mill Road, Ferron, UT 84523
San Rafael Health and Rehabilitation is a nursing home in Ferron, Utah. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionNovember 15, 2024 (1 year ago)
- Health citations since June 17, 202127 (Utah average 26)
- Fines in the past three years2, $29,347 in total
- CMS flagsSpecial Focus Facility candidate, CMS abuse icon
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CMS flags
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of May 27, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of November 20, 2025
Fire safety citation
CMS removed citation K0100 from the fire safety inspection on October 23, 2024.
Fire safety citation
CMS removed citation K0363 from the fire safety inspection on October 23, 2024.
Fire safety citation
CMS removed citation K0511 from the fire safety inspection on October 23, 2024.
Fire safety citation
CMS removed citation K0921 from the fire safety inspection on October 23, 2024.
CMS update of May 28, 2025
Fine
CMS changed the fine from November 15, 2024 from $39,890 to $25,929.
CMS update of March 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on November 15, 2024
14 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
9 of 97 Utah homes (9%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $25,929 on November 15, 2024.
Show the 14 citations
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 13, 2024.
Citation F0609. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 13, 2024.
Citation F0610. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on December 13, 2024.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 13, 2024.
CMS has cited this home for F0689 2 times since 2021.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 13, 2024.
Citation F0943. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on December 13, 2024.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on December 13, 2024.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 13, 2024.
CMS has cited this home for F0656 2 times since 2021.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on December 13, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 13, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on December 13, 2024.
CMS has cited this home for F0690 2 times since 2021.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on December 13, 2024.
CMS has cited this home for F0756 3 times since 2021.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 13, 2024.
CMS has cited this home for F0758 2 times since 2021.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on December 13, 2024.
CMS has cited this home for F0842 2 times since 2021.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of September 26, 2024
Fine
CMS changed the fine from February 6, 2024 from $3,387 to $3,418.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
February 6, 2024
FineCMS fine of $3,418 on February 6, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.8 to 3.8 hours per resident per day.
Health inspection on March 15, 2023
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 24, 2023.
Citation F0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS lists it as corrected on March 29, 2023.
CMS has cited this home for F0712 2 times since 2021.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on March 24, 2023.
Health inspection on June 17, 2021
10 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
10 of 97 Utah homes (10%) got a citation at the actual harm level in 2021.
Show the 10 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 23, 2021.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on July 23, 2021.
Citation F0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS lists it as corrected on July 23, 2021.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 23, 2021.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 23, 2021.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 23, 2021.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 23, 2021.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 23, 2021.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on July 23, 2021.
Citation F0868. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on July 23, 2021.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (435) 384-2301
- Last standard health inspection
- November 15, 2024 (1 year ago)
- Certified beds
- 51
- Residents per day, on average
- 34.4
- Ownership type
- Government - County
- Legal business name
- Emery County Care and Rehabilitation Center
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Utah average (27 vs 26).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- COUNTY OF EMERY5% or greater direct ownership interest · 100% · since 09/14/2010
- TRADITIONS HEALTH CARE, INC.Operational/managerial control · not applicable · since 08/01/1996
- ALLEN, GLORIOperational/managerial control · not applicable · since 09/02/2021
- BRAMALL, CHARLESOperational/managerial control · not applicable · since 07/01/2023
- BRONEMANN, NATHANOperational/managerial control · not applicable · since 09/16/2018
Show 1 more
- HANSEN, QUINLINOperational/managerial control · not applicable · since 09/01/2020
Questions
When was San Rafael Health and Rehabilitation last inspected?
CMS lists November 15, 2024 as the date of its most recent standard health inspection.
How many citations (violations) does San Rafael Health and Rehabilitation have?
CMS lists 27 health citations since June 17, 2021. CMS also calls these deficiencies.
Has San Rafael Health and Rehabilitation been fined?
CMS lists 2 fines in the past three years, $29,347 in total.
What is the CMS star rating of San Rafael Health and Rehabilitation?
Its CMS overall star rating is 1 of 5.
Is San Rafael Health and Rehabilitation a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.