Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 1
Date: Nov 12, 2025
Visit Reason
The inspection was conducted to investigate a deficiency related to ensuring each resident receives food prepared in a form designed to meet individual needs, following a resident choking incident that resulted in death.
Findings
The facility failed to ensure a resident with a soft and bite-sized diet order was served a sandwich, leading to choking and death. The deficiency was determined to be past noncompliance due to corrective actions implemented before the survey. The facility implemented staff education, limited sandwich access in the memory care unit, and improved access to resident diet orders and education.
Deficiencies (1)
Failure to ensure each resident received food prepared in a form designed to meet individual needs, resulting in a resident choking and passing away.
Report Facts
Residents sampled: 3
Residents affected: 1
Date of resident death: Oct 16, 2025
Date corrective action plan implemented: Oct 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Provided the resident a half ham and cheese sandwich and performed Heimlich maneuver |
| RN Supervisor | Registered Nurse Supervisor | Witnessed the choking incident, assisted with care, and called 911 |
| DON | Director of Nursing | Educated staff on diet textures and oversaw corrective actions |
| ADMIN | Administrator | Investigated incident, debriefed staff, and participated in corrective action planning |
| CNA 2 | Certified Nursing Assistant | Provided meals and ensured correct diet textures |
| CNA 1 | Certified Nursing Assistant | Observed resident eating sandwiches before incident and participated in post-incident education |
| SLP | Speech-Language Pathologist | Provided diet recommendations and staff training |
| RD | Registered Dietician | Reviewed new snack options after choking incident |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as a regulatory annual survey of the William E Christofferson Salt Lake Veterans Home to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs, failure to notify the Ombudsman of resident discharges, inadequate supervision leading to a resident fall, improper food service hygiene practices, and breaches in infection prevention and control during medication administration.
Deficiencies (5)
Failure to reasonably accommodate the needs and preferences of resident 50 by not providing individualized accommodations to keep telephone and radio within reach.
Failure to provide timely notification to the resident representative and Ombudsman before transfer or discharge for resident 30.
Failure to ensure adequate supervision and assistance to prevent accidents, resulting in a fall for resident 6 who required substantial two-person assistance.
Failure to store, prepare, distribute and serve food in accordance with professional standards; food service staff were not wearing hair restraints.
Failure to establish and maintain an infection prevention and control program; staff member observed touching resident medications with bare hands during medication administration for residents 62 and 70.
Report Facts
Residents sampled: 23
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication administration observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed touching resident medications with bare hands during medication administration |
| RN 1 | Registered Nurse | Interviewed regarding proper hand hygiene and medication handling practices |
| Director of Nursing | Director of Nursing | Interviewed regarding shelving issues for resident 50, fall supervision, and infection control practices |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed regarding fall response and resident transfer assistance |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed regarding resident 50's shelf and resident 6's transfer needs |
| Maintenance Manager | Maintenance Manager | Interviewed regarding shelving repairs and wall conditions in resident 50's room |
| Dietary Manager | Dietary Manager | Interviewed regarding hair covering policies in kitchen staff |
| Licensed Clinical Social Worker | Licensed Clinical Social Worker | Interviewed regarding notification of Ombudsman about resident discharges |
| Administrator | Administrator | Interviewed regarding awareness of Ombudsman notification requirements |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 9, 2022
Visit Reason
The inspection was conducted as part of an annual recertification survey to assess compliance with regulatory standards related to housekeeping, food service safety, and quality assessment and assurance processes.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to missing seat cushions on chairs in the Memory Care Unit. Food safety violations were identified including food items in the walk-in refrigerator past their use-by dates and food items in the walk-in freezer open to air. Additionally, the Quality Assessment and Assurance committee failed to develop and implement appropriate corrective plans for previously identified deficiencies.
Deficiencies (3)
Facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; four chairs with missing seat cushions on the Memory Care Unit.
Facility did not store, prepare, distribute and serve food in accordance with professional standards; food items in the walk-in freezer were open to air, and food items in the walk-in refrigerator were past the manufacturers use-by date.
Facility did not ensure that the Quality Assessment and Assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies, including repeated non-compliance with prior cited deficiencies.
