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Health Inspection Summary

St George Rehabilitation

1032 East 100 South

St George, UT 84770

(435) 628-0488

Deficiency Category	Inspection Date: 6/7/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 1/12/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 5/20/21 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	3	0	3
Quality of Life and Care Deficiencies	0	2	1
Infection Control Deficiencies	0	0	3
Resident Assessment and Care Planning Deficiencies	3	0	1
Nursing and Physician Services Deficiencies	0	0	1
Resident Rights Deficiencies	0	1	1
Nutrition and Dietary Deficiencies	1	1	3
Pharmacy Service Deficiencies	1	1	2
Environmental Deficiencies	0	1	0
Administration Deficiencies	0	0	1

Detailed result for inspection on 6/7/24

Date of last standard health inspection:	6/7/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	6/7/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in Utah:	9
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure medication error rates are not 5 percent or greater.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 1/12/23

Date of last standard health inspection:	1/12/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	6
Average number of Health Deficiencies in Utah:	9.7
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	1/12/23	3/1/23	2 - Minimal harm or potential for actual harm	Few
Assist a resident in gaining access to vision and hearing services.	1/12/23	3/1/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	1/12/23	3/1/23	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	1/12/23	3/1/23	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	1/12/23	3/1/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide bedrooms that don't allow residents to see each other when privacy is needed.	1/12/23	3/1/23	2 - Minimal harm or potential for actual harm	Few

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 5/20/21

Date of last standard health inspection:	5/20/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	3/21/23Read the full report (PDF) 1/12/23Read the full report (PDF) 6/1/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	3/21/23Read the full report (PDF) 6/1/22Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	16
Average number of Health Deficiencies in Utah:	9.1
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement policies and procedures for flu and pneumonia vaccinations.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that the resident and his/her doctor meet face-to-face at all required visits.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Few

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Some
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Some
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident’s drug regimen must be free from unnecessary drugs.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few
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.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	5/20/21	6/28/21	2 - Minimal harm or potential for actual harm	Few

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	6/7/24	7/16/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	1/12/23	3/1/23	2 - Minimal harm or potential for actual harm	Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Some
Ensure that the resident and his/her doctor meet face-to-face at all required visits.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	3/21/23	5/19/23	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Some
Ensure that the resident and his/her doctor meet face-to-face at all required visits.	6/1/22	6/27/22	2 - Minimal harm or potential for actual harm	Few

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