Based on interview, record review, and facility policy review, the facility failed to store all medications in a locked compartment and limit access only to authorized staff. Specifically, for 1 of 19 sampled residents, a resident was able to access the medication cart that was unlocked and unattended in a public hallway, allowing the resident to obtain multiple medications blister packs, and possibly ingest of unauthorized medication. This resulted in a finding of harm. Resident Identifier: 32.Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder.Review of resident 32's medical record was completed on 6/1/26 through 6/4/26.On 3/13/25 at 12:10 PM, an Event… …
F761 citations in Utah
Drug labeling and storage · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Utah cites F761 less often than its own record predicts
0.76 times the national share — cited less often here than elsewhere.
Of every deficiency written in Utah in 2025, this is the portion that was F761.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F761 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 and interview it was determined that the facility did not store drugs under proper temperature controls. Specifically, observations were made of multiple medications stored in the refrigerator at improper temperatures. Findings included:On 7/15/26 at 8:21 AM, the medication refrigerator was inspected. The thermometer read 26 degrees Fahrenheit and was verified by Registered Nurse (RN) 1. Observations were made of two multidose vials of insulin and multiple packages of insulin pens for different residents. Additionally, multiple syringes of Lorazepam were present. On 7/15/26 at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON). …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 2.55% | 0.80× |
| 2024 | 3.11% | 1.01× |
| 2025 | 2.45% | 0.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
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