Citations in Utah
Statistics, citations and compliance trends for long-term care facilities in Utah.
Statistics for Utah (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Utah
A resident with chronic pain, dementia, and other diagnoses repeatedly requested PRN oxycodone-acetaminophen after being assisted to bed, while multiple CNAs alerted an RN that the resident was also making threatening comments. The RN addressed the behavior but did not complete a documented pain assessment, contact the provider, or give the opioid until hours later, after the resident reported being in agony and said the medication had been withheld because of her statements.
Resident choice was not honored when three residents who were documented as able to smoke or vape safely were still placed on supervised smoking with fixed times. One resident with intact cognition and safe smoking behaviors, another resident with stroke-related weakness but observed safe smoking, and a third resident with intact cognition and an incomplete smoking evaluation were all restricted by a facility-wide supervised smoking policy despite staff acknowledging they could smoke safely on their own. In addition, a resident with psychiatric diagnoses asked to stop olanzapine because of weight gain and pain, but the medication change was not completed as ordered at the time.
Incomplete and inaccurate resident records were found for three residents. One resident’s psychotropic medication notes were entered late and did not match the timing of the physician visit and medication changes, another resident’s wander guard checks were inconsistently documented on the MAR despite the device being observed in place, and a third resident’s Lyrica documentation included late entries and conflicting information about the medication order and administration.
The facility failed to maintain documentation for 4 staff members regarding COVID-19 vaccination. Record review showed no evidence that the staff were educated on the vaccine’s benefits and risks, offered the vaccine or information on how to obtain it, or had their vaccination status documented for CDC NHSN reporting. The DON stated the COVID-19 immunization was offered to all staff during flu season, but it was not documented.
Failure to document informed consent for Olanzapine. A resident with multiple psychiatric diagnoses had an order for OLANZapine 10 mg at bedtime, but the medical record contained no consent form. The DON stated there was no documentation that the resident was informed in advance of the risks and benefits of the medication or of treatment alternatives.
A resident with MDD with psychotic symptoms, unspecified psychosis, delusional disorders, anxiety, and PTSD asked to be taken off Olanzapine because of weight gain and increased pain, but the medication was only reduced and then continued for weeks. The record showed an unsigned 7.5 mg order, a psychotropic note describing a taper schedule that was not an actual order, and staff interviews confirmed the resident’s request to stop the medication had not been carried out as documented until the medication was later discontinued.
Delayed PRN opioid pain medication after repeated requests
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with chronic pain when a nurse did not timely assess and administer a prescribed PRN opioid after repeated requests from the resident and alerts from multiple CNAs. Resident 33 had diagnoses including muscular dystrophy, major depressive disorder, moderate dementia without behavioral disturbance, and personality disorder, and her care plan identified chronic pain with a goal to remain free from pain or at a level of discomfort acceptable to her. Her physician orders included oxycodone-acetaminophen 7.5-325 mg every 6 hours as needed for moderate pain and acetaminophen 325 mg, 2 tablets every 8 hours as needed for pain. On the night of the incident, Resident 33 was assisted to bed and repeatedly requested her pain medication while also making statements about killing people with guns, a BB gun, a paint gun, and a water gun. Multiple CNAs reported both the resident’s statements and her request for pain medication to RN 1. RN 1 entered the room to address the threatening statements, but the resident became hostile and told the nurse to leave. Documentation showed no pain assessment, no contact with the provider or facility leadership, and no documented response to the resident’s repeated requests for pain medication at that time. Resident 33 did not receive pain medication until approximately 4:09 AM, more than 18 hours after the prior dose and more than 4 hours after the initial request during the night. The resident reported that she had been in agony for hours and that the nurse refused to give her the medication because of the statements she had made. CNA statements and RN 1’s own account confirmed that the resident asked for the medication multiple times before it was finally administered. The DON stated that pain must be treated subjectively based on the resident’s report and that if a nurse had safety concerns about giving a narcotic, the nurse must contact the on-call medical provider or facility clinical leadership for guidance.
