A new investigation by FOX 13 News finds that chronic understaffing in Utah’s nursing homes is leaving residents without showers for days, lying in their own waste, and in some cases facing far more serious consequences — including sexual abuse, dangerous wandering, and death.
According to FOX 13 News, a review of thousands of pages of federal inspection reports and dozens of lawsuits filed in Utah courts since 2019 reveals that staffing is a pervasive and recurring problem across the state’s long-term care facilities. About one third of Utah’s 97 nursing homes currently hold “below average” or “much below average” staffing ratings from the Centers for Medicare and Medicaid Services. The state’s average nursing home staff turnover rate is 51% — higher than the national average of 46%.
FOX 13 identified at least 15 Utah facilities cited by federal regulators for insufficient staffing since 2019. The consequences documented in those inspection reports are direct and serious. At one Provo facility, a resident was sent to the hospital with acute sepsis after staff told inspectors the facility “was so short staffed” they had been unable to check catheter bags. A resident at an Orem center told inspectors the facility “was so understaffed that she could be dead and no one would notice.” At an Ogden facility, an administrator allowed a nurse with a history of missing narcotics to continue working with patients — even after she arrived appearing intoxicated, with red and watery eyes, repeatedly scratching at her face and chest. When inspectors asked why, the administrator said: “I don’t have anyone else to work, and agency nurses charge $85 an hour.”
The investigation also centers on Lesa Fonoti, a registered nurse whose mother, “Leu” Togiola, died on April 5, 2023 at a Taylorsville nursing home then known as Sandstone Taylorsville. Togiola, 79, had moved into the facility after suffering a stroke in 2020. In early April 2023, Fonoti received a call about a bruise on her mother’s thigh. A scan revealed a broken femur. Despite documented pain and visible bruising, the facility left Togiola in bed with the undiagnosed fracture for at least 12 hours before transporting her to the hospital, according to a lawsuit Fonoti filed. The facility never investigated how the injury occurred to an immobile patient. At the hospital, doctors recommended surgery — but Togiola crashed during recovery and died that night. The lawsuit alleges the facility failed “to budget for and provide sufficient staffing levels to meet the needs of residents.” Sandstone Healthcare Group did not respond to requests for comment. Both Sandstone and Gunnison Valley — the government entity that owns the facility through Utah’s Upper Payment Limit program and has received $34.4 million in federal care-improvement funds since 2019 — have denied wrongdoing.
Alianne Sipes, Utah’s Long-Term Care Ombudsman, told FOX 13: “Staffing is the root cause of almost all concerns that we see in facilities.” Barry Toone, an attorney with the Elder Care Injury Group who is pursuing malpractice complaints against several Utah nursing homes, said: “We look at it as a question of life or death. If you don’t have enough people to take care of these residents, things will get missed. Mistakes will get made. And those mistakes have very real consequences.”
A University of Pennsylvania analysis estimated that the now-repealed Biden-era federal staffing mandate — which would have set minimum nursing care hours per resident per day and required a registered nurse on-site 24/7 — would have saved approximately 13,000 lives per year nationally, and up to 100 lives annually in Utah. A 2024 American Health Care Association report showed that 30% of Utah nursing homes were not meeting the proposed minimum care hours, and about 70% lacked a registered nurse available around the clock. The rule was repealed following heavy industry lobbying, with the nursing home industry citing workforce shortages. Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, responded: “These are multibillion-dollar industries. And to say that a staffing rule that will assure better patient care is going to cripple them, I think, is really ridiculous.”
Utah’s experience with understaffing is not an outlier — it is a window into a national crisis. The specific harms FOX 13 documents are consistent with what federal inspection data show across the country: when facilities operate below safe staffing thresholds, residents don’t receive timely medications, don’t get turned and repositioned to prevent pressure ulcers, are left in soiled linens, and are not monitored closely enough to catch medical emergencies before they become fatal. High turnover compounds the problem. The National Consumer Voice for Quality Long-Term Care found that nursing homes with turnover rates between 50% and 59% are cited for abuse one and a half times more often than facilities with lower turnover.
The repeal of the federal staffing mandate removes a floor that advocates argue would have protected the most vulnerable residents — those in the worst-staffed facilities. Without that minimum standard, advocates say the status quo of chronic understaffing, high turnover, and inadequate oversight will continue, and residents will continue to bear the consequences.
Understaffing is not an abstraction. It is the direct cause of some of the most serious and preventable harms in nursing home care — pressure ulcers that develop because no one turned a resident, infections that spread because catheter bags went unchecked, falls that happen because there was no one to assist with mobility, and medical emergencies that go unrecognized because staff are stretched across too many residents to notice warning signs. When a facility knowingly operates below safe staffing levels and a resident is harmed as a result, that is neglect — and the facility may bear legal responsibility for the consequences.
If your family member has experienced a serious injury, medical decline, or preventable harm in a nursing home or assisted living facility, you have the right to know what happened and why. Contact us to speak with one of our experienced attorneys about your options.
FOX 13 News Utah — FOX 13 Investigates
https://www.fox13now.com/news/fox-13-investigates/a-question-of-life-or-death-how-understaffing-affects-care-in-utahs-nursing-homes
