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 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
178% worse than Utah average
Utah average: 7.9 deficiencies/year
Deficiencies per year
80
60
40
20
0
Inspection Report
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights, specifically regarding their ability to manage their financial affairs.
Findings
The facility did not provide two of 41 sampled residents with reasonable access to their personal funds, particularly on weekends when no staff was available to distribute money. Interviews and grievance reviews confirmed gaps in fund access and delays in obtaining money due to limited cash availability and staffing.
Deficiencies (1)
F 0567: The facility failed to honor the residents' right to manage their financial affairs. Two residents who authorized the facility to manage their funds did not have ready and reasonable access to their money, especially on weekends.
Report Facts
Sample residents reviewed: 41
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding residents' access to funds and stated he only worked Monday through Friday | |
| Administrator | Interviewed about fund access issues and plans to allocate responsibility to activities staff |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 16, 2025
Visit Reason
Routine inspection of Sandy Health and Rehab to assess compliance with regulatory standards related to resident rights, environment, treatment, food service, vaccination, and safety.
Findings
The facility had multiple deficiencies including failure to honor residents' rights to manage financial affairs, inadequate housekeeping and maintenance causing malodorous and disrepair conditions in shower rooms, delays in treatment such as suture removal, incomplete laboratory and radiology records, poor food quality and temperature control, failure to accommodate resident allergies, unsanitary food handling practices, incomplete vaccination administration, and nonfunctional call light systems in shower rooms.
Deficiencies (10)
F 0567: The facility did not provide residents with the right to manage their financial affairs, limiting access to personal funds on weekends for 2 residents.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment; shower rooms were in disrepair and malodorous affecting multiple residents.
F 0684: A resident experienced a delay in suture removal, not receiving timely treatment according to professional standards.
F 0775: The facility did not file complete, dated laboratory reports in a resident's clinical record, missing serum phenytoin and phenobarbital lab results.
F 0779: The facility did not file signed and dated radiological reports in a resident's medical record; a chest x-ray report was missing.
F 0804: Food served was not palatable, attractive, or at safe temperatures; multiple residents complained about food quality, temperature, and portion sizes.
F 0806: The facility failed to provide food accommodating resident allergies; a resident was served peas despite a documented allergy.
F 0812: Food was not stored, prepared, distributed, or served in a sanitary manner; staff touched food and plates with dirty gloves and used unclean cutting boards.
F 0883: The facility did not ensure all residents were offered or administered influenza, pneumococcal, and COVID-19 vaccines; 3 residents lacked vaccine administration documentation.
F 0919: Call light systems in shower rooms were nonfunctional or missing cords, preventing residents from summoning staff assistance; staff sometimes did not respond to calls.
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
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 13, 2025
Visit Reason
Complaint, Unannounced Annual inspection conducted to review compliance with nursing care facility regulations.
Complaint Details
Inspection was complaint-related as indicated by the inspection type 'Complaint, Unannounced Annual'. Specific substantiation status is not stated.
Findings
The inspection identified 7 rule noncompliances related to various regulatory requirements including staff identification badges, provider duties, scope of services, and resident rights among others.
Deficiencies (7)
R432-1-4. Identification Badges: The licensee failed to ensure all direct care employees and volunteers wore identification badges with required information.
R380-80-4. Providers' Duty to Help Protect Clients: The licensee did not fully protect clients from abuse, neglect, exploitation, and mistreatment as required.
R380-80-5. Provider Code of Conduct: The licensee failed to fully protect clients from abuse, neglect, harm, exploitation, mistreatment, fraud, and other compromising actions.
R432-150-4. Scope of Services: The licensee did not fully provide required services including occupational, physical, respiratory, speech therapy, and other ordered therapies.
R432-150-4(8). The licensee failed to ensure individuals receiving respite services received a copy of resident rights documents upon initiation.
R432-150-4(9). The licensee did not ensure respite records contained all required elements including post-service summary, accident reports, advanced directives, and nursing notes.
R432-150-4(10). The licensee failed to ensure retention and storage of respite records complied with regulatory requirements.
Report Facts
Number of rule noncompliances: 7
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 15, 2024
Visit Reason
The inspection was conducted in response to complaints and allegations regarding facility sanitation, investigation of neglect, treatment and care deficiencies, resident safety including elopement incidents, and medication administration errors.
Complaint Details
The complaint investigation involved multiple allegations including unsanitary conditions in shower rooms, failure to investigate neglect allegations, inadequate treatment and wound care, resident elopements resulting in injuries, and medication administration errors. Some allegations were substantiated, such as the elopement incidents and medication errors, while others highlighted procedural and documentation deficiencies.
