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
Two residents receiving insulin did not have ordered blood glucose checks completed, including missed checks when one resident was sleeping and a documented shortage of test strips. One resident with type 2 DM had multiple missed BG checks and no documentation that the provider was contacted when BG exceeded the ordered threshold, while another resident with type 2 DM, CHF, chronic respiratory failure, and obesity also had missed q4h BG checks and no provider notification documented for BG readings over 400 mg/dL.
Sewage flooded the second-floor hallway, resident rooms, and bathrooms, with wastewater also leaking into a first-floor office. Video and interviews showed staff laying towels and sheets across the corridor to soak up the sewage while confused residents and wheelchair users moved through the contaminated water, and one resident reported sewage backing up from toilets and shower drains with urine and feces in the water.
Failure to maintain the sewer line and sanitary environment resulted in raw sewage backing up through toilets and shower drains into resident rooms and hallways, with wastewater also leaking into an office area. Residents reported repeated clogs, the building water supply was shut off for hours, and staff confirmed corroded piping, flushed wipes, and that no medical or clinical assessments were completed after residents were exposed to sewage and fumes.
A resident with type 2 DM, CHF, chronic respiratory failure, and obesity did not receive a prescribed daily Tradjenta 5 mg dose as ordered. The MAR documented the medication was out of stock on one occasion and not in stock on another, while the DON stated the pharmacy had received the prescription and the medication should have been available for administration; staff also described standard processes for reordering and obtaining medications when supply is low or unavailable.
Failure to supervise a resident at risk for elopement: A resident with hemiplegia, altered mental status, and schizophrenia was assessed as unsafe to leave unsupervised due to exit-seeking behavior, poor compliance with safety instructions, and lack of awareness of safety concerns. Staff later found the resident outside the facility after a CNA saw her on the sidewalk, and records show she eloped, was located hours later, returned refusing assessment, and was sent for an emergency involuntary psych commitment.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Missed Blood Glucose Monitoring for Residents Receiving Insulin
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not completing ordered blood glucose monitoring for two residents receiving insulin. One resident with type 2 diabetes mellitus had a physician order for insulin lispro before meals and at bedtime, with blood glucose checks to guide treatment, but the July 2026 MAR documented 25 instances where the resident was sleeping and the blood glucose was not drawn. The MAR also documented that no glucose test strips were in the building on July 28, 2026, and it did not show blood glucose checks at 4:00 PM on July 2, 4, 5, 11, 17, and 18, 2026. The resident stated that the facility had run out of glucose test strips, so staff could not test blood sugar or administer insulin that day. A second resident with type 2 diabetes mellitus and other diagnoses including chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for blood sugar checks every 4 hours, with instructions to contact the provider if blood sugar exceeded 400 mg/dL. The May 2026 MAR showed missed blood glucose checks at 12:00 AM on May 13, 12:00 PM on May 15, and 12:00 AM and 4:00 AM on May 16. The MAR and progress notes also did not show that the physician was contacted when blood glucose levels exceeded 400 mg/dL on May 13 at 8:00 PM and May 14 at 4:00 PM. Staff interviews confirmed that sleeping residents were expected to be awakened for ordered blood glucose testing and that the facility should not run out of strips or insulin.
Sewage Flood Exposed Residents to Contaminated Water
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when a sewage flood occurred on the second floor. Video reviewed by the surveyor showed standing sewage water covering portions of the second-floor hallway, wet bath towels and bedsheets laid across the corridor to soak up wastewater, water flooding both sides of the hallway, and sewage leaking through the first-floor ceiling into an administrative office. During interviews, staff stated the flooding affected resident rooms, bathrooms, and the hallway, and that some confused residents were seen walking through the contaminated sewage water in the hallway and their rooms wearing only socks. One resident stated that sewage water containing urine and feces backed up through toilets and shower drains, ran down the second-floor hallway and into resident rooms on both sides of the corridor, and that residents in wheelchairs or wearing socks traversed the contaminated water to go outside because of the odor. Another resident stated that sewage flooded out of the bathrooms into resident rooms and the main hallway, and that staff placed sheets and towels across the hallway floor to soak up the water while the resident had to drive a wheelchair directly through the flooded sewage water to go outside. The Maintenance Director stated residents were instructed to stay in their rooms, but some chose not to due to the smell, and observed residents wheeling their wheelchairs through the sewage water and then touching their faces.
