Inspection Reports for
Sandy Health and Rehab
50 East 9000 South, Sandy, UT, 84070
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
22.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
189% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Routine
Deficiencies: 10
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care, food service, infection control, and other facility operations.
Findings
The facility was found deficient in several areas including residents' rights to manage financial affairs, maintenance and cleanliness of shower rooms, timely medical treatment, proper documentation of lab and radiology reports, food quality and safety, accommodation of resident allergies, vaccination administration, and functioning call light systems in bathing areas.
Deficiencies (10)
Facility did not provide residents with the right to manage their financial affairs, with limited access to personal funds on weekends.
Facility failed to maintain a safe, clean, comfortable, and homelike environment; shower rooms were in disrepair and malodorous.
Resident had a delay in getting sutures removed, not receiving treatment according to professional standards and care plan.
Facility did not keep complete, dated laboratory records in the resident's record; missing serum phenytoin and phenobarbital lab results.
Facility did not keep signed and dated reports of x-rays and other diagnostic services in the resident's record.
Facility did not provide food that was palatable, attractive, and served at a safe and appetizing temperature; multiple residents complained about food quality and temperature.
Facility failed to provide food that accommodated resident allergies; a resident was served food containing peas despite allergy.
Facility did not store, prepare, distribute, and serve food in a sanitary manner; staff observed touching food and plates with dirty gloves and using unclean cutting boards.
Facility did not ensure that each resident was offered and administered influenza, pneumococcal, and COVID-19 vaccines as required.
Facility was not adequately equipped with working call systems in residents' bathroom and bathing areas; call lights in shower rooms were non-functional or missing cords.
Report Facts
Sample residents: 41
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 14
Residents affected: 1
Residents affected: 3
Residents affected: 1
Food temperatures: 66
Food temperatures: 63
Food temperatures: 40
Food temperatures: 153.7
Food temperatures: 146.5
Food temperatures: 160.9
Food temperatures: 43.2
Food temperatures: 64.1
Food temperatures: 43.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding resident financial affairs access |
| Administrator | Administrator | Interviewed regarding resident financial affairs and food quality |
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Interviewed regarding shower room odor complaints |
| Maintenance Director | Maintenance Director | Interviewed regarding shower room maintenance and mold |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Interviewed regarding shower room odor complaints |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding shower room cleaning |
| Housekeeping Staff | Housekeeping Staff | Interviewed regarding shower room cleaning |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Interviewed regarding odor complaints and maintenance reporting |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding resident suture care |
| Director of Nursing | Director of Nursing | Interviewed regarding resident suture care and lab record handling |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding lab records and vaccination procedures |
| Medical Records | Medical Records Staff | Interviewed regarding lab record uploading |
| Registered Nurse 1 | Registered Nurse | Interviewed regarding resident pneumonia care |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and allergy issues |
| Dietary Aide 1 | Dietary Aide | Observed during food service with glove hygiene issues |
| Cook 1 | Cook | Observed during food service with glove hygiene issues |
| Certified Nursing Assistant 6 | Certified Nursing Assistant | Interviewed regarding call light system in shower rooms |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed regarding call light system in shower rooms |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide residents with the right to manage their financial affairs, specifically access to personal funds on weekends.
Complaint Details
The visit was complaint-related, investigating grievances from residents 30 and 295 about lack of access to funds on weekends. The complaint was substantiated based on interviews and record reviews.
Findings
The facility did not provide residents with reasonable access to their personal funds on weekends due to limited staff availability and cash shortages. Interviews and grievance reviews confirmed that residents had to wait until weekdays to access their money, and there were gaps in the process for fund disbursement.
Deficiencies (1)
Facility did not provide residents with the right to manage their financial affairs, specifically access to personal funds on weekends.
Report Facts
Sample residents reviewed: 41
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding resident funds access and management |
| Administrator | Administrator | Interviewed regarding fund disbursement process and gaps |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 13, 2025
Visit Reason
The inspection was a complaint investigation combined with an unannounced annual inspection conducted from April 13 to April 16, 2025.
Complaint Details
The inspection was complaint-related as well as an unannounced annual inspection. Specific substantiation status is not stated.
Findings
The inspection identified 7 rule noncompliances related to various regulatory requirements including resident care, staff qualifications, medication management, resident rights, and facility maintenance. The facility was found non-compliant in several areas such as resident care plans, medication error monitoring, and emergency preparedness.
