Based on observation, interview and record review it was determined, for 7 of 32 sampled residents, that the facility did not implement their written policies and procedures to prevent abuse, neglect, and investigate and report allegations. Specifically, the facility did not have written policies and procedures that defined sexual abuse, how to evaluate a resident's capacity to consent to a sexual relationship and elopements. These examples were cited at an Immediate Jeopardy level. Resident identifiers: 11, 27, 33, 31, 36, 42 and 49. NOTICE On 8/8/25 at 1:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to implement policies and procedures to prevent various forms of abuse. …
F607 citations in Utah
Abuse-prevention policies · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Utah cites F607 less often than its own record predicts
0.68 times the national share — cited less often here than elsewhere.
Of every deficiency written in Utah in 2025, this is the portion that was F607.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F607 findings written in Utah, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review the facility did not develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegations; Include training as required; and Establish coordination with the QAPI program. Specifically, multiple residents were repeatedly abused physically, sexually and verbally, without interventions to protect the residents, appropriate reporting, or thorough investigations. These instances were determined to have occurred at an Immediate Jeopardy level for F600, F609, and F610. …
Based on interview and record review, the facility did not implement written policies and procedures on prohibiting and preventing abuse and investigating any such allegations. Specifically, for 1 out of 40 sampled residents, staff were aware of allegations of roughness during care but did not escalate the allegation up the chain of command to be investigated as a possible allegation of abuse. Resident identifier: 46. Findings included:Resident 46 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.On 6/22/26 at 9:55 AM, an interview was conducted with resident 46. …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 0.31× |
| 2024 | 1.73% | 2.29× |
| 2025 | 0.45% | 0.68× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
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