Based on observations, interviews and record review, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, abuse occurred within the facility on multiple occasions,but was not identified, reported or investigated; the staffing was inadequate and resulted in falls, abuse, and activities of daily living not being completed; Quality Assurance (QA) was not completed as required for approximately one year; medically necessary appointments were not scheduled by facility staff or the administrator; wound reports and pharmacy reviews were only accessible to the Administrator, who did not… …
F835 citations in Utah
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Utah cites F835 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 F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F835 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 was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. Resident identifiers: 7,11, 12, 25, 27, 33, 31, 36, 42, 47, and 49.1. Based on interview and record review, it was determined for 7 out of 32 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level. …
Based on interview, observation and record review, the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298. Findings include: 1. …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 0.46% | 1.61× |
| 2024 | 0.35% | 1.06× |
| 2025 | 0.22% | 0.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
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