Deficiencies (7)
Failure to ensure residents receive necessary care and services to maintain or improve their abilities.
Failure to maintain complete and accurate medical records for each resident.
Failure to provide a safe, clean, and comfortable environment and maintain buildings and grounds in good repair.
Failure to ensure proper medication management including monitoring medication errors and proper storage.
Failure to ensure resident rights are protected including privacy, visitation, and freedom from abuse.
Failure to maintain adequate staffing and ensure staff qualifications and training.
Failure to develop and implement an emergency response and preparedness plan including fire safety and disaster drills.
Report Facts
Number of rule noncompliances: 7
Inspection start date: Apr 13, 2025
Inspection end date: Apr 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tim Needles | Administrator | Named as the individual informed of the inspection. |
| Jami Sutch | Licensor | One of the licensors conducting the inspection. |
| Tiffany Stone | Licensor | One of the licensors conducting the inspection. |
| Taryn Degroot | Licensor | One of the licensors conducting the inspection. |
| Jessica Bolander | Licensor | One of the licensors conducting the inspection. |
| Marcie Price | Licensor | One of the licensors conducting the inspection. |
| Nicole Kololli | Licensor | One of the licensors conducting the inspection. |
| Cathie Bristow | Licensor | One of the licensors conducting the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 15, 2024
Visit Reason
The inspection was conducted based on complaints and allegations including housekeeping deficiencies, failure to thoroughly investigate neglect allegations, inadequate treatment and care for wounds, elopement incidents, and medication errors.
Complaint Details
The complaint investigation involved 28 sampled residents. Specific complaints included failure to maintain a clean environment, inadequate investigation of neglect allegations, failure to provide appropriate wound care, elopement incidents resulting in injury, and medication administration errors. Resident 7's neglect allegation was not thoroughly investigated. Residents 10 and 26 had multiple elopements with resulting harm. Medication errors involved residents 15 and 26.
Findings
The facility was found deficient in maintaining a clean environment, properly investigating neglect allegations, providing appropriate wound care and treatment, preventing resident elopements, and ensuring timely administration of medications. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (5)
Facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; black spots observed in resident showers.
Facility did not have evidence that allegations of neglect were thoroughly investigated for a resident who fell and sustained injury.
Facility did not ensure all residents received treatment and care according to orders; one resident did not receive treatment to a full thickness laceration and another had wounds with no documented measurements.
Facility did not ensure resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents; two residents eloped and sustained burns or were found outside wearing wander guards.
Facility did not ensure residents were free from significant medication errors; antibiotics were not administered as ordered to residents with wounds and burns.
Report Facts
Residents sampled: 28
Fall incident date: Jan 26, 2024
Laceration measurement: 1
Wound measurements: 210.5
Wound measurements: 125.4
Wander guard order dates: 6
Medication order date: Aug 4, 2024
Inspection Report
Annual Inspection
Deficiencies: 32
Date: Jul 31, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity and respect, loss of residents' personal possessions, inadequate accommodation of resident needs, failure to provide timely access to medical records, unsanitary and unsafe living conditions, failure to resolve grievances, abuse and neglect incidents, inaccurate resident assessments, inadequate care and supervision, medication errors, failure to provide adequate nutrition and hydration, improper food storage and handling, inadequate respiratory care, and insufficient quality assurance and performance improvement activities.
Deficiencies (32)
Staff did not knock prior to entering resident rooms and dietary manager was disrespectful to residents.
Residents' clothing was lost and inventory sheets were not completed or located.
Facility did not provide return transportation to a resident on two separate occasions after leave of absence.
Resident's legal representative was not provided timely access to medical records despite multiple requests.
Facility shower rooms were dirty and residents' rooms were cold, dirty, and in disrepair; smoking area exit door malfunctioned causing injury.
Resident's grievance regarding missing clothing was not filed or resolved promptly.
Resident reported agency CNA sexually assaulted her months prior; allegation was not verified due to insufficient evidence.
Resident fell off bed during transfer by agency CNA; resident sustained femur fracture; CNA continued to work with resident despite incident.
Resident's left leg was tied to wheelchair footrest with cloth strip tied in a knot, constituting a restraint without proper assessment or monitoring.
Residents verbally and physically abused each other; incidents not always reported timely or managed effectively.
Facility failed to provide timely access to medical records and delayed release of requested records.
Facility did not maintain sanitary, comfortable, and homelike environment; multiple maintenance and housekeeping issues noted.
