Utah State Developmental Center

May 14, 2026 · Unannounced, Annual Inspection

No citations from this inspection.

September 24, 2025 · Follow-Up Inspection

No citations from this inspection.

June 23, 2025 · Follow-Up Inspection, Investigation Inspection(under appeal)

• Moderate Abuse, neglect or exploitation policies and procedures(R432-152-7(4)(a)-(f))

  The provider was out of compliance with rule R432-152-7(4)(b) by not ensuring the nearest peace officer, law enforcement agency, or local office of Adult Protective Services (APS) was notified immediately after an allegation that a disabled adult had been the subject of abuse. During the inspection, the licensor identified that the facility staff did not notify APS until three days after they received notification of an incident of alleged abuse regarding 1 client. This is a repeat noncompliance as noted on January 14, 2025.

  How was this corrected? On September 24, 2025, the licensor verified through record review and interview that the facility ensured the nearest peace officer, law enforcement agency, or local office of adult protective services (APS) was notified immediately after an allegation that a disabled adult had been subject to abuse, as stated by rule.

  Corrected on September 24, 2025, verified by the state. · $150 penalty

• Moderate Provider shall protect each client(R380-80-4(1))

  The provider was out of compliance with rule R380-80-4(1) by not ensuring that each client was protected from abuse. During the inspection, the licensor identified that 1 client was not protected from abuse. Specifically, a client was hit in the head by staff.

  How was this corrected? On September 24, 2025, the licensor verified through record review and interview that the facility ensured clients were protected from abuse, as stated by rule.

  Corrected on September 24, 2025, verified by the state.

• High Provider shall protect each client(R380-80-4(1))

  The provider was out of compliance with rule R380-80-4(1) by not ensuring that each client was protected from abuse. During the inspection, the licensor identified that 1 client was not protected from abuse when they were hit in the head with a skateboard by another client, causing a head laceration that required 17 staples.

  How was this corrected? On September 24, 2025, the licensor verified through record review and interview that the facility ensured clients were protected from abuse, as stated by rule.

  Corrected on September 24, 2025, verified by the state. · $200 penalty

April 10, 2025 · Investigation Inspection

No citations from this inspection.

February 27, 2025 · Unannounced, Annual Inspection

No citations from this inspection.

February 20, 2025 · Conditional, Monitoring Inspection, Investigation Inspection

No citations from this inspection.

February 11, 2025 · Conditional, Monitoring Inspection, Follow-Up, Additional Follow-Up Inspection, Investigation Inspection

• Low Committee duties(R432-152-13(2)(a)-(c))

  The licensee was out of compliance with R432-152-13(2)(a) by not ensuring the committee outlined in Subsection R432-152-13(1) (“Human Rights Committee”) reviewed, approved, and monitored individual programs designed to manage inappropriate behavior and any other programs considered to involve risks to client protection and rights. During the inspection, the licensor identified 2 clients who had their personal electronics removed due to maladaptive behaviors. The licensee failed to provide evidence that these restrictions were reviewed, approved, and monitored by the facility's Human Rights Committee.

  How was this corrected? On June 23, 2025, the licensor verified through record review and interview that the human rights committee reviewed, approved, and monitored individual programs designed to manage inappropriate behaviors, as stated by rule.

  Corrected on June 23, 2025, verified by the state.

January 14, 2025 · Conditional, Monitoring Inspection, Follow-Up Inspection(under appeal)

• High Provider shall protect clients from abuse, prevent abuse(R380-80-5(4))

  The provider was out of compliance with this rule by not ensuring they protected clients from neglect, harm, and any action that compromised the health of clients through acts or omissions. Specifically, 1 client was restrained without proper checks and releases, did not receive appropriate nursing assessment, care, and oversight and subsequently developed 2 pressure injuries and an infection. In addition, the provider did not follow 2 written policies and safe practices.

  How was this corrected? On 2/11/2025, the licensor verified the licensee ensured clients received appropriate nursing assessment, care, and oversight and followed written policies and procedures to protect clients from abuse, as stated in rule.

  Corrected on February 11, 2025, verified by the state. · $200 penalty

• High Protect clients during others behaviors(R432-152-15(6))

  The provider was out of compliance with this rule by not ensuring interventions to manage inappropriate client behavior were employed with safeguards and supervision to ensure that the safety and welfare of clients were adequately protected. During the inspection, 1 client was documented to have been restrained due to maladaptive behaviors after a medical procedure, and the facility did not employ safeguards and supervision to ensure the client did not acquire 2 pressure injuries and an infection.

  How was this corrected? On 2/11/2024, the licensor verified the licensee employed safeguards and supervision when clients were restrained due to maladaptive behaviors, as stated in rule.

  Corrected on February 11, 2025, verified by the state.

• High Restraint restrictions(R432-152-15(12)(a)-(d))

  The provider was out of compliance with this rule by not ensuring staff checked clients placed in restraints at least every 30 minutes, by not maintaining documentation of each check, did not ensure restraints did not cause physical injury to the client, and did not ensure staff provided and documented opportunities for motion and exercise for a period of not less than 10 minutes during each two hour period that a restraint was employed. During the inspection, 1 client was restrained by bilateral elbow immobilizers, did not receive checks of the restraint at least every 30 minutes, staff did not provide and document opportunity for motion and exercise of not less than 10 minutes every two hour period the restraint was used, and physical injury was not prevented. The elbow immobilizers were identified by the provider as having resulted in two pressure injuries to the client.

  How was this corrected? On 2/11/2025, the licensor verified the licensee ensured staff checked clients placed in restraints at least every 30 minutes and maintained documentation of each check.

  Corrected on February 11, 2025, verified by the state.

October 31, 2024 · Focus Inspection

• High Provider shall comply with policies and safe practices(R380-80-5(3))

  Based on observation, record review, and interview, it was determined that the provider did not ensure compliance with applicable written policies and safe practices that addressed the appropriate treatment of clients. During the inspection, two written policies were determined not to have been complied with, and subsequently, the death of 1 client was documented to have occurred. Client Identifier: 5. Findings include: Client 5 was admitted to the facility on 9/9/2020 with diagnoses that included mild intellectual disabilities and oppositional defiant disorder. The incident report, dated 10/4/2024 for Client 5, was reviewed. The incident report detailed that Client 5 had been found unresponsive, with vomit on his face and around his mouth. Cardiopulmonary resuscitation (CPR) was performed, and Emergency Medical Services (EMS) were called. Client 5 expired approximately one hour later. A nursing note, dated 10/4/2024 at 5:44 AM for Client 5, was reviewed and documented that Staff 2 and Staff 3 contacted the on-call Registered Nurse (RN) and informed them that Client 5 was unresponsive and had vomit in his mouth, on his face, and in his nose. The RN contacted the switchboard, who contacted the paramedics. Staff 2 and Staff 3 were noted to have contacted the RN again and asked if they should begin cardiopulmonary resuscitation (CPR). The RN was documented to have stated, "Yes." The RN later arrived at the scene with another RN and began CPR. The paramedics arrived and attempted to revive Client 5, but he was pronounced dead approximately 25 minutes after their arrival. On 10/21/2024 at 1:20 PM, Admin 2 was interviewed about the 10/4/2024 incident involving Client 5. When asked if Staff 2 and Staff 3 should have started CPR upon discovering Client 5 was unresponsive, Admin 2 stated, "Yes. It is our policy that all direct care staff will be trained in BLS [Basic Life Support], including CPR. They should not wait for the nurse before beginning CPR." The facility's Life Threatening Emergency Medical Care policy, last revised on 5/25/2021, was reviewed. According to the policy, all direct care staff at USDC were to be trained in BLS, which included first aid and CPR, and the use of associated emergency medical equipment - including an automated external defibrillator (AED) and staff would recertify as needed. Additionally, per the policy, staff would provide basic life support during a medical emergency to any USDC Individual in need, and staff would continue emergency procedures until relieved by emergency personnel or USDC nursing/medical staff. The facility's Bed Check Procedures policy, last revised 2/2023, was reviewed. According to the policy, all individuals were to be visually accounted for every hour while they were scheduled to be sleeping unless otherwise indicated in their person center plan or behavior support plan. Per the policy, a bed check form was to be filled out for each individual at USDC every night; the form was to include a list of all individuals with a minimum of one-hour visual checks. The last documented bed check before Client 5's death on 10/4/2024 at 3:21 AM was on 10/3/2024 at 10:00 PM. Two staff, Staff 2 and Staff 3, were documented to have worked in the area where Client 5 resided on the night of his death. Verification of current CPR certification was requested for Staff 2 and Staff 3. Staff 2 was observed to have an expired CPR certification in their employee file, with an issue date of 11/4/2020 and an expiration date of 11/4/2022. A current CPR certification was not provided. Staff 3 had a current CPR certification issued on 6/23/2023, with an expiration date of 6/23/2025. Following the review of the employee files, an interview was conducted with Admin 3, who acknowledged Staff 2 did not have current CPR certification as required by the facility's "Life Threatening Emergency Medical Care" policy. On 10/21/2024 at 5:30 PM, an interview was conducted with the facility Admin 1, who acknowledged the facility's "Life Threatening Emergency Medical Care" policy and "Bed Check Procedures" policy were not followed. On 10/31/2024, a review of the video surveillance footage from Client 5's former living area was conducted with Admin 4 and Admin 5. Client 5's former living area was observed to be adjacent to Client 5's former bedroom. The video footage showed that Staff 2 performed Client 5's last bed check observation at approximately 10:59 PM. The video surveillance did not capture any movement in the living area from approximately 11:42 PM to 2:22 AM. At 2:44 AM, Staff 2 was observed entering Client 5's room and immediately leaving to get Staff 3, another staff member who was working in the area at that time. At 2:45 AM, Staff 2 and Staff 3 were observed entering Client 5's room and then contacting someone on the telephone [presumably the on-call RN]. Approximately 5 minutes are observed to pass, with Staff 2 and Staff 3 were not observed to start CPR. At 2:50 AM, the on-call RN and the other RN are observed entering the living area and beginning CPR on Client 5. At 2:58 AM, the paramedics were observed to arrive, and the time of death was observed to be called at 3:22 AM. Admin 4 and Admin 5 were interviewed and acknowledged that Staff 2 and Staff 3 did not begin CPR immediately upon discovering Client 5, per the facility's policy. On 10/31/2024 at 1:02 PM, Staff 3 was interviewed regarding the incident that occurred on 10/4/2024 with Client 5. Staff 3 was asked if CPR was initiated by themselves or Staff 2 prior to Admin 9 and Admin 10 arriving at Client 5's unit. Staff 3 stated that they [Staff 2 and Staff 3] did not begin CPR as instructed by Admin 9. Staff 3 acknowledged that the initiation of CPR was delayed for Client 5. On 10/31/2024, telephone interviews were conducted with Admin 9 and Admin 10. Admin 9 and Admin 10 were identified as personnel involved in the incident with Client 5. Admin 9 and Admin 10 both stated that they began CPR upon arrival to Client 5's unit, that CPR was not initiated by Staff 2 and Staff 3, as per the facility policy, and that they acknowledged the delay in beginning CPR for Client 5.

