Based on interview and record review, it was determined that the facility did not demonstrate identification, reporting, investigation, analysis and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective action. Specifically, the facility did not identify or investigate in their Quality Assurance Performance Improvement (QAPI) three respiratory-related resident deaths. This will be cited at a harm level. Resident identifiers: 1, 5, and 9.Findings included:1. There was noncompliance identified at an IJ (Immediate Jeopardy) level for residents who were on ventilators and had a tracheostomy changed by respiratory staff when they were not supposed to and another resident's tracheostomy broke. …
F865 citations in Utah
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Utah cites F865 less often than its own record predicts
0.94 times the national share — cited less often here than elsewhere.
Of every deficiency written in Utah in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Utah surveyors wrote
F865 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 develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program. Specifically, the facility did not identify and prioritize problems related to resident abuse and elopements and corrective actions were not identified, monitored, or evaluated for effectiveness. The facility was found to be in non-compliance with F600, F607, F609, F610, and F689 at an Immediate Jeopardy level, indicating substandard quality of care. Resident identifiers: 7, 11, 12, 27, 31, 33, 36, 42, 47, and 49.Findings included:On 8/19/25 at 11:54 AM, an interview was conducted with the Administrator (Admin). …
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 1.34× |
| 2025 | 0.22% | 0.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
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