Failure to Maintain Sewer Line and Sanitary Conditions
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary for a safe, functional, sanitary, and comfortable environment when the main sewer plumbing line backed up and raw sewage containing urine and feces entered resident rooms and corridors. Surveyors observed that the flooding extended through the second-floor hallway, with wet bath towels and bedsheets used to soak up wastewater, and that the sewage also leaked through the first-floor ceiling into an administrative office. Stained ceiling tiles were later observed in a resident room, and a resident reported that a prior clogged toilet had caused the damage about six months earlier. Residents 2, 6, and 7 reported that sewage water backed up through toilets and shower drains, flooding the hallway and their rooms, and that the building water supply was shut off for several hours after the incident. Resident 6 also reported another clog the following week. Maintenance staff stated the main sewer drain backed up because of corroded cast-iron piping and flushed wipes, and confirmed that sewage entered resident rooms and that residents in wheelchairs traveled through the contaminated water. The Administrator confirmed the sewer line backed up due to pipe separation and flushed wipes, that staff tried to divert traffic and kept unaffected residents in their rooms, and that no medical or clinical assessments were conducted on residents after exposure to the sewage and fumes.
Missed Antidiabetic Medication Doses
Penalty
Summary
The facility failed to ensure that Resident 4 received a prescribed antidiabetic medication in accordance with the physician’s order, the comprehensive person-centered care plan, and the resident’s choices. Resident 4 was admitted with diagnoses including type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity. A physician order initiated on 2/2/26 directed staff to administer Tradjenta 5 mg by mouth once daily. The medical record documented that on 5/9/26 the medication could not be administered because it was out of stock and had been reordered, and on 5/11/26 it again could not be administered because it was not in stock. During interviews, an LPN stated residents should not run out of medications and that medications are reordered through the eMAR when five pills remain; if a medication is completely out of stock, staff must notify the provider and pharmacy immediately. An RN stated that if a medication is in the emergency medication supply system, staff retrieve it from there, and if not, staff write it down, obtain it from the pharmacy, and contact the pharmacy. The DON stated Tradjenta was not in the emergency medication supply system and had to be ordered directly from the pharmacy, and that the pharmacy received Resident 4’s prescription on 5/9/26, meaning the medication was in stock at the facility and should have been administered on 5/9/26 and 5/11/26. The DON stated it was unknown why staff did not administer the medication on 5/9/26 after it was received, or why the dose was given on 5/10/26 but omitted again on 5/11/26.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure that a resident assessed as unsafe to leave the facility unsupervised was supervised to prevent elopement. Resident 1 was admitted with diagnoses including hemiplegia, altered mental status, and schizophrenia. A Community Risk Assessment dated 9/11/2025 documented that the resident did not know the facility address or phone number, was unaware of basic traffic laws, and lacked awareness of surroundings and safety concerns. An Elopement Risk Assessment identified the resident as at-risk due to exit-seeking behaviors, poor compliance with safety instructions, and non-cooperation with safety plans. A nursing note documented that a CNA saw Resident 1 operating her wheelchair on the sidewalk at about 6:40 AM, and staff then searched for the resident and notified the DON, Administrator, and police. A facility investigation documented that Staff 1 responded to an outside kitchen alarm and found Resident 1 at the door; the resident stated she had signed papers to leave and went outside, after which Staff 1 sought help from other staff. Another nursing note documented that the resident later returned by van, refused assessment, and was sent to the hospital for an emergency involuntary psychiatric commitment. A certification for emergency commitment documented that the resident eloped around 6:50 AM and was located around 3:40 PM, and she returned with altered mental status, hallucinations, dehydration, and refusal of all care.
Missed Insulin Dose Due to Medication Unavailability
Penalty
Summary
A resident with type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for Insulin Glargine Solostar 300 units/mL, 50 units subcutaneously once daily. On 3/20/26 at 11:19 AM, an RN documented that the insulin was not administered because the medication was unavailable. During interviews on 7/30/26, an LPN stated that medications should be reordered through the eMAR when five doses remain and that if a medication is completely out, staff must immediately notify the provider and pharmacy and use the emergency medication supply system. An RN confirmed that backup insulin was available in a lockbox in the third-floor refrigerator and that staff should not run out of insulin. The DON also confirmed the backup insulin location and the pharmacy restocking alert system, and stated there was no documentation in the progress notes or TAR explaining the omission; because she was not employed at the facility at the time, the exact reason for the unavailable medication and omitted dose remained unknown.
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Compliance trends in Utah
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 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 1-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): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 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 1 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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