Based on interview and record review it was determined that the facility did not ensure that the services provided by the facility met professional standards of practice. Specifically, for 1 out of 9 sampled residents, the facility Respiratory Therapist Director did not ensure that a Verbal Order (VO) was entered into the resident's medical record which resulted in the respiratory staff providing a treatment that deviated from the prescribed order. This will be cited at a harm level. Resident identifier: 1.Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage.Resident 1's medical records were reviewed.Resident 1's physician orders revealed the following:a. …
F658 citations in Utah
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Utah cites F658 less often than its own record predicts
0.50 times the national share — cited less often here than elsewhere.
Of every deficiency written in Utah in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F658 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 observation, interview, and record review, the facility did not ensure that the services provided met professional standards of quality. Specifically, for 1 out of 40 sampled residents, a resident's tube feeding was labeled with an incorrect formula, an incorrect administration rate, and was not labeled with the initials of the nurse who initiated the infusion. Furthermore, additional tube feedings were missing required labeling information. Resident identifier: 3.Findings included:Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase.A review of resident 3's physician orders revealed:a. …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 0.69% | 0.43× |
| 2024 | 0.52% | 0.32× |
| 2025 | 0.89% | 0.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction