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)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 3
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, and staff competency at Holladay Healthcare Center.
Findings
The facility was found deficient in providing appropriate pressure ulcer care, ensuring a safe environment free from accident hazards, and verifying nurse aide training and competency. Specific issues included failure to consistently apply podus boots to prevent pressure ulcers, unsafe bathroom conditions for a cognitively impaired resident, unsecured oxygen tanks being carried improperly, and employment of a nurse aide without timely certification.
Deficiencies (3)
F 0686: The facility failed to ensure a resident received necessary treatment to prevent pressure ulcers. Specifically, podus boots were not consistently applied to resident 37's left foot despite physician orders.
F 0689: The facility failed to ensure adequate supervision and a safe environment to prevent accidents. Tools were left in a cognitively impaired resident's bathroom and oxygen tanks were carried unsecured in the hallway.
F 0728: The facility did not ensure nurse aides working more than 4 months were trained and competent. A nurse aide was employed full-time for approximately 8 months without completing required training and competency evaluation.
Report Facts
Residents sampled: 37
Residents affected: 1
Residents affected: 1
Nurse aide employment duration: 8
Inspection Report
Routine
Deficiencies: 11
Date: Mar 24, 2025
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident assessments, pressure ulcer care, accident prevention, respiratory care, staff competency, medication management, food service, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including timely completion of resident assessments, pressure ulcer prevention, accident hazard control, respiratory care orders, nurse aide competency, medication administration, food quality and safety, dish machine sanitation, and infection prevention practices.
Deficiencies (11)
F0636: The facility did not complete a comprehensive resident assessment every 12 months; one resident's annual Minimum Data Set was completed over 13 months after the previous assessment.
F0638: Quarterly Minimum Data Set assessments were not completed at least every 3 months for four residents, with assessments completed greater than 3 months apart.
F0686: The facility failed to ensure a resident received ordered podus boots to prevent pressure ulcers; observations showed the boots were not applied as ordered.
F0689: The facility failed to ensure adequate supervision and a safe environment; tools were left in a cognitively impaired resident's bathroom and oxygen tanks were carried unsecured in hallways.
F0695: The facility did not ensure respiratory care was provided with physician orders; one resident lacked an active oxygen order and orders for tubing and humidifier changes.
F0728: A nurse aide was employed full-time for approximately 8 months without completing required training and competency evaluation.
F0757: A resident's metoprolol was administered outside physician-ordered parameters despite low systolic blood pressure readings.
F0761: An opened insulin injector pen was labeled with an open date past 28 days and was available for use in the medication cart.
F0804: Food served was often cold, bland, and not as ordered; resident council minutes documented ongoing complaints about food quality and temperature.
F0812: Dish machine wash and rinse temperatures were below required levels for sanitation; staff were instructed to stop using the machine until corrected.
F0880: Hand hygiene was not performed between feeding multiple residents or when delivering lunch trays between rooms, increasing infection risk.
Report Facts
Sampled residents: 37
Days late for insulin pen use: 6
Dish machine sanitizer PPM: 200
Dish machine temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding late completion of Minimum Data Set assessments | |
| Staff Development (SD) | Interviewed about podus boots and meal tray delivery | |
| Licensed Practical Nurse (LPN) 1 | Interviewed about podus boots application and medication administration | |
| Assistant Director of Nursing (ADON) 1 | Interviewed about podus boots orders, medication administration, infection control expectations | |
| Maintenance Director (MD) | Interviewed about bathroom repairs and tools left in resident bathroom | |
| Dietary Manager (DM) | Interviewed about food complaints and dish machine sanitation | |
| Regional Nurse Consultant (RNC) 1 | Interviewed about nurse aide training and competency | |
| Clinical Resource Nurse (CRN) 1 | Interviewed about medication administration and oxygen orders | |
| Director of Nursing (DON) | Interviewed about infection control and food complaints |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 8, 2023
Visit Reason
The inspection was conducted due to multiple allegations of abuse, neglect, and medication errors reported at the facility involving several residents.
Complaint Details
The complaint investigation was triggered by allegations of abuse, neglect, and medication errors involving multiple residents (#34, #77, #242, #292, #14, #7, #75, #243). The facility failed to timely report abuse allegations, failed to conduct thorough investigations, and failed to maintain accurate medication records. Several interviews with facility staff confirmed these failures.
Findings
The facility failed to timely report allegations of abuse to the state survey agency for multiple residents, failed to thoroughly investigate abuse allegations, failed to protect residents from potential further abuse during investigations, failed to maintain accurate controlled medication records, and failed to ensure medications were administered and documented as ordered.
Deficiencies (5)
F0609: The facility failed to timely report allegations of physical and sexual abuse to the state survey agency for 4 of 5 residents reviewed.
F0610: The facility failed to thoroughly investigate allegations of abuse for 3 of 5 residents and failed to protect 2 residents from potential further abuse during investigations.
F0755: The facility failed to maintain an accurate account of controlled medication for 1 resident, with 13 oxycodone tablets unaccounted for on 06/16/2023.
F0760: The facility failed to ensure 1 resident was free from a significant medication error when a 75 mcg fentanyl patch was applied instead of the ordered 12 mcg dose.
F0842: The facility failed to document medication administration for 3 residents during a nurse's blackout shift and failed to transcribe medication orders to reflect the route of administration for 1 resident.
Report Facts
Unaccounted oxycodone tablets: 13
Fentanyl patch dose error: 75
Residents reviewed for abuse: 5
Residents with abuse reporting failures: 4
Residents with incomplete investigations: 3
Residents with medication documentation failures: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Worked half shift on 06/15/2023 and blacked out during second half, resulting in undocumented medication administration. |
| Certified Nursing Assistant #30 | Named in allegation of careless transfers and rough handling of Resident #242. | |
| Certified Nursing Assistant #16 | Named in allegation of abuse to Resident #34; removed from care on 05/05/2023 after investigation. | |
| Certified Nursing Assistant #1 | Named in allegation of neglect and rude behavior to Resident #77. | |
| Registered Nurse #22 | Received abuse allegation report from Resident #292 and reported to DON and ADON. | |
| Social Services Director | Responsible for reporting allegations to Administrator and state agency; acknowledged failures in timely reporting and investigation. | |
| Director of Nursing | Acknowledged failures in timely reporting, investigation, and medication administration oversight. | |
| Administrator | Expected timely reporting and thorough investigations; deferred nursing questions to DON. |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, respiratory care, medication administration documentation, and resident medical record maintenance at Holladay Healthcare Center.
Findings
The facility failed to ensure proper assessment and documentation for residents self-administering medications, appropriate storage of CPAP masks to prevent contamination, and complete medication administration records for several residents. Additionally, the facility did not transcribe medication orders to reflect changes in administration routes for a resident with a feeding tube.
Deficiencies (3)
F 0554: The facility failed to assess Resident #23 for safe self-administration of medications and lacked proper documentation and physician orders for self-administration despite the resident having inhalers at bedside.
F 0695: The facility failed to ensure CPAP masks for Residents #54 and #146 were stored to prevent contamination when not in use, with masks observed opened to air or improperly stored.
F 0842: The facility failed to document medication administration for Residents #7, #14, and #75 during a nurse's blackout shift and failed to transcribe medication orders to reflect enteral administration 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 self-administration assessment failure: 1
Residents affected by CPAP mask storage failure: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in relation to medication administration documentation failure during blackout shift on 06/15/2023 |
| RN #12 | Registered Nurse | Interviewed regarding Resident #23's inhaler use and lack of physician orders for self-administration |
| RN #6 | Registered Nurse | Interviewed regarding proper CPAP mask storage |
| Director of Nursing | Director of Nursing | Provided statements on medication self-administration assessment and CPAP mask storage expectations |
| Administrator | Facility Administrator | Provided statements on medication storage policies and expectations for staff compliance |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Dec 16, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding resident dignity during feeding, timely reporting of abuse allegations, adequacy of personal care and hygiene assistance, psychotropic medication use, food quality, feeding assistant training, and infection prevention and control practices.
Complaint Details
The investigation was complaint-driven, focusing on allegations of resident mistreatment, abuse reporting failures, inadequate personal care, inappropriate medication use, food quality complaints, untrained feeding assistance, and infection control lapses. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during feeding, failure to timely report an abuse allegation to Adult Protective Services, inadequate bathing assistance for dependent residents, inappropriate use of antipsychotic medication without documented necessity, poor food palatability and temperature control, untrained staff providing feeding assistance, and lapses in infection prevention and control practices including improper use of PPE and failure to follow transmission-based precautions.
Deficiencies (7)
F 0550: Facility staff were observed standing while feeding residents on the memory care unit, failing to treat residents with dignity and respect. Resident identifiers: 10, 45, and 55.
F 0609: An allegation of abuse involving resident 66 was not reported to Adult Protective Services within required timeframes.
F 0677: Two residents (36 and 44) did not receive showers or bathing assistance in a timely manner, failing to maintain good personal hygiene.
F 0758: Resident 73 was prescribed Seroquel for Alzheimer's disease without documented necessity; no delusions or hallucinations were observed or documented.
F 0804: Four residents (25, 40, 49, 67) reported food was often cold, unpalatable, and unattractive; test tray items were served at unsafe temperatures and vegetables were overcooked.
F 0811: A non-medical concierge staff member provided feeding assistance to resident 45 without completing required state-approved training.
F 0880: Infection prevention and control program deficiencies included staff not properly wearing masks and eye protection, failure to perform hand hygiene, and failure to follow transmission-based precautions for resident 229 in quarantine.
Report Facts
Residents sampled: 40
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Assistant | Observed feeding residents standing, involved in dignity and respect deficiency |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding feeding practices and feeding assistant observations |
| Speech Therapist | Speech Therapist | Observed feeding resident 45 and interviewed about feeding techniques |
| Administrator | Facility Administrator and Abuse Coordinator | Interviewed regarding abuse reporting procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting, shower schedules, medication use, and feeding assistant policies |
| CNA 2 | Certified Nursing Assistant | Interviewed about shower schedules and resident care |
| LPN 1 | Licensed Practical Nurse | Interviewed about resident care and medication use |
| Dietary Manager | Dietary Manager | Interviewed about food temperature and meal service |
| Concierge Staff | Non-medical aide | Observed feeding resident 45 without required training |
| Maintenance Staff 1 | Maintenance Staff | Observed entering resident 229's room without proper PPE and hand hygiene |
| RN 2 | Registered Nurse | Observed with improper mask and eye protection use |
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