When an older adult dies in a Utah nursing home or assisted living facility, there is often no formal investigation into whether that death was preventable. A new investigation by FOX 13 News finds that this gap in oversight is leaving families without answers — and allowing the same failures to happen again.
FOX 13 News identified at least 24 cases in Utah’s assisted living facilities and nursing homes since 2019 that raised questions of negligence, inadequate staffing, medical errors, or poor staff training. Federal regulators cited the state’s nursing homes for their role in six deaths during that period, according to a review of thousands of pages of federal inspection reports.
Among the cases documented: a resident who developed bed sores that led to sepsis; a medication error that resulted in a possible accidental overdose; and a resident who allegedly choked to death on a breakfast burrito that was not safe for him to eat. These are the kinds of preventable harms advocates say are contributing to the premature deaths of vulnerable older adults who rely on these facilities for their most basic care needs.
Nate Crippes, an attorney with the nonprofit Disability Law Center of Utah, told FOX 13 News: “I’ve certainly seen reports of deaths that didn’t make a lot of sense. You look at enough of these and you really see the same problems over and over again.” He argues many of these fatalities do not receive the scrutiny they deserve — in part because of a presumption that older adults in care settings were simply bound to die.
In Utah, deaths in nursing homes and assisted living facilities are generally not reviewed by the state’s Fatality Review Committees, which are designed to identify systemic failures and prevent future harm. Those committees do review deaths only if the resident had an open Adult Protective Services case at the time of death or in the prior year — and only if the cause of death was deemed a homicide, suicide, or undetermined. Deaths attributed to neglect or poor care that fall outside those narrow categories receive no formal review.
Crippes noted that Utah ranked 39th in the country for financial penalties against nursing homes over a recent three-year period, with an average survey-based fine of about $14,000 per facility. “Ultimately, the cost to them matters,” he said. “And so I think if the state is unwilling to impose serious fines on places, that does seem problematic.” His proposed solution — requiring broader fatality reviews system-wide — has been met with skepticism by some lawmakers, one of whom told him many nursing home deaths simply would not be suspicious. “I’m not going to disagree that when you’re talking about an aging population, a lot of people probably are going to pass away in facilities,” Crippes responded. “But again, I don’t think it’s too much to ask to really take a look at what were the circumstances.”
One of the cases at the center of the investigation involves Ruth Ditty, a retired registered nurse and nursing instructor who moved to Covington Senior Living in Orem in 2022 as her dementia progressed. According to a lawsuit filed by her family, she fell regularly as her health declined. Her last fall was down a stairwell after church services. She broke her shoulder and suffered traumatic head injuries. The lawsuit alleges she lay injured and unattended for more than six hours before she was found, that staff did not call 911 or bring in a doctor, and that she was instead lifted, walked down the hall, placed in a wheelchair, and put to bed. She was then given morphine by a hospice agency despite a known allergy to it. She died on January 24, 2024, from what the lawsuit alleges was an untreated brain bleed. The complaint also accuses Covington of encouraging the family to pay approximately $5,450 per month for ancillary services — including two-hour wellness checks that the lawsuit alleges were not performed the day Ruth Ditty spent more than six hours in the stairwell. Covington has denied all claims of wrongdoing.
Rachel Sykes, an attorney who has represented clients against long-term care facilities, told FOX 13 News: “Sadly, sometimes the only way to hold these facilities accountable is through litigation. The family and victims that have lost a loved one due to nursing home abuse or neglect would love to see more oversight and love to see more accountability from the agencies that regulate and look at what’s going on in these facilities.”
The Utah Health Care Association said in a statement that providers operate “under some of the most rigorous oversight in health care,” and that “allegations raised in lawsuits are not findings of fact.”
The accountability gap that FOX 13 documents in Utah is not unique to that state. A 2011 ProPublica investigation found that suspicious deaths of older adults are rarely thoroughly investigated nationwide. Arkansas stands as an outlier — it requires reviews even of nursing home fatalities attributed to natural causes. In the first four and a half years after that law took effect, the Pulaski County Coroner reported 86 deaths due to suspected resident neglect to state regulators. A U.S. Government Accountability Office report on those referrals concluded that the “serious, undetected care problems identified by the Pulaski County coroner are likely a national problem not limited to Arkansas.” More than two-thirds of those cases listed pressure sores as the primary indicator of neglect.
When nursing home residents die, the cause is frequently attributed to age, pre-existing conditions, or the natural progression of illness — without any formal inquiry into whether failures of staffing, supervision, medication management, or basic care contributed. Low financial penalties compound the problem: without meaningful consequences, the same failures repeat. Crippes put it plainly: “I think a lot of our system is yeah, we just say, ‘Oh, you did this wrong, don’t do this again, here’s your plan of correction.’ And then a week later the same thing happens and we’re going to do the same thing. You know, at the end of the day, that’s not going to solve any problem.”
The pattern FOX 13 describes — preventable deaths, inadequate investigations, low penalties, repeat violations — is one we see reflected in cases across the country. Bed sores that progress to sepsis, medication errors, fall deaths after hours of being undiscovered: these are not inevitable outcomes of aging. They are the foreseeable results of facilities that are understaffed, undertrained, or simply not held to account. Families who lose a loved one in a nursing home or assisted living facility often have no idea whether their loss was truly preventable — because no one looked closely enough to find out.
If you believe a family member died or was seriously harmed due to neglect in a long-term care setting, you deserve honest answers. Contact us to speak with one of our experienced attorneys about what happened and what options may be available to your family.
FOX 13 News Utah — FOX 13 Investigates
https://www.fox13now.com/news/fox-13-investigates/deaths-of-older-adults-in-long-term-care-often-underexamined-advocates-say