Findings
The facility was found deficient in maintaining a sanitary environment, thoroughly investigating allegations of neglect, providing appropriate treatment and care according to orders, ensuring resident safety to prevent elopements and accidents, and administering medications as ordered. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (5)
F 0584: The facility failed to maintain a safe, clean, and homelike environment as black spots, possibly mold or scum, were observed in the resident shower rooms.
F 0610: The facility did not thoroughly investigate an allegation of neglect for a resident who sustained a fall with injury, lacking complete information and follow-up.
F 0684: The facility failed to ensure residents received treatment and care according to professional standards and care plans, including delayed wound treatment and lack of wound measurements for burns.
F 0689: The facility did not ensure a safe environment free from accident hazards and adequate supervision, resulting in two residents eloping and sustaining injuries including burns.
F 0760: The facility failed to ensure residents were free from significant medication errors, including failure to administer prescribed antibiotics and prophylactic medications for wounds and burns.
Report Facts
Residents sampled: 28
Residents affected: 2
Residents affected: 2
Medication doses: 5
Wound measurements: 20.9
Wound measurements: 19
Wound measurements: 0.1
Wound measurements: 17.1
Wound measurements: 12.2
Wound measurements: 0.1
Inspection Report
Re-Inspection
Deficiencies: 28
Date: Aug 16, 2023
Visit Reason
The survey was a recertification inspection with a focus on multiple complaint allegations, resident rights, quality of care, and safety concerns.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity and respect, loss of personal possessions, inadequate accommodation of resident needs, failure to provide timely medical records, unsanitary and unsafe environment conditions, failure to resolve grievances, abuse and neglect incidents, inaccurate resident assessments, inadequate nutrition and hydration, insufficient activities, pressure ulcer care deficiencies, medication errors, inadequate respiratory care, improper medication storage and labeling, incomplete laboratory services, inadequate dental care, poor food quality and service, and inadequate infection control and environmental sanitation. Immediate jeopardy was identified related to food storage temperatures.
Deficiencies (28)
F0550: The facility failed to ensure residents were treated with dignity and respect, including knocking before entering rooms and respectful staff interactions.
F0557: The facility failed to ensure residents' right to retain and use personal possessions, with multiple residents reporting lost clothing and lack of inventory documentation.
F0558: The facility failed to reasonably accommodate resident needs and preferences, including transportation after leave of absence.
F0573: The facility failed to allow timely access to resident medical records upon request by resident representatives.
F0584: The facility failed to maintain a safe, clean, comfortable environment, including dirty shower rooms, cold resident rooms, wheelchair disrepair, malfunctioning exit doors, and facility disrepair.
F0585: The facility failed to ensure residents' right to voice grievances without discrimination and failed to file grievances for missing property and other complaints.
F0600: The facility failed to protect residents from abuse and neglect, including physical abuse, verbal abuse, and inappropriate staff assignments after abuse allegations.
F0604: The facility failed to ensure residents were free from physical restraints imposed for convenience and failed to assess and monitor restraint use.
F0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
F0644: The facility failed to provide accurate resident assessments, including failure to document weight loss and mental health needs, and failure to provide mental health services as recommended.
F0676: The facility failed to provide care and assistance with activities of daily living, including bathing, and failed to provide adequate activities to meet resident needs and preferences.
F0684: The facility failed to provide appropriate treatment and care according to orders, resident preferences and professional standards, including delayed x-rays, inadequate dental care, and incomplete laboratory services.
F0692: The facility failed to provide routine and emergency laboratory services as ordered and failed to maintain complete laboratory records in resident medical records.
F0695: The facility failed to provide or obtain routine and emergency dental care to meet resident needs, including failure to provide dentures and timely dental services.
F0803: The facility failed to ensure menus met nutritional needs, were prepared in advance, followed, updated, and reviewed by a dietitian; and failed to provide palatable, attractive, and safe food and drink at appropriate temperatures.
F0804: The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, with multiple resident complaints about food quality, portion sizes, and substitutions.
F0809: The facility failed to provide meals and snacks at times consistent with resident needs, preferences, and requests, and failed to provide suitable and nourishing alternative meals and snacks for residents wanting to eat at non-traditional times.
F0812: The facility failed to procure, store, prepare, distribute and serve food in accordance with professional standards, resulting in immediate jeopardy due to freezer temperatures exceeding required thresholds and improper food storage.