Report Facts
Deficiencies cited: 3
Number of chairs with missing seat cushions: 4
Dates of expired food items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Interviewed regarding missing seat cushions on Memory Care Unit chairs. |
| Speech Therapist 1 | Speech Therapist | Interviewed regarding missing seat cushions on Memory Care Unit chairs. |
| Housekeeping Manager | Housekeeping Manager | Interviewed about removal and cleaning of seat cushions from Memory Care Unit. |
| Administrator | Administrator | Interviewed regarding expectations for cleaning and return of soiled furniture and Quality Assessment and Assurance meeting details. |
| Dietary Aide 1 | Dietary Aide | Interviewed about food handling practices and date checking. |
| Dietary Manager | Dietary Manager | Interviewed about food safety practices, date checking, and removal of expired food items. |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 19, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident safety, abuse prevention, care planning, respiratory care, medication errors, and food service safety at the William E Christofferson Salt Lake Veterans Home.
Findings
The facility was found deficient in multiple areas including failure to properly assess and document medication self-administration, failure to notify physicians timely of medication refusals and changes, unsafe and unsanitary conditions of resident wheelchairs, inadequate prevention of resident-to-resident abuse and timely reporting of abuse allegations, incomplete and outdated care plans, failure to prevent falls and update interventions accordingly, medication errors including wrong dose and substitution, failure to provide oxygen as ordered, improper medication storage and labeling, and food service safety violations such as lack of hair restraints and cross contamination.
Deficiencies (13)
Facility did not determine if a resident was clinically appropriate to self-administer medications and lacked timely assessments and physician orders for self-administration.
Facility did not notify physicians timely when residents refused insulin, had elevated blood pressure, or when medication was substituted without notification.
Resident wheelchairs were soiled and had cracked arm rests, indicating failure to maintain a safe, clean, and homelike environment.
Facility failed to prevent multiple resident-to-resident altercations involving physical contact and did not provide adequate supervision or interventions.
Facility did not report suspected abuse and injuries of unknown origin to the State Survey Agency and Adult Protective Services within required timeframes.
Facility did not develop and implement comprehensive person-centered care plans for residents, including failure to update care plans with interventions after falls and for oxygen use.
Residents had long and soiled fingernails; one resident was cut during nail care and staff did not document nail care.
Facility failed to provide adequate supervision and assistance to prevent falls and did not implement new interventions after falls.
Resident with an order for oxygen was observed without oxygen and had low pulse oxygen saturation levels; staff did not consistently provide oxygen as ordered or document oxygen use properly.
Facility had a medication error rate of 10.87%, including wrong dose, medication substitution, and failure to follow physician orders for medication administration.
Facility failed to ensure residents were free from significant medication errors, including failure to administer insulin per physician orders and failure to take apical pulse as ordered.
Facility failed to ensure safe and secure storage of drugs and biologicals; medications were not labeled correctly and expired medication was administered.
Facility did not store, prepare, distribute, and serve food in accordance with professional standards; staff were observed without hairnets, not changing gloves after touching soiled items, reusing plate domes without cleaning, and cross contamination in the dining room.
Report Facts
Medication opportunities observed: 46
Medication errors: 5
Medication error rate: 10.87
Fall Risk Evaluation score: 19
Fall Risk Evaluation score: 19
Fall Risk Evaluation score: 16
Fall Risk Evaluation score: 14
Fall Risk Evaluation score: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Observed preparing and administering medications; interviewed about medication administration and self-administration assessments |
| Licensed Practical Nurse 2 | LPN | Interviewed about medication self-administration assessments and resident to resident altercations |
| Registered Nurse 1 | RN | Observed administering medications; interviewed about medication administration and self-administration assessments |
| Licensed Practical Nurse 4 | LPN | Interviewed about oxygen administration and medication administration |
| Certified Nursing Assistant 2 | CNA | Interviewed about resident to resident altercations and nail care |
| Certified Nursing Assistant 3 | CNA | Interviewed about resident to resident altercations |
| Director of Nursing | DON | Interviewed about medication administration, resident to resident altercations, care planning, and oxygen administration |
| Assistant Director of Nursing | ADON | Interviewed about medication self-administration assessments and medication administration |
| Medical Director 1 | MD | Interviewed about medication administration and expectations for notification |
| Administrator | Administrator | Interviewed about resident to resident altercations and reporting procedures |
| Dietary Manager | DM | Interviewed about food service safety and kitchen observations |
| Pharmacist 1 | Pharmacist | Interviewed about medication substitution |
| Social Services Assistant | SSA | Interviewed about abuse investigation and reporting |
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