Based on observation, interview and record review, it was determined that for 5 of 29 sampled residents, the facility did not ensure that residents were free from significant medication errors. Specifically, one resident was administered insulin outside of a physician's ordered parameters and had to receive glucagon to raise his blood glucose to normal levels, a second resident was administered oxycodone 10mg (milligrams) instead of his prescribed clonazepam 0.5mg for seizures, and a third resident missed two consecutive doses of insulin, then received long acting insulin instead of short acting insulin as prescribed. Resident identifiers: 1, 25, 32, 34 and 52. The findings for three residents were determined to have resulted in immediate jeopardy. …
F760 citations in Utah
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Utah cites F760 more often than its own record predicts
1.03 times the share F760 takes of citations nationally.
Of every deficiency written in Utah in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F760 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 failed to ensure one resident (Resident #2) was free from significant medication errors for one of 12 residents sampled for medication administration. Specifically, Resident #2 was inadvertently administered 13 medications intended for their roommate, including high-risk antihypertensives and antidiabetics, resulting in hypoglycemia, hypotension, and the need for acute hospitalization.The facility's noncompliance was determined to be Past Noncompliance. …
Based on interview and record review, it was determined the facility failed to ensure that each resident was free of any significant medication errors. Specifically, for 1 out of 11 sampled residents, the facility failed to administer a prescribed dose of long-acting insulin, due to the medication being unavailable and the staff failed to access the facility's emergency medication supply. Resident Identifier 4.Resident 4 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity.A physician order, initiated on 2/26/26 at 6:00 AM, prescribed Insulin Glargine Solostar Subcutaneous Solution Pen-injector 300 units/mL, to inject 50 units subcutaneously once daily.On 3/20/26 at 11:19 AM,… …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 2.08% | 1.88× |
| 2024 | 1.90% | 1.63× |
| 2025 | 1.34% | 1.03× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
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