Based on interview and record review it was determined, for 2 out of 28 sampled residents, that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility failed to promptly identify, monitor, and intervene for an acute change in condition after two residents sustained a fall. Additionally, one resident did not have neurological assessments completed status post fall, and the other resident did not have timely intervention after changes were identified on the neurological assessment. …
F684 citations in Utah
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Utah cites F684 less often than its own record predicts
0.52 times the national share — cited less often here than elsewhere.
Of every deficiency written in Utah in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F684 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 it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 1 out of 16 residents sampled, the facility did not seek timely emergency care for a resident who was displaying signs and symptoms of a Gastrointestinal (GI) bleed. This was cited at a harm level. Resident identifier 11. Findings included:Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epilepsy, myocardial infarction, chronic kidney disease, congestive heart failure, osteoporosis, and repeated falls. Resident 11's progress notes revealed the following: a. …
Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for 1 out of 43 sampled residents, the facility did not assess and treat a resident's skin breakdown or injury. Resident identifier: 129. Findings included:Resident 129 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, hemiplegia, metabolic encephalopathy, aphasia, Parkinson's Disease, cognitive communication deficit, repeated falls, polyneuropathy, atrial fibrillation, urinary tract infection, pain, and hypertension.Resident 129 physician orders were reviewed and no documentation was found for… …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 1.85% | 0.51× |
| 2024 | 3.28% | 0.82× |
| 2025 | 2.23% | 0.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
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