Resident's clothing was lost and inventory sheets were not completed or located; grievance not filed.
Resident was not provided reasonable accommodation for needs and preferences related to leave of absence.
Resident's legal representative was not provided timely access to medical records despite multiple requests.
Facility failed to provide timely and adequate care for residents' personal possessions, including clothing.
Facility failed to provide adequate nutrition and hydration; residents experienced significant weight loss without timely interventions.
Facility failed to provide adequate supervision and assistance to prevent accidents; residents eloped, water temperatures were unsafe, and falls were not properly managed.
Facility failed to provide or obtain laboratory services as ordered and failed to maintain lab results in resident records.
Facility failed to provide or obtain routine and emergency dental care; resident was not provided dentures or follow-up dental care.
Facility failed to provide food that met nutritional needs; menus were not followed and residents complained about food quality and quantity.
Facility failed to provide food and snacks that were palatable, attractive, and at safe and appetizing temperatures; residents complained about food quality and limited snack options.
Facility failed to provide adequate respiratory care; residents did not receive CPAP machines or care as ordered, and equipment was not cleaned properly.
Facility failed to ensure nursing staff and aides had appropriate competencies and skills; improper transfer techniques resulted in resident injury and lack of fall assessments after falls.
Facility failed to label and store drugs and biologicals properly; expired insulin pens and unlocked narcotic box were observed.
Facility failed to obtain laboratory tests as ordered and failed to maintain lab results in resident records.
Facility failed to provide timely dental care and follow-up for residents with dental needs.
Facility failed to provide adequate bathing and hygiene care; residents missed showers and refusals were not properly documented or managed.
Facility failed to provide adequate activities to meet residents' interests and needs; one-on-one activities were not provided as planned.
Facility failed to provide adequate nutrition and hydration; residents experienced weight loss and pressure sores without timely and appropriate interventions.
Facility failed to provide food that met nutritional needs; menus were not followed and residents complained about food quality and quantity.
Facility failed to maintain adequate ventilation; strong odors of urine, stool, and body odor were observed throughout the facility.
Report Facts
Medication errors: 7
Weight loss percent: 21
Weight loss percent: 6.8
Weight loss percent: 16
Weight loss percent: 10.7
Weight loss percent: 17.9
Weight loss percent: 15.3
Freezer temperature: 42
Freezer temperature: 51.7
Freezer temperature: 20
Freezer temperature: 31
Freezer temperature: 37
Freezer temperature: 35
Freezer temperature: 118
Medication error rate: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency CNA 1 | Certified Nursing Assistant | Involved in resident fall causing femur fracture and continued to work with resident |
| Dietary Manager | Reportedly disrespectful to residents and responsible for food portion and snack issues | |
| Resident Advocate | Involved in resident grievance and mental health service coordination | |
| Administrator 1 | Administrator | Conducted investigation of resident fall and abuse allegations, involved in QAPI |
| Administrator 2 | Administrator | New administrator involved in QAPI and facility oversight |
| Certified Nursing Assistant Coordinator | Provided education on transfers and restraints | |
| Licensed Practical Nurse 1 | Administered medication and involved in resident care | |
| Registered Nurse 1 | Involved in resident fall assessment and care | |
| Registered Nurse 9 | Involved in resident fall assessment and care | |
| Physical Therapy Director | Provided training on resident transfers and mobility aids | |
| Corporate Director of Nutrition Services | Provided dietary oversight and staff education | |
| Registered Dietitian | Conducted kitchen audits and dietary assessments | |
| Wound Nurse | Provided wound care and assessments | |
| Social Services Assistant | Involved in resident grievance and mental health service coordination | |
| Masters of Therapeutic Recreation Services | Provided activity programming and recommended staffing | |
| Certified Nursing Assistant 9 | Involved in resident transfer resulting in injury | |
| Certified Nursing Assistant 10 | Involved in resident transfer resulting in injury | |
| Certified Nursing Assistant 13 | Provided information on shower scheduling and refusals |
Inspection Report
Annual Inspection
Deficiencies: 21
Date: Jul 31, 2023
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity, loss of personal possessions, inadequate care planning, insufficient staff competencies, medication errors, inadequate infection control, poor food quality and safety, failure to provide adequate activities, and failure to provide appropriate mental health services. Immediate jeopardy was identified related to unsafe food storage temperatures.
Deficiencies (21)
Staff did not knock before entering resident rooms, and residents reported disrespectful behavior by the Dietary Manager.
Residents' personal clothing was lost and inventory sheets were not completed or located in medical records.
A resident was not provided return transportation after leave of absence, causing safety concerns.
Resident's legal representative was not provided timely access to medical records despite requests.
Facility shower rooms were dirty and smelled of mildew; resident rooms were cold below acceptable temperatures; wheelchairs were in disrepair; exit door to smoking area was unsafe and caused injury.
Resident's missing property grievances were not filed or resolved promptly.
Resident was verbally and physically abused by another resident; facility failed to intervene effectively or report timely.
Resident was left overnight in wheelchair despite requests to be put to bed, resulting in wound deterioration.
Resident was sexually assaulted by agency CNA; CNA was removed from schedule but later worked again.
Residents with cognitive impairment were allowed to share a room and have a sexual relationship without proper capacity assessment and documentation.
Resident sustained a femur fracture during transfer by CNA without use of proper equipment or assistance.
Resident had extensive weight loss and pressure ulcers; facility failed to provide timely skin checks and appropriate wound care.
Resident did not receive CPAP machine or care as ordered; facility staff did not clean CPAP equipment properly.
Resident did not receive medications on admission day; blood pressure medications administered outside ordered parameters; expired medications and unlabeled medications found.
Laboratory orders were not completed timely or lab results were missing from medical records.
Resident was not provided dentures timely; dental services were not arranged despite requests.
Menus did not meet nutritional needs; substitutions were not equivalent; food was bland, cold, and portions were small; snacks were limited and not available as requested.
Residents did not receive showers as scheduled; refusals were not consistently documented; shower aide position was vacant for a period.
Facility failed to maintain freezer temperatures within safe limits; food was stored improperly; immediate jeopardy was cited and abated.
Facility failed to maintain adequate infection control; clean linens stored in soiled laundry area; linens transported without bags; staff handled medications with bare hands; medication dropped and reused.
Facility had pervasive odors of urine, stool, and body odor throughout hallways and resident rooms.
Report Facts
Medication errors: 7
Weight loss percentage: 21
Freezer temperature: 42
Freezer temperature: 51.7
Freezer temperature: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA 3 | Certified Nursing Assistant | Named in transfer injury to resident 22 causing femur fracture. |
| Agency CNA 1 | Certified Nursing Assistant | Named in resident 20 fall and sexual assault allegation. |
| Resident Advocate (RA) | Resident Advocate/Medical Records | Involved in mental health service coordination and grievance follow-up. |
| Administrator 1 | Administrator | Involved in investigation of resident 22 injury and other incidents. |
| Dietary Manager (DM) | Dietary Manager | Named in resident complaints of food quality and disrespectful behavior. |
| Director of Nursing (DON) | Director of Nursing | Involved in multiple investigations and interviews regarding care deficiencies. |
| Registered Nurse 7 | Registered Nurse | Named in medication administration and resident care interviews. |
Inspection Report
Routine
Deficiencies: 15
Date: Oct 12, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, environment, care planning, transfers, nutrition, medication management, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to accurately document resident preferences, inadequate housekeeping and maintenance services, incomplete transfer documentation, insufficient care planning and implementation, failure to provide adequate assistance with activities of daily living such as showers, improper medication labeling and storage, delayed meal delivery, improper infection control practices including PPE use and hand hygiene, and failure to maintain complete and accurate medical records.
Deficiencies (15)
Failure to accurately document resident's life-saving preferences regarding code status.
Inadequate housekeeping and maintenance services resulting in unsanitary conditions and loss of resident property.
Failure to ensure transfer or discharge documentation was complete and communicated appropriately.
Failure to develop and implement comprehensive care plans addressing falls, weight loss, bathing, and aspiration pneumonia.
Failure to provide adequate assistance with activities of daily living, including showers, for multiple residents.
Failure to provide proper treatment and assistive devices to maintain vision abilities for a resident.
Failure to prevent development of pressure ulcers and provide appropriate care for existing pressure ulcers.
Failure to ensure resident environment was free from accident hazards and provide adequate supervision to prevent falls.
Failure to post nurse staffing information daily as required.
Failure to label all drugs and biologicals in accordance with professional principles and store expired medications properly.
Failure to provide sufficient support personnel to safely and effectively carry out food and nutrition service functions, resulting in delayed meal delivery.
Failure to ensure menus were followed and therapeutic diets were served according to prescribed specifications.
Failure to provide drinks consistent with resident needs and preferences and sufficient to maintain hydration, including provision of thin liquids instead of nectar thick liquids as ordered.
Failure to maintain complete, accurate, and readily accessible medical records including missing hospital records and hospice documentation.
Failure to maintain an infection prevention and control program including improper PPE use, inadequate hand hygiene, improper cleaning of shared equipment, and cross contamination during meal service and wound care.
Report Facts
Residents sampled: 49
Weight loss percentage: 16.45
Weight loss percentage: 13.16
Morse Fall Scale score: 75
Morse Fall Scale score: 65
Morse Fall Scale score: 40
Medication refusal count: 27
Medication refusal count: 17
Medication refusal count: 11
Medication refusal count: 4
Medication refusal count: 13
Medication refusal count: 6
Medication refusal count: 2
Medication refusal count: 2
Medication refusal count: 27
Medication refusal count: 1
Medication refusal count: 1
Medication refusal count: 3
Medication refusal count: 5
Medication refusal count: 7
Medication refusal count: 1
Medication refusal count: 4
Medication refusal count: 6
Medication refusal count: 4
Medication refusal count: 3
Medication refusal count: 5
Medication refusal count: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Named in medication error finding related to resident 76's code status |
| RN 1 | Registered Nurse | Named in medication error finding related to resident 76's code status |
| Maintenance Director | Named in housekeeping and maintenance services deficiency | |
| Social Services Director | Named in missing wheelchair investigation for resident 17 | |
| Physical Therapist 1 | Named in missing wheelchair investigation for resident 17 | |
| Physical Therapy Director | Named in missing wheelchair investigation for resident 17 | |
| Assistant Director of Nursing | Named in missing wheelchair investigation for resident 17 | |
| Director of Nursing | Named in missing wheelchair investigation for resident 17 | |
| Administrator | Named in missing wheelchair investigation for resident 17 | |
| CNA 3 | Certified Nursing Assistant | Named in missing wheelchair investigation for resident 17 and shower assistance |
| CNA 4 | Certified Nursing Assistant | Named in missing wheelchair investigation for resident 17 |
| CNA 14 | Certified Nursing Assistant | Named in shower assistance deficiency for resident 54 |
| RN 2 | Registered Nurse | Named in shower assistance deficiency for resident 54 |
| CNA 2 | Certified Nursing Assistant | Named in shower assistance deficiency for resident 54 |
| Dietary Manager | Named in nutrition and meal service deficiencies | |
| Dietary Aide 1 | Named in meal service and therapeutic diet deficiencies | |
| CNA 10 | Certified Nursing Assistant | Named in hydration and hand hygiene deficiencies |
| CNA 11 | Certified Nursing Assistant | Named in hand hygiene deficiency |
| Restorative Nursing Assistant 1 | Named in hand hygiene deficiency | |
| LPN 6 | Licensed Practical Nurse | Named in medication labeling deficiency |
| RN 4 | Registered Nurse | Named in medication labeling deficiency |
| Central Supply Staff | Named in medication storage deficiency | |
| Dietary 1 | Named in meal service and therapeutic diet deficiencies | |
| CNA 9 | Certified Nursing Assistant | Named in infection control and shower assistance deficiencies |
| RN 5 | Registered Nurse | Named in infection control deficiency |
| RN 6 | Registered Nurse | Named in infection control deficiency |
| CNA 15 | Certified Nursing Assistant | Named in infection control deficiency |
| CNA 16 | Certified Nursing Assistant | Named in infection control deficiency |
| CNA 17 | Certified Nursing Assistant | Named in infection control deficiency |
| Nursing Assistant 1 | Named in infection control deficiency | |
| Nursing Assistant 2 | Named in infection control deficiency | |
| LPN 3 | Licensed Practical Nurse | Named in infection control deficiency |
| CNA 18 | Certified Nursing Assistant | Named in infection control deficiency |
| RN 7 | Registered Nurse | Named in infection control deficiency |
| Transportation Staff Member 1 | Named in infection control deficiency | |
| Outside Vendor | Named in infection control deficiency | |
| CNA 7 | Certified Nursing Assistant | Named in infection control deficiency |
| CNA 21 | Certified Nursing Assistant | Named in infection control deficiency |
| LPN 7 | Licensed Practical Nurse | Named in infection control deficiency |
| CNA 20 | Certified Nursing Assistant | Named in infection control deficiency |
| Maintenance Director | Named in infection control deficiency | |
| RNA 1 | Restorative Nursing Assistant | Named in hand hygiene deficiency |
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