Inspection Reports for Holladay Healthcare Center
4782 South Holladay Boulevard, Salt Lake City, UT, 84117
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 24, 2025
Visit Reason
The inspection was conducted based on complaints regarding inadequate pressure ulcer care, unsafe environment hazards, and nurse aide competency at Holladay Healthcare Center.
Complaint Details
The complaint investigation included allegations of inadequate pressure ulcer prevention for resident 37, unsafe environment hazards including tools left in a bathroom and unsecured oxygen tanks, and employment of an uncertified nurse aide for over 4 months. Substantiation is implied by the findings.
Findings
The facility failed to ensure appropriate pressure ulcer prevention for a resident, left hazardous tools accessible to a cognitively impaired resident, improperly handled oxygen tanks, and employed a nurse aide without proper certification for over 8 months.
Deficiencies (3)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for resident 37.
Failure to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents; tools left in bathroom of cognitively impaired resident and unsecured oxygen tanks carried in hallway.
Failure to ensure nurse aides working more than 4 months were trained and competent; a nurse aide worked approximately 8 months without completing required training and competency evaluation.
Report Facts
Residents sampled: 37
Resident cognitive score: 15
Resident cognitive score: 7
Nurse aide employment duration: 8
Nurse aide hire date: Feb 9, 2024
Nurse aide certification date: Oct 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Interviewed regarding podus boot application and verification. |
| Assistant Director of Nursing 1 | ADON | Interviewed regarding podus boot orders and resident supervision. |
| Staff Development | SD | Interviewed about communication of podus boot orders to CNAs. |
| Regional Nurse Consultant 1 | RNC | Interviewed about nurse aide certification and employment. |
| Clinical Resource Nurse 1 | CRN | Interviewed about proper oxygen tank handling. |
| Director of Nursing | DON | Interviewed about resident 47's behavior and safety measures. |
| Nurse Aide SM 1 | Nurse Aide | Employed full-time approximately 8 months without completing training and competency evaluation. |
Inspection Report
Routine
Deficiencies: 11
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, pressure ulcer care, accident prevention, respiratory care, nurse aide training, medication management, food service, and infection control.
Findings
The facility was found deficient in timely completion of resident assessments, pressure ulcer prevention, accident hazard prevention, respiratory care orders, nurse aide competency, medication administration, drug labeling, food quality and temperature, dish machine sanitation, and infection prevention practices including hand hygiene.
Deficiencies (11)
Failure to complete comprehensive resident assessments every 12 months in a timely manner.
Failure to update resident assessments at least once every 3 months.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Failure to provide safe and appropriate respiratory care due to lack of physician orders for oxygen and tubing changes.
Failure to ensure nurse aides working more than 4 months were trained and competent.
Failure to ensure each resident's drug regimen was free from unnecessary drugs; metoprolol administered outside ordered parameters.
Failure to label drugs and biologicals in accordance with professional principles; insulin pen used beyond 28 days.
Failure to provide food that was palatable, attractive, and served at a safe and appetizing temperature.
Failure to store, prepare, distribute and serve food in accordance with professional standards; dish machine temperatures below required sanitation levels.
Failure to provide and implement an infection prevention and control program; hand hygiene not performed between residents during feeding or when delivering lunch trays.
Report Facts
Sample residents: 37
Residents with late annual MDS: 1
Residents with late quarterly MDS: 4
Opened insulin pen days: 34
Food temperature - meat: 138
Food temperature - rice: 113
Food temperature - peas: 118
Food temperature - dessert: 56.3
Food temperature - milk: 44
Dish machine wash temperature: 100
Dish machine rinse temperature: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SM 1 | Nurse Aide | Employed full-time approximately 8 months without completion of training and competency evaluation program |
| ADON 1 | Assistant Director of Nursing | Interviewed regarding multiple deficiencies including pressure ulcer care, accident hazards, medication administration, insulin labeling, respiratory care, and infection control |
| CRN 1 | Clinical Resource Nurse | Interviewed regarding medication administration and respiratory care |
| DM | Dietary Manager | Interviewed regarding food quality complaints and dish machine sanitation |
| DON | Director of Nursing | Interviewed regarding infection control and food service complaints |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Sep 8, 2023
Visit Reason
The inspection was conducted due to allegations of physical and sexual abuse and neglect reported for multiple residents, as well as concerns about medication errors and failure to follow proper medication administration procedures.
Complaint Details
The complaint investigation involved allegations of physical and sexual abuse and neglect for residents #34, #292, #77, #242, and others. The facility failed to timely report these allegations to the state survey agency and failed to conduct thorough investigations. Some allegations were not reported at all or were reported late. The facility also failed to protect residents from further potential abuse during investigations.
Findings
The facility failed to timely report allegations of abuse to the state survey agency for 4 of 5 residents reviewed, failed to thoroughly investigate allegations of abuse for 3 residents, failed to protect 2 residents from further potential abuse during investigations, failed to maintain accurate controlled medication records for 1 resident, and failed to ensure medications were administered and documented as ordered for multiple residents.
Deficiencies (6)
Failed to timely report allegations of physical and sexual abuse to the state survey agency for 4 residents.
Failed to thoroughly investigate allegations of abuse for 3 residents and failed to protect 2 residents from further potential abuse during investigations.
Failed to maintain an accurate account of controlled medication for 1 resident; 13 oxycodone tablets were unaccounted for.