F0842: The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, including missing sleep study and respiratory therapy notes, and incomplete hospital documentation.
F0865: The facility failed to have an effective QAPI program to review quality deficiencies and develop corrective plans of action, resulting in repeat deficiencies in multiple areas including abuse prevention, care planning, activities, nutrition, medication management, infection control, and food storage.
F0867: The facility failed to ensure sufficient nursing staff with appropriate competencies and skills to provide nursing and related services, resulting in resident injury from improper transfers and lack of post-fall assessment.
F0689: The facility failed to provide medication services in accordance with professional standards, including medication errors such as administering expired medications, wrong doses, missed medications, and unlabeled medications.
F0690: The facility failed to provide timely, quality laboratory services to meet resident needs, including failure to obtain ordered labs and failure to file lab results in resident records.
F0691: The facility failed to provide or obtain laboratory services only when ordered by a physician, including labs drawn without orders.
F0692: The facility failed to keep complete, dated laboratory records in resident medical records, including missing lab results for ordered tests.
F0790: The facility failed to provide or obtain outside resources for routine and emergency dental services to meet resident needs, including failure to provide dentures.
F0842: The facility failed to maintain accurate and complete medical records, including missing documentation of sleep study, respiratory therapy, emergency department notes, and advance beneficiary notices.
F0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications and failed to monitor resident behaviors when administering psychotropic drugs.
Report Facts
Medication errors: 7
Weight loss percent: 21
Freezer temperature: 51.7
Freezer temperature: 42
Freezer temperature: 20
Freezer temperature: 31
Freezer temperature: 40
Medication error rate: 14
Medication doses missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA 3 | Certified Nursing Assistant | Involved in resident 78 fall and injury; did not use Hoyer lift; terminated. |
| CNA 9 | Certified Nursing Assistant | Involved in resident 22 fall and injury; transferred resident without Hoyer sling. |
| RN 9 | Registered Nurse | Assessed resident 22 after fall; no Hoyer sling present. |
| Admin 1 | Administrator | Conducted investigation of resident 22 fall; provided staff education. |
| DM | Dietary Manager | Responsible for food preparation and menu; involved in food safety issues. |
| RD | Registered Dietitian | Conducted kitchen audits; involved in nutrition care plans. |
| DON | Director of Nursing | Oversaw nursing care; involved in investigations and care planning. |
| MTRS | Master of Therapeutic Recreation Services | Reported insufficient activity staffing and lack of one-on-one visits. |
| CNAC | Certified Nursing Assistant Coordinator | Provided education on transfers and shower refusals. |
Inspection Report
Routine
Deficiencies: 20
Date: Aug 16, 2023
Visit Reason
Routine recertification survey and complaint investigation of Sandy Health and Rehab to assess compliance with state and federal regulations.
Complaint Details
Complaint investigations were included in the survey with substantiated findings of harm related to abuse, neglect, and inadequate care for residents. Specific substantiations included verbal and physical abuse, neglect of personal possessions, and failure to provide necessary care and services.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights and dignity, loss of personal possessions, inadequate accommodation of resident needs, failure to provide timely and adequate care including bathing and nutrition, medication errors, improper handling of restraints, inadequate infection control, unsafe food storage temperatures resulting in immediate jeopardy, and insufficient staffing and activity programming. Several residents experienced harm due to these deficiencies.
Deficiencies (20)
F 0550: Facility failed to ensure residents were treated with dignity and respect; staff entered rooms without knocking and dietary manager was verbally abusive to residents.
F 0557: Facility failed to ensure residents' right to retain and use personal possessions; residents' clothing was lost and inventory sheets were not maintained.
F 0558: Facility failed to provide reasonable accommodation of resident needs; a resident was not provided return transportation after leave of absence.
F 0573: Facility failed to allow resident or representative timely access to medical records upon request.
F 0584: Facility failed to maintain a safe, clean, comfortable environment; issues included dirty shower rooms, cold resident room temperatures, disrepair of facility areas, malfunctioning exit door, and broken wheelchairs.
F 0585: Facility failed to establish a grievance policy and ensure prompt efforts to resolve grievances; residents' complaints about loud television and missing property were not properly addressed.
F 0600: Facility failed to protect residents from abuse; a resident was subjected to verbal abuse and trauma from an agency CNA who caused a fall; other residents experienced verbal and physical abuse incidents.
F 0604: Facility failed to ensure residents were free from physical restraints imposed for convenience; a resident's leg was tied to wheelchair footrest with a cloth strip without proper assessment or monitoring.