  How was this corrected? On 2/11/2025, the licensor ensured the provider complied with policies and safe practices, as stated in rule.

  Corrected on February 11, 2025, verified by the state.

June 5, 2024 · Follow-Up Inspection

No citations from this inspection.

April 15, 2024 · Investigation Inspection

• High Abuse, neglect or exploitation policies and procedures(R432-152-7(4)(a)-(f))

  The provider was out of compliance with this rule by not ensuring that the abuse allegation investigation report results were reported within five working days of the incident. In addition, the facility did not ensure that their "Code of Conduct" policy was implemented. During the inspection, 6 incident reports were reviewed and one abuse allegation was not reported, by the administrator, within 5 working days from the incident. One incident report was reviewed and revealed that the staff did not follow procedure on the abuse of the individual.

  How was this corrected? On 6/5/2024, the licensor verified that the abuse allegation investigation report results were reported within five working days of the incident, as stated in rule.

  Corrected on June 5, 2024, verified by the state. · $200 penalty

• High Client Rights(R432-152-7(1)(a)-(n))

  The provider was out of compliance with this rule by not ensuring that clients were not subjected to physical, verbal, sexual or psychological abuse or punishment. During the inspection, 3 clients incident reports were reviewed; they revealed that these clients were potentially physically, verbally or psychologically abused by the facility staff.

  How was this corrected? On 6/5/2024, the licensor verified that that clients were not subjected to physical, verbal, sexual or psychological abuse or punishment, as stated in rule.

  Corrected on June 5, 2024, verified by the state. · $200 penalty