Failed to ensure medications were administered and documented as ordered for 3 residents; missing documentation and blacked out nurse shift.
Failed to ensure a resident was free from significant medication error; a 75 mcg fentanyl patch was applied instead of the ordered 12 mcg patch.
Failed to transcribe physician orders to reflect the route of medication administration for 1 resident.
Report Facts
Residents reviewed for abuse and/or neglect: 5
Residents with failure to timely report abuse: 4
Residents with failure to thoroughly investigate abuse: 3
Residents not protected from further abuse during investigation: 2
Oxycodone tablets unaccounted for: 13
Fentanyl patch dose error: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Nurse who blacked out during shift on 06/15/2023, resulting in undocumented medication administration. |
| RN #22 | Registered Nurse | Reported abuse allegation from Resident #292 and notified DON and ADON. |
| CNA #30 | Certified Nursing Assistant | Alleged to have been careless with transfers and grabbed Resident #242's arm. |
| CNA #16 | Certified Nursing Assistant | Alleged perpetrator in abuse incident with Resident #34; removed from direct care after investigation. |
| CNA #1 | Certified Nursing Assistant | Alleged to have refused to change Resident #77's clothes and was rude. |
| Social Services Director | Interviewed regarding reporting and investigation of abuse allegations. | |
| Director of Nursing | Responsible for reporting abuse allegations and investigating incidents; acknowledged failures in reporting and investigation. | |
| Administrator | Expected timely reporting and thorough investigation of abuse allegations. |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess compliance with medication self-administration policies, respiratory care practices, medication administration documentation, and proper transcription of medication orders.
Findings
The facility failed to ensure proper assessment and documentation for residents self-administering medications, safe storage of CPAP masks to prevent contamination, and accurate medication administration records for multiple residents. Additionally, the facility did not transcribe medication orders to reflect changes in administration routes for one resident.
Deficiencies (3)
Failed to ensure Resident #23 was assessed for self-administration of medication as required by facility policy.
Failed to ensure CPAP masks were stored to prevent contamination for Residents #54 and #146.
Failed to ensure documented evidence of medication administration for Residents #7, #14, and #75 during a nurse's blackout shift and failed to transcribe medication orders to reflect route changes for Resident #243.
Report Facts
Residents sampled: 18
Residents reviewed for respiratory care: 3
Residents affected by medication administration documentation failure: 3
Residents affected by transcription failure: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in medication administration documentation failure during blackout shift |
| RN #12 | Registered Nurse | Interviewed regarding Resident #23's medication self-administration |
| RN #6 | Registered Nurse | Interviewed regarding CPAP mask storage |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration and CPAP mask storage |
| Administrator | Administrator | Interviewed regarding medication storage and facility policy adherence |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 16, 2021
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, timely reporting of abuse allegations, provision of activities of daily living such as bathing, appropriate use of psychotropic medications, food palatability and temperature, feeding assistant training, and infection prevention and control practices.
Deficiencies (7)
Facility staff were observed standing while feeding residents on the memory care unit, which did not promote dignity.
Failure to timely report an allegation of abuse to Adult Protective Services.
Two dependent residents did not receive showers or bathing assistance in a timely manner.
Resident received psychotropic medication (Seroquel) without documented necessity for the specific condition.
Food served was not consistently palatable, attractive, or at a safe and appetizing temperature.
A Concierge staff member provided feeding assistance without completing a State-approved training course.
Transmission-based precautions and PPE guidelines were not consistently followed, including improper mask use and lack of hand hygiene.
Report Facts
Residents sampled: 40
Residents affected by dignity deficiency: 3
Residents affected by abuse reporting deficiency: 1
Residents affected by bathing deficiency: 2
Residents affected by psychotropic medication deficiency: 1
Residents affected by food palatability deficiency: 4
Residents affected by feeding assistant training deficiency: 1
Residents affected by infection control deficiency: 3
Temperature of breaded chicken on test tray: 72.4
Temperature of spaghetti noodles on test tray: 104
Temperature of broccoli on test tray: 94
Temperature of chicken before service: 165
Temperature of broccoli/cauliflower before service: 160
Temperature of noodles before service: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Assistant | Observed feeding residents and interviewed regarding feeding practices |
| CNA 8 | Certified Nursing Assistant | Interviewed about feeding assistance and dementia training; observed feeding residents |
| Speech Therapist | Speech Therapist | Observed feeding resident and interviewed about feeding techniques |
| Administrator | Facility Administrator and Abuse Coordinator | Interviewed about abuse reporting procedures |
| Director of Nursing | Director of Nursing | Interviewed about abuse reporting, bathing schedules, medication use, feeding assistant policies, and infection control |
| Resident Advocate | Resident Advocate | Responsible for abuse investigations and reporting |
| CNA 2 | Certified Nursing Assistant | Interviewed about bathing schedules and resident care |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed about resident care, bathing schedules, and medication use |
| Dietary Manager | Dietary Manager | Interviewed about food preparation and complaints |
| Concierge Staff / Non-Medical Aide | Concierge Staff / Non-Medical Aide | Observed feeding resident without training; interviewed about role |
| CNA Coordinator | Certified Nursing Assistant Coordinator | Interviewed about feeding assistant training and policies |
| Laundry Staff | Laundry Staff | Observed with improper PPE use and interviewed about PPE policies |
| Maintenance Staff 1 | Maintenance Staff | Observed entering isolation room without proper PPE or hand hygiene |
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