F 0609: Facility failed to provide necessary treatment and care; a resident developed pressure ulcers without timely skin checks or wound treatment and was not repositioned appropriately.
F 0684: Facility failed to provide treatment and care according to orders and resident preferences; multiple residents experienced medication errors, delayed or missing lab tests, inadequate dental care, insufficient bathing, poor nutrition, and unsafe medication administration practices.
F 0692: Facility failed to provide timely laboratory services as ordered; a resident's ordered basic metabolic panel was not completed and lab results were missing from the medical record.
F 0695: Facility failed to obtain laboratory tests only when ordered by a physician; a resident had labs drawn without physician orders.
F 0759: Facility medication error rate exceeded 5%; observed errors included administration of blood pressure medications outside ordered parameters, missed antibiotic dose, wrong dose of vitamin D, wrong medication timing, and expired medication given.
F 0812: Facility failed to maintain safe food storage temperatures; two freezers had temperatures above required thresholds resulting in immediate jeopardy; food items were discarded and corrective actions initiated.
F 0842: Facility failed to maintain accurate resident medical records; missing hospital discharge documentation and sleep study results for a resident with obstructive sleep apnea and CPAP use.
F 0865: Facility failed to develop and implement effective QAPI plans to address repeated deficiencies in multiple areas including abuse prevention, care planning, ADL assistance, nutrition, medication management, infection control, and food storage.
F 0866: Facility failed to provide pharmaceutical services to meet resident needs; a resident did not receive medications on admission day due to unavailable emergency medications.
F 0867: Facility failed to ensure nursing staff and aides had appropriate competencies; a resident was transferred without proper two-person assist resulting in femur fracture; a fall was not assessed or monitored properly.
F 0880: Facility failed to implement an effective infection prevention and control program; clean linens were stored in soiled laundry area, linens transported without bags, and medications handled with bare hands.
F 0923: Facility failed to provide adequate ventilation; multiple strong odors of urine, stool, and body odor were observed throughout the facility.
Report Facts
Medication errors: 7
Weight loss percentage: 21
Freezer temperature: 51.7
Freezer temperature: 42
Freezer temperature: 20
Medication administration opportunities: 50
Medication errors: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA 3 | Certified Nursing Assistant | Involved in resident 78 fall and injury; received additional training after incident. |
| CNA 9 | Certified Nursing Assistant | Involved in resident 22 transfer resulting in femur fracture. |
| RN 1 | Registered Nurse | Assessed resident 78 after fall; delayed X-ray and notification. |
| Admin 1 | Administrator | Conducted investigation of resident 22 fall; provided staff training. |
| DM | Dietary Manager | Responsible for food preparation and menu substitutions; involved in food safety issues. |
| RD | Registered Dietitian | Conducted kitchen audits and nutrition assessments; noted food budget constraints. |
| DON | Director of Nursing | Oversaw nursing care, medication administration, and investigations. |
Inspection Report
Routine
Census: 94
Deficiencies: 17
Date: Oct 12, 2021
Visit Reason
Routine inspection of Sandy Health and Rehab nursing home to assess compliance with regulatory requirements including resident rights, environment, care planning, transfers, nutrition, medication management, infection control, and staffing.
Findings
The facility had multiple deficiencies including failure to accurately document resident preferences, inadequate housekeeping and maintenance, missing resident property, incomplete transfer documentation, incomplete and untimely care planning, insufficient shower assistance, failure to provide ordered vision aids, pressure ulcer care deficiencies, fall prevention failures, nutritional interventions lacking after significant weight loss, late meal deliveries, improper food handling and storage, incomplete medical records, and infection control lapses including improper PPE use and hand hygiene.
Deficiencies (17)
F578: The facility did not accurately document a resident's life-saving treatment preferences, with conflicting code status documentation for resident 76.
F584: The facility failed to maintain a safe, clean, and homelike environment, with observations of urine spills, unclean rooms, debris, and housekeeping shortages affecting residents 13, 17, and 22.
F622: The facility did not ensure proper documentation and communication for resident transfers, missing transfer forms and discharge summaries for resident 288.
F656: The facility failed to develop and implement comprehensive, updated care plans addressing falls, weight loss, bathing, and hospitalization needs for residents 22, 32, 54, and 289.
F677: The facility did not provide adequate assistance with showers and personal hygiene for residents 22, 29, 32, 51, and 288, resulting in missed showers and inconsistent bathing.
F685: The facility failed to ensure a resident received proper vision care and assistive devices; resident 15 had a new prescription for glasses but the glasses were not ordered or provided.