Resident Choice Restricted for Smoking and Medication Requests
Penalty
Summary
The facility failed to honor resident self-determination by restricting three residents to supervised smoking and designated smoking times even though the records and observations described them as capable of smoking independently. Resident 66 had a Safe Smoking Evaluation stating she could light cigarettes independently, use ashtrays appropriately, hold cigarettes safely, and extinguish them safely, yet she was still placed on assisted supervised smoking. During interview, she said she disliked the smoking schedule and wanted to smoke after breakfast, but was told she could not smoke independently because she had tried to cross the street at the facility; that behavior was not documented on the smoking evaluation. She was later observed smoking in her wheelchair, lighting and smoking her own cigarette without assistance during a supervised session. Resident 32, who had diagnoses including hemiplegia and hemiparesis after cerebral infarction, history of falls, muscle weakness, chronic pain syndrome, and acquired absence of the left foot, was also restricted to supervised smoking based on the facility’s smoking policy. His Safe Smoking Evaluation showed intact cognition with a BIMS score of 15 and documented independent and safe smoking behaviors, including lighting cigarettes safely, using an ashtray appropriately, and following smoking area rules. Despite this, the evaluation totaled 3 points because of his stroke history and wheelchair use, which triggered assisted smoking. Interviews with staff described him as alert, oriented, able to smoke safely on his own, and able to sign himself out and leave the facility independently. He was observed smoking safely, holding and ashing his cigarette appropriately, and he stated he could light his own cigarette if staff allowed him. Resident 6, who had diagnoses including major depressive disorder, psychosis, delusional disorder, anxiety disorder, PTSD, and nicotine dependence, was also restricted to supervised vaping and designated vaping times. Her record showed intact cognition with a BIMS score of 15, and she told staff she felt safe alone, was independent with walking and showering, and wanted to vape on her own because the scheduled times did not fit her routine. The facility’s smoking evaluation for her was incomplete, with smoking observation not completed, yet it still concluded she required assisted smoking. In addition, Resident 6 asked to be taken off olanzapine because of weight gain and worsening pain, but the medication change was not carried out as ordered at the time; the record showed a taper note without a corresponding signed order, later dose changes, and staff interviews confirmed the documentation and order process for the olanzapine changes was inconsistent.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility did not maintain complete and accurately documented medical records for 3 sampled residents. For one resident with major depressive disorder, psychosis, delusional disorder, anxiety disorder, and PTSD, physician progress notes related to olanzapine were entered as late entries, and the Director of Nursing stated the documentation did not match the actual timing of the physician’s visit and medication decisions. The record reflected a taper plan and later a continued dose, while the DON stated the physician had given a verbal order and that the late note was intended to clarify the medication plan after the fact. For another resident with Alzheimer’s disease and severe dementia with psychotic disturbance, the physician ordered a wander guard to the left wrist with checks each shift. The MAR documented a “y” for some shifts and then a dash for many subsequent shifts, even though the resident was observed wearing the wander guard on the day of observation. The RN interviewed stated he believed the resident was supposed to be wearing the device and that nurses verified placement by visualizing it, but he did not know why the dash was being used. The DON reviewed the MAR and stated the negative sign documentation was concerning and that she would look into it. For a third resident with brain disorder, alcohol dependence, alcoholic polyneuropathy, and seizure-related diagnoses, the resident stated he had not received Lyrica for a couple of weeks because staff told him the order had run out. The record showed a 30-day Lyrica order, a MAR documenting administration through the end of May, and a physician progress note entered later that referenced a visit date in early May and Lyrica use, which the DON said was based on what the resident should have been on. A nurse’s late-entry note about a new NP order for Lyrica 100 mg twice daily was also not found in the medical record when progress notes were reviewed, and the DON stated she needed to call the physician because the note included medications the resident was not on.
Missing Documentation for Staff COVID-19 Vaccination
Penalty
Summary
The facility failed to maintain documentation related to staff COVID-19 vaccination for 4 staff members identified as Staff 1, 2, 3, and 4. Record review showed there was no documentation that these staff members were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, offered the vaccine or information on how to obtain it, or had their COVID-19 vaccination status documented as required by CDC NHSN reporting. During the record review, the employee files for these staff members did not show that immunizations had been offered or administered. In interview, the DON stated that the COVID-19 immunization was offered to all staff during flu season but was not documented.
Failure to Document Informed Consent for Olanzapine
Penalty
Summary
The facility failed to ensure that a resident was informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment alternatives, or treatment options and was able to choose the preferred option. Resident 6 was admitted with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; and post-traumatic stress disorder. The resident had a physician's order for OLANZapine 10 mg by mouth at bedtime for schizoaffective disorder, but the medical record contained no consent form for Olanzapine. During an interview, the DON stated there was no documentation that Resident 6 was informed in advance of the risks and benefits of Olanzapine or of treatment alternatives.
Failure to Honor Resident Request to Taper Off Olanzapine
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices when Olanzapine was not tapered off as requested. The resident, who had diagnoses including major depressive disorder with psychotic symptoms, unspecified psychosis, delusional disorders, anxiety disorder, and PTSD, told the surveyor that she had asked weeks earlier to be taken off Olanzapine because it caused weight gain of 10-15 pounds and worsened pain related to scoliosis and prior neck surgeries. She stated that she had also spoken with the MD and RN about stopping or changing the medication, but only a dose reduction had occurred. The record showed physician orders for Olanzapine 10 mg at bedtime beginning 5/1/26 and a later order for 7.5 mg at bedtime on 5/14/26, but there was no documentation that the 7.5 mg order was signed by the provider. A psychotropic note dated 5/20/26 documented a taper schedule to discontinue Olanzapine, but the DON stated this taper note was not an order. The MAR showed the resident continued receiving Olanzapine 7.5 mg through 6/22/26. The physician progress note on 6/23/26 documented that Olanzapine was discontinued after the resident was seen in person for follow-up and medication changes were discussed. RN and DON interviews indicated the resident had requested to stop or taper the medication earlier, but the taper off did not occur as documented in the psychotropic note, and the DON stated the NP had given a verbal order to decrease the dose rather than taper it off.
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Compliance trends in Utah
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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