CMS · Utah Department of Health and Human Services publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F880Provide and implement an infection prevention and control program.Scope/severity KHarm
Infection control
Pattern; immediate jeopardy to resident health or safety.Corrected 2026-02-20Record 465086-20260108-F880
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F656
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F689
F728Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F728
F770Provide timely, quality laboratory services/tests to meet the needs of residents.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F770
F775Keep complete, dated laboratory records in the resident's record.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F775
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F849
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F867
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-20Record 465086-20260108-F887
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2026-02-20Record 465086-20260108-F732
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-10-11Record 465086-20240814-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-10-11Record 465086-20240814-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-10-11Record 465086-20240814-F692
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-10-11Record 465086-20240814-F697
F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.Scope/severity JHarm
Records
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-10-11Record 465086-20240814-F776
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity HHarm
Records
Pattern; actual harm that is not immediate jeopardy.Corrected 2024-10-11Record 465086-20240814-F867
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F550
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F580
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F584
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F610
F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F622
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F657
F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F661
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F688
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F695
F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F712
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F727
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F759
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F760
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F761
F770Provide timely, quality laboratory services/tests to meet the needs of residents.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F770
F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F773
F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F777
F779Keep signed and dated reports of x-rays and other diagnostic services in the residents record.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F779
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F812
F814Dispose of garbage and refuse properly.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F814
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F835
F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F840
F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F841
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F842
F843Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F843
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F880
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F881
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F882
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F883
F923Have enough outside ventilation via a window or mechanical ventilation, or both.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-11Record 465086-20240814-F923
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2022-12-30Record 465086-20221031-F600
F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F603
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2022-12-30Record 465086-20221031-F609
F610Respond appropriately to all alleged violations.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2022-12-30Record 465086-20221031-F610
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F684
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F692
F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F693
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F697
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity HHarm
Staffing
Pattern; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F725
F760Ensure that residents are free from significant medication errors.Scope/severity GHarm
Medication
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F760
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity KHarm
Records
Pattern; immediate jeopardy to resident health or safety.Corrected 2022-12-30Record 465086-20221031-F835
F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Scope/severity GHarm
Records
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F840
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity HHarm
Records
Pattern; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F867
F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyScope/severity HHarm
Records
Pattern; actual harm that is not immediate jeopardy.Corrected 2022-12-30Record 465086-20221031-F868
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F550
F565Honor the resident's right to organize and participate in resident/family groups in the facility.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F565
F567Honor the resident's right to manage his or her financial affairs.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F567
F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F568
F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F569
F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F573
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F578
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F580
F583Keep residents' personal and medical records private and confidential.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F583
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F584
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F607
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F623
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F658
F660Plan the resident's discharge to meet the resident's goals and needs.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F660
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F676
F679Provide activities to meet all resident's needs.Scope/severity FStandard
Care planning
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F679
F680Ensure the activities program is directed by a qualified professional.Scope/severity FStandard
Care planning
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F680
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F755
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F757
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F761
F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F773
F775Keep complete, dated laboratory records in the resident's record.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F775
F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F805
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F812
F836Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F836
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F838
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F842
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F880
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F882
F886Perform COVID19 testing on residents and staff.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F886
F923Have enough outside ventilation via a window or mechanical ventilation, or both.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F923
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-30Record 465086-20221031-F925