F686: Resident 288 developed an unstageable pressure ulcer on the right foot with incomplete preventive interventions and inconsistent wound care practices.
F689: Resident 54 had multiple falls with injuries including a hip fracture; the facility failed to provide adequate supervision, timely interventions, and fall prevention measures.
F692: Resident 54 experienced significant weight loss without timely nutritional interventions; the facility failed to provide adequate nutritional support and monitoring.
F732: The facility did not post nurse staffing information daily as required, with the last posting dated 10/6/21 and census of 94.
F761: Multiple opened insulin vials and pens were not labeled with open dates or resident identifiers; expired medications were available for use.
F802: The facility did not provide sufficient support personnel to safely and effectively carry out food and nutrition services, resulting in late meal deliveries up to 70 minutes after posted times.
F803: Dietary staff provided incorrect meals and serving sizes for therapeutic diets during tray line service, including inconsistent scoop sizes and wrong entrees.
F807: Resident 33 with a physician order for nectar thick liquids was provided thin liquids by staff and on meal trays.
F812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; cross contamination occurred via hand hygiene lapses and unclean sanitation rags; resident communal refrigerator contained unlabeled, undated, and expired food items.
F842: Resident 187's hospital records were missing from the medical record and resident 38's hospice plan of care, nurse assessments, and CNA visit notes were not in the medical record.
F880: The facility failed to implement an effective infection prevention and control program; staff, vendors, and visitors did not consistently wear required PPE including eye protection and N95 masks during outbreak; hand hygiene was not performed between residents or during wound care; shared vital sign equipment was not sanitized between uses.
Report Facts
Resident census: 94
Weight loss percentage: 16.45
Weight loss percentage: 13.16
Weight loss percentage: 5.82
Morse Fall Scale score: 40
Morse Fall Scale score: 75
Morse Fall Scale score: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Interviewed about resident 76's code status discrepancy |
| RN 1 | Registered Nurse | Interviewed about resident 76's code status discrepancy |
| Maintenance Director | Interviewed about housekeeping staffing and facility remodel | |
| Social Services Director | Interviewed about missing wheelchair for resident 17 | |
| Physical Therapist 1 | Interviewed about missing wheelchair for resident 17 | |
| Physical Therapy Director | Interviewed about missing wheelchair for resident 17 | |
| Assistant Director of Nursing | Interviewed about missing wheelchair for resident 17 | |
| Director of Nursing | Interviewed about missing wheelchair for resident 17 | |
| Administrator | Interviewed about missing wheelchair for resident 17 | |
| LPN 2 | Licensed Practical Nurse | Interviewed about transfer documentation and shower CNA skin assessments |
| RN 2 | Registered Nurse | Interviewed about fall interventions and resident 54 care |
| LPN 4 | Licensed Practical Nurse | Interviewed about fall interventions and resident 54 care |
| CNA 14 | Certified Nursing Assistant | Interviewed about resident 54 care and call light use |
| RN 3 | Registered Nurse | Interviewed about resident 288 wound care and pressure ulcer interventions |
| Wound Nurse | Observed and interviewed about resident 288 wound care | |
| CNA 3 | Certified Nursing Assistant | Interviewed about resident 288 wound care and pressure ulcer interventions |
| RNC | Regional Nurse Consultant | Interviewed about wound care, fall prevention, infection control, and medical record completeness |
| Dietary Manager | Interviewed about meal delivery times, food preferences, and therapeutic diet plating | |
| Dietary Aide 1 | Observed plating meals and interviewed about scoop sizes | |
| CNA 2 | Certified Nursing Assistant | Interviewed about thickened liquids and meal assistance hand hygiene |
| LPN 6 | Licensed Practical Nurse | Interviewed about medication labeling and insulin vial expiration |
| RN 4 | Registered Nurse | Interviewed about medication labeling and insulin vial expiration |
| CSS | Central Supply Staff | Interviewed about expired medications in storage |
| CNA 4 | Certified Nursing Assistant | Observed delivering meals and interviewed about hand hygiene |
| CNA 11 | Certified Nursing Assistant | Observed delivering meals and interviewed about hand hygiene |
| CNA 9 | Certified Nursing Assistant | Observed assisting residents with meals and interviewed about hand hygiene |
| CNA 12 | Certified Nursing Assistant | Observed delivering meals and interviewed about hand hygiene |
| RNA 1 | Restorative Nursing Assistant | Interviewed about hand hygiene during meal assistance |
| LPN 7 | Licensed Practical Nurse | Interviewed about glucometer cleaning